Preoperative Echocardiography Research Articles

Masquerade of an Emergency: Cardiac Tamponade as a Deceptive Presentation of Primary Cardiac Diffuse Large B-Cell Lymphoma – A Case Report

Abstract Background Primary cardiac diffuse large B-cell lymphoma (CDLBCL) is an exceptionally rare entity, estimated to represent less than 1% of all primary cardiac tumours. In this case-report, we emphasise the diagnostic importance of multimodality imaging and the need for additional procedures, such as tissue biopsy, in a case with a primary cardiac lymphoma presenting with cardiac tamponade. Case summary An 80-year-old male was admitted to the emergency department with a life-threatening tamponade demanding immediate sternotomy. Preoperative echocardiography unveiled pericardial effusion and a thickened apex. While computed tomography ruled out an aortic dissection, surgery revealed an unexpected vascular-rich mass at the right ventricle and apex, too perilous for biopsy. Postoperative imaging misinterpreted this mass as a benign hematoma. Subsequently, the patient was admitted to the ICU, but after a conservative treatment strategy, the patient died. An autopsy revealed a primary CDLBCL. Discussion This case demonstrates the deceptive nature of primary CDLBCL, often complicated by cardiac tamponade. It underscores the pivotal role of pathologic assessment, even amidst the perils of sternotomy, to determine the origin of abnormal cardiac masses. A heightened awareness among physicians is imperative, for such elusive diagnoses may slip by, with potentially fatal outcomes.

Remimazolam for general anesthesia in a patient with aortic stenosis and severe obesity undergoing transcatheter aortic valve implantation

IntroductionThere is currently limited research on the clinical use of remimazolam in severely obese patients. In this report, we describe the anesthesia management of transcatheter aortic valve implantation (TAVI) in a severely obese patient using remimazolam.Case descriptionA 76-year-old woman (height 1.54 m; total body weight 104 kg; body mass index 43.9 kg/m2) was scheduled for TAVI via the femoral artery approach for aortic valve stenosis. Preoperative echocardiography showed an aortic valve peak flow of 4.0 m/s and an effective orifice area of 0.75 cm2. Anesthesia induction was performed with a bolus dose of 100 μg fentanyl, 15 mg remimazolam, 60 mg rocuronium, and a continuous infusion of remifentanil at 0.4 mg/h. Intraoperatively, remimazolam was administered at a rate of 35 mg/h. General anesthesia management was completed without any complications, although the patient required temporary catecholamine and inhalation anesthesia assistance due to hemodynamic changes.ConclusionOwing to its pharmacological advantages, remimazolam may be an option for anesthesia induction and maintenance in severely obese patients with unstable circulation.

Risk Factors for Delayed Atrioventricular Block after Aortic Valve Surgery: A Retrospective Study

Objective: This study aimed to examine the potential factors that contribute to the occurrence of delayed high-grade atrioventricular block (DHAVB) following transcatheter aortic valve replacement (TAVR). Methods: A retrospective analysis was conducted on the clinical data of 115 patients who underwent TAVR at Jiaozhou Central Hospital of Qingdao Hospital between January 2018, and June 2023. A follow-up period of 30 days post-operation was observed for all patients. The patients were categorized into two groups on the basis of the occurrence of DHAVB: DHAVB group (n = 35) and control group (n = 80). The general clinical data preoperative and postoperative heart disease characteristics of the groups were compared. The risk factors associated with DHAVB after TAVR were analyzed. Results: The mean systolic blood pressure (SBP) level of the DHAVB group significantly increased compared with that of the control group, whereas the heart rate (HR) level significantly reduced (p < 0.05). The average preoperative left ventricular ejection fraction (LVEF) was significantly lower in the DHAVB group than in the control group (p < 0.05). The control group exhibited a significantly higher prevalence of preoperative QRS wave broadening, severe calcification of the aortic valve, and right bundle branch block than the control group (p < 0.05). Spearman's correlation and logistic regression analyses identified increased SBP, decreased HR, diminished LVEF, the presence of preoperative and postoperative right bundle branch block, and thickened interventricular septum were as risk factors for DHAVB in patients undergoing TAVR (p < 0.05). Conclusion: Close surveillance of blood pressure, heart rate, and cardiac function is recommended for individuals undergoing TAVR. Pre-operative and post-operative electrocardiography and echocardiography are valuable tools in identifying potential risk factors for DHAVB, offering a solid foundation for effective patient prognostic management.

Outcomes and Complications after Left Ventricular Assist Device Implantation

Heart transplantation is the treatment of choice for selected patients with end-stage heart failure. Persistent donor organ shortage causes a growing demand for mechanical circulatory support not only as a bridge to transplantation but mainly as a destination therapy (DT). The aim of the study was to analyze the indications, comorbidities, and complications during the follow-up of all patients undergoing left ventricular assist device (LVAD) implantation with at least 12 months of follow-up time in one of the most experienced clinics in Poland between 2015 and 2023. There were 125 individuals with LVAD implantation, from which 90 had full 12 months of follow-up (85 males - 94%, 5 females - 6%), with a median age of 58 (50.25-63.75) years. The median body mass index was 27.12 (25.27-29.68). The etiology of heart failure was ischemic (n = 44, 49%), dilated cardiomyopathy (n = 44, 49%), and others. Preoperative echocardiography revealed a mean LV ejection fraction of 13.8% and a median LV dimension of 7.55 (6.92-8.2) cm. In 61 patients (68%), imaging confirmed pulmonary hypertension. Thirty-four patients (38%) had diabetes and 16 (18%) were active smokers. Median follow-up was 30 (17.25-42) months, with the longest period being about 82 months. 40 (44%) patients had kidney failure before LVAD implantation, and in 43 cases (48%), we observed relevant, transient deterioration of kidney function. Almost all patients (n = 82, 91%) suffered from anemia (Hb <13 g/dL in males and <12 g/dL in females) in different periods after LVAD implantation due to perioperative bleeding, gastrointestinal bleeding or unknown causes. The lowest Hb level was observed in the first week after LVAD implantation in 53 cases (58%). Median red cell concentrate transfusion demand before the discharge after surgery was 6 (2-8, 5) units. Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of DT. Anemia and kidney failure are the most frequent follow-up complications. Improved results and increased applicability and durability of LVADs have established this treatment option as an excellent alternative for patients with end-stage heart failure.

Driveline Infection in Patients With Left Ventricular Assist Devices Implanted as Destination Therapy

Donor organ shortages cause increasing demand for mechanical circulatory support in patients with end-stage heart failure not only as a bridge to heart transplantation but mainly as a destination therapy. Improved results and increased applicability and durability of left ventricular assist devices (LVADs) have established this treatment option as an alternative to heart transplantation in selected patients. One of the most common complications after LVAD implantation is driveline infections (DLIs). This study aimed to expand the understanding of DLI epidemiology and potential changes in implantation techniques regarding optimizing DLI prevention and treatment among all patients undergoing LVAD (Medtronic's Heartware HVAD and HeartMate 3 Abbott LVAD system) implantation with at least 12 months of follow-up time between 2015 and 2022. There were 120 individuals with LVAD implantation, of whom 90 had 12 months of follow-up (85 men [94%], 5 women [6%]) with a median age of 58 years (50.25-63.75). The median body mass index was 27.12 kg/m2 (25.27-29.68). Of the 90 patients, 43 had ischemic heart failure (48%), 43 had dilated cardiomyopathy (48%), and the remaining 3 had other etiologies (3%), such as postinflammatory, and the remaining 1 had congenital heart defect (1%). Preoperative echocardiography revealed a mean left ventricle ejection fraction of 13.8% and a median left ventricle dimension of 7.55 cm (6.92-8.2). Imaging confirmed pulmonary hypertension in 61 patients (68%). Thirty-four of the 90 patients had diabetes (38%), and 16 were active smokers (18%). Median follow-up was 30 months (17.25-42), with the longest period being 82 months. More than half of the patients (n = 52; 57%) experienced a DLI. The median time to the first episode of DLI was 13 months (6-25). The most common pathogen revealed in wound swab culture was methicillin-sensitive Staphylococcus aureus (n = 23; 44%), Pseudomonas aeruginosa (n = 9; 17%), Proteus mirabilis (n = 4; 7%), and others. We observed that deeper driveline implantation below the left rectus muscle and just above the posterior rectus sheath resulted in fewer DLIs and longer free-from-DLI follow-up time. There was no statistically significant difference in DLI frequency between patients with or without diabetes mellitus. Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of destination therapy. DLI is the most common complication after LVAD implantation. Optimal surgical techniques and early implementation of targeted antibiotics are crucial. Significant challenges remain in optimizing DLI prevention and treatment.

Preoperative echocardiography as a predictor of spinal anesthesia-induced hypotension in older patients with mild left ventricular diastolic dysfunction: a retrospective observational study.

Spinal anesthesia-induced hypotension (SAH) frequently occurs in older patients, many of whom have mild left ventricular (LV) diastolic dysfunction, often asymptomatic at rest. This study investigated the association between preoperative echocardiographic measurements and SAH in older patients with mild LV diastolic dysfunction. We conducted a retrospective observational study using data from electronic medical records. The patients ≥ 65 years old who underwent spinal anesthesia for urologic surgery between January 2016 and December 2017 and whose preoperative echocardiography within 6 months before surgery revealed grade I LV diastolic dysfunction were recruited. SAH was investigated using the anesthesia records. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. A total of 163 patients were analyzed. SAH and significant SAH developed in 55 (33.7%) patients. The mitral inflow E velocity was an independent risk factor for SAH (odds ratio [OR], 0.886; 95% confidence interval [CI], 0.845-0.929; P < 0.001). The area under the ROC curve for mitral inflow E velocity to predict SAH was 0.819 (95% CI, 0.752-0.875; P < 0.001). If mitral inflow E velocity was ≤ 60 cm/s, SAH was predicted with a sensitivity of 83.6% and specificity of 70.4%. The preoperative mitral inflow E velocity demonstrated the greatest predictability of SAH in older patients with mild LV diastolic dysfunction. This may assist in identifying patients at high risk of SAH and guiding preventive strategies in the future.

Evaluation of echocardiography and computed tomography characteristics related to aortic valve replacement technique through the right anterior thoracotomy at the 2nd intercostal space

Objective: evaluate echocardiographic and computed tomography characteristics related to minimally invasive aortic valve replacement technique through the right anterior thoracotomy at the 2nd intercostal space. Methods: study on 74 patients undergoing aortic valve replacement surgery through the right anterior thoracotomy at the 2nd intercostal space at Hanoi Heart Hospital and 108 Military Central Hospital, from October 2019 to December 2022. Patients underwent preoperative echocardiography and multiple slices computed tomography to assess the lessons of aortic valve, valve annulus diameter, and intercostal space width. Results: The ratio of aortic valve stenosis is 55.4%, stenosis combined with regurgitation is 31.1%, and aortic regurgitation is 13.5%. The average valve annulus diameter on computed tomography scans is 26.5 ± 3.1 mm (smallest 20; largest 36); average 2nd intercostal space width 18.1 ± 3.1 mm (smallest 11; largest 25). Valve annulus diameter measured by computed tomography correlates closely with actual prosthetic valve size (r = 0.54, p &lt; 0.001); measured by echocardiography had a weak correlation and not statistically significant. The prosthetic valve size to be replaced is smaller than the valve annulus diameter measured on computed tomography, with an average of 4.8 ± 2.7 mm in aortic valve stenosis, 5.7 ± 2.0 mm in combined stenosis and regurgitation, and 7.2 ± 2.9 mm in aortic regurgitation, in which the difference between valve stenosis and regurgitation is statistically significant (p = 0.01). Conclusions: Minimally invasive aortic valve replacement technique through the 2nd intercostal space right thoracotomy, with cutting the 3rd rib, is suitable for Vietnamese anatomy. Valve annulus diameter measured by computed tomography has a good linear correlation and can be a predictor for prosthetic valve size before surgery.

Left atrial strain predicts the rhythm outcome in patients with persistent atrial fibrillation undergoing left atrial cryoablation during minimally invasive mitral valve repair.

Patients with atrial fibrillation (AF) have lower left atrial (LA) strain, which is a predictor for LA function. Here, we evaluated the prognostic value of LA strain to predict the rhythm outcome in patients with persistent AF undergoing LA cryoablation concomitant to minimally invasive mitral valve repair. Between 01/2016 and 12/2020, 72 patients with persistent AF underwent LA cryoablation during minimally invasive mitral valve surgery. All patients received a complete LA lesion set and left atrial appendage (LAA) closure with a clip. All patients received preoperative transthoracic echocardiography (TTE) with LA and left ventricular strain measurements. Preoperative LA and LV strain analysis was correlated with postoperative rhythm outcome. The mean age of the patients was 66.9 ± 7.2 years, of whom 42 (58%) were male patients. No major ablation-related complications occurred in any of the patients. Successful LAA closure was confirmed by intraoperative echocardiography in all patients. The 1-year survival rate was 97%. Freedom from AF at 12 months was 72% and 68% off antiarrhythmic drugs. Preoperative LA strain values were statistically significantly higher in patients with freedom from AF at 12 months of follow-up (12.7% ± 6.9% vs. 4.9% ± 4.1%, p = 0.006). Preoperative LV strain value was not associated with postoperative rhythm outcome. In multivariate logistic regression analysis, LA strain (p < 0.001) and AF duration (p = 0.017) were predictors for freedom from AF at 12 months of follow-up. In our study, LA strain analysis predicted the rhythm outcome in patients with persistent AF undergoing concomitant surgical AF ablation. In the future, LA strain might be a useful tool to guide decision-making on ablation strategies in patients with persistent AF.

Predicting Peri-Operative Cardiorespiratory Adverse Events in Children with Idiopathic Pulmonary Arterial Hypertension Undergoing Cardiac Catheterization Using Echocardiography: A Cohort Study.

General anesthesia in children with idiopathic pulmonary arterial hypertension (PAH) carries an increased risk of peri-operative cardiorespiratory complications though risk stratifying individual children pre-operatively remains difficult. We report the incidence and echocardiographic risk factors for adverse events in children with PAH undergoing general anesthesia for cardiac catheterization. Echocardiographic, hemodynamic, and adverse event data from consecutive PAH patients are reported. A multivariable predictive model was developed from echocardiographic variables identified by Bayesian univariable logistic regression. Model performance was reported by area under the curve for receiver operating characteristics (AUCroc) and precision/recall (AUCpr) and a pre-operative scoring system derived (0-100). Ninety-three children underwent 158 cardiac catheterizations with mean age 8.8 ± 4.6years. Adverse events (n = 42) occurred in 15 patients (16%) during 16 catheterizations (10%) including cardiopulmonary resuscitation (n = 5, 3%), electrocardiographic changes (n = 3, 2%), significant hypotension (n = 2, 1%), stridor (n = 1, 1%), and death (n = 2, 1%). A multivariable model (age, right ventricular dysfunction, and dilatation, pulmonary and tricuspid regurgitation severity, and maximal velocity) was highly predictive of adverse events (AUCroc 0.86, 95% CI 0.75 to 1.00; AUCpr 0.68, 95% CI 0.50 to 0.91; baseline AUCpr 0.10). Pre-operative risk scores were higher in those who had a subsequent adverse event (median 47, IQR 43 to 53) than in those who did not (median 23, IQR 15 to 33). Pre-operative echocardiography informs the risk of peri-operative adverse events and may therefore be useful both for consent and multi-disciplinary care planning.

Clinical Predictors of Device-Detected Atrial Fibrillation During 2.5 Years After Cardiac Surgery: Prospective RACE V Cohort

BackgroundPostoperative atrial fibrillation (POAF) is a frequent complication after cardiac surgery that is associated with late atrial fibrillation (AF) recurrences (late-POAF) and increased morbidity and long-term mortality. ObjectivesThis study sought to determine device-detected POAF incidence and to identify clinical variables associated with POAF, both in patients with and without preoperative AF history. MethodsA total of 133 consecutive patients undergoing cardiac surgery were prospectively enrolled and continuously monitored with an implantable loop recorder for 2.5 years after surgery. Preoperative transthoracic echocardiography, 12-lead electrocardiogram, blood biomarkers, and clinical data were analyzed to develop prediction models for early- and late-POAF. ResultsIn patients without preoperative AF history, early-POAF within the first 90 postoperative days occurred in 41 (47.1%) of 87 patients. Late-POAF after the first 90 postoperative days occurred in 22 (25%) of 87 patients, and 20 of these patients also had early-POAF during the first 90 days (20 of 22 [91%]). Increased right atrial minimum volume indexed for body surface area (RAVImin) and early-POAF were independently associated with late-POAF. A prediction model for late-POAF, which included RAVImin >11 mL/m2, age >65 years, and early-POAF, achieved an area under the curve of 0.82 (95% CI: 0.72-0.92). For patients with preoperative AF-history, late-POAF recurrences were frequent (22 of 33 [67%]). Increased RAVImin was independently associated with a higher incidence of late-POAF. ConclusionsIn patients with and without AF history, late-POAF recurrences are frequent, including in patients undergoing surgical AF ablation. In patients with no history of AF, late-POAF might be predicted with excellent accuracy by using a combination of preoperative variables. In patients with a history of AF, signs of advanced AF substrate (eg, increased right atrial volumes) were associated with long-term AF recurrences. [Reappraisal of Atrial Fibrillation: Interaction Between Hypercoagulability, Electrical Remodeling, and Vascular Destabilisation in the Progression of AF; NCT03124576]

Florida sleeve procedure for type II aortic regurgitation with aortic root enlargement: a case report

Abstract Background Florida sleeve procedure is an operative technique for aortic root reconstruction that offers advantages such as reduced bleeding risk, shorter operation time, and improved formation of the atrioventricular junction (AVJ) and sinotubular junction (STJ). In our department, we perform a Florida sleeve procedure for aortic regurgitation (AR) associated with aortic root enlargement of less than 40 mm in diameter of the Valsalva sinus. Here, we present a case of severe type II AR with aortic root enlargement where we successfully performed Florida sleeve procedure and augmented it with autologous pericardium. Case presentation A 62-year-old male patient was referred for cardiovascular surgery after a transthoracic echocardiogram indicated left ventricular enlargement and severe AR. Preoperative multidetector computed tomography (MDCT) revealed AVJ of 28.2 mm, Valsalva sinus of 38.4 mm, STJ of 36.1 mm, and ascending aorta of 40.1 mm, indicating enlargement from the aortic root to ascending aorta. Preoperative transesophageal echocardiography (TEE) revealed that the main cause of AR was suspected to be the right coronary cusp prolapse (RCC). Intraoperative findings showed that the tricuspid aortic valve had no limitation of motion, but the RCC was subjected to central bending and prolapsed. The leaflet bend was thickened and shortened causing AR (type II). The geometric height (gH) of RCC was short at 14 mm, while the other valve cusps were 20 mm. An augmentation of RCC was performed using autologous pericardium, followed by a Florida sleeve procedure performed using 26-mm Gelweave Valsalva™ grafts. The gH of RCC after augmentation was 23 mm, and the effective height was adjusted to 10 mm by central plication, showing no AR by TEE. Postoperative MDCT revealed AVJ of 22.2 mm, Valsalva sinus of 30.9 mm, and STJ of 21.9 mm. Therefore, the Florida sleeve procedure provided a reduction that preserved the geometry of the aortic root, including AVJ and STJ, as intended. Conclusions Florida sleeve procedure is a reliable and simple method for ensuring uniform aortic root geometry. A favorable outcome was obtained using the Florida sleeve procedure and augmentation with autologous pericardium in a patient with type II AR and aortic root enlargement.

Prognostic factors of surgical management for heart failure patients with reduced left ventricular ejection fraction

ObjectivesThere are many available pharmaceutical and surgical management for Coronary artery disease (CAD) patients. However, coronary artery bypass grafting (CABG) is the preferred treatment modality for CAD patients with low ejection fraction (EF) in view of the more favorable outcomes. This study aimed to determine the associated factors of poor outcomes post-CABG for heart failure patients with reduced left ventricular ejection fraction who underwent on-pump and off-pump CABG. MethodsA retrospective review of CAD patients who underwent isolated on-pump CABG (ONCAB) or off-pump CABG (OPCAB) in Beijing Anzhen Hospital Affiliated with Capital Medical University from January 2013 to March 2021. Only those with confirmed reduced left ventricular ejection fraction (LVEF) ≤40% on preoperative echocardiography were included. By analyzing the clinical and surgical data, postoperative mortality and morbidity, as well as major cardiovascular and cerebrovascular adverse events (MACCE) as endpoints, certain risk factors of the postoperative complications were identified. ResultsOut of the 500 patients, 64 developed MACCE, of which 14 (13.6%) occurred in the ONCAB group and 50 (14.0%) in the OPCAB group. Univariate COX regression analysis showed that age ≥65 years, history of diabetes, and preoperative renal insufficiency were independent risk factors for postoperative primary endpoint events in CAD patients with heart failure with reduced ejection fraction (HFrEF). Following the multivariate COX regression analysis, in addition to the above three risk factors, a history of previous percutaneous coronary angiography (PCI) intervention was also a risk factor for the occurrence of the primary endpoints post-CABG. ConclusionBased on the analysis, significant predictors of post-CABG MACCE in patients with HFrEF included being older than 65 years old, having diabetes, preoperative renal insufficiency, and having previous PCI.

Off-pump minimally invasive coronary artery bypass grafting in patients with left ventricular dysfunction: the lampang experience.

The minimally invasive cardiac surgery off-pump coronary artery bypass (MICSOPCAB) is technically difficult; therefore, previous studies have indicated that MICSOPCAB should be contraindicated in patients with impaired left ventricular (LV) function. In this study, we investigated the feasibility of MICSOPCAB in patients with impaired LV function. The 226 patients underwent MICSOPCAB between August 2017 and September 2022. Our study defined impaired LV function as ejection fraction (EF) in echocardiography 40% or less. The patients were divided into Low EF group (n = 39) and Normal EF group (n = 187). The Low EF group was in a more critical preoperative condition than Normal EF group (41.0% in the Low EF group vs. 14.4% in the Normal EF group; p < 0.001). For preoperative transthoracic echocardiography, LV end-diastolic diameter (5.5 ± 0.9 cm in the Low EF group vs. 5.0 ± 0.8 cm in the Normal EF group; p < 0.001) and LV end-systolic diameter (4.4 ± 1.0 cm in the Low EF group vs. 3.4 ± 1.0 cm in the Normal EF group; p < 0.001) were significantly larger in the Low EF group. No differences were found in the operative time (180 [160-240] min in the Low EF group vs. 205 [165-253] min in the Normal EF group; p = 0.231) and the median number of distal anastomoses (2 [1-2] in the Low EF group vs. 2 [1-3] in the Normal EF group; p = 0.073). Intensive care unit stay was longer in the Low EF group than in the Normal EF group (2 [1-2] in the Low EF group vs. 1 [1-2] in the Normal EF group; p = 0.010). Perioperative transfusion was more common in the Low EF group than in the Normal EF group (69.7% vs. 49.2%; p = 0.023). There were no differences in major complications, hospital stay, and 30-day mortality. The Kaplan-Meier curve showed no significant difference in postoperative major adverse cardiac or cerebrovascular events rates between the two groups (p = 0.185). In this study, MICSOPCAB can be performed in patients with low EF having short- and mid-term outcomes similar to patients with normal EF. Therefore, low EF should not be contraindicated in MICSOPCAB.

Remodeling on Lateral Side of Posterior Mitral Leaflet in Recurrent Mitral Regurgitation after Mitral Annuloplasty for Patients with Atrial Functional Mitral Regurgitation

Objective. The high recurrence rate of mitral regurgitation (MR) in patients with atrial functional mitral regurgitation (AFMR) who underwent mitral annuloplasty (MAP) is reported. However, the mechanism of recurrence is not fully understood and appropriate surgical intervention remains unknown. Herein, we reviewed patients with AFMR who underwent MAP at our institution and investigated the preoperative geometric characteristics of the mitral valve in terms of MR recurrence after surgery. Methods. We retrospectively evaluated 20 patients with AFMR who underwent MAP between 2010 and 2022. The mean follow-up period was 3.2 ± 2.3 years. Preoperative three-dimensional transesophageal echocardiography (3D TEE) was available for all patients, and geometric analysis of the mitral valve was performed using the Philips Q-Lab software. Results. MR recurred in six patients. The rates of freedom from MR recurrence were 79% and 57% at one and three years, respectively. The lateral portion of the posterior mitral leaflet (PML) in patients with recurrent MR was longer and thicker than that in patients without recurrent MR (length of P1; 10 ± 3 vs. 15 ± 5 mm, p&lt;0.01, length of P2; 11 ± 4 vs. 14 ± 4 mm, p=0.23, length of P3; 8 ± 3 vs. 10 ± 3 mm, p=0.13). Conclusions. Patients with remodeling of the lateral portion of PML tended to have recurrent MR after MAP. This factor could indicate progressive remodeling, and MAP alone may not be a sufficient intervention for these patients.

Left atrial myxoma with mitral valve prolapse detected on preoperative transthoracic echocardiography by a perioperative ultrasonographer: A case report

Left atrial myxoma with mitral valve prolapse detected on preoperative transthoracic echocardiography by a perioperative ultrasonographer: A case report

Prediction of myocardial contractility after coronary bypass surgery according to preoperative contrast-enhanced magnetic resonance imaging and echocardiography

To establish the criteria for reversibility of myocardial contractility in patients with coronary artery disease (CAD) after coronary artery bypass grafting considering data of cardiac magnetic resonance imaging (MRI) and echocardiography. We studied the results of coronary artery bypass grafting in 186 patients with CAD complicated by reduced left ventricular ejection fraction (<30%). All patients underwent cardiac MRI and echocardiography before surgery. Immediate and long-term results were evaluated according to echocardiography and MRI data. We confirmed the previously established predictors of improvement in left ventricular contractility: diastolic IVST ≥10.5 mm and PWT ≥9.5 mm, score of LV myocardium damage according to MRI with delayed contrast enhancement (p<0.05). Multivariate analysis makes it possible to calculate prognostic index and obtain information about further myocardial contractility after revascularization with an error of 6%. Echocardiography and contrast-enhanced cardiac MRI are valuable to assess morphological and functional state of the left ventricle in patients with ischemic cardiomyopathy and preoperatively determine functional reserve of the myocardium.

Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis

BackgroundHeart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency. MethodsWe conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF. ResultsWe included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P = .99), body mass index (P = .74), or type of hemodialysis access created (P = .54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P > .05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P = .029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P < .0001 for both). ConclusionsIn this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation.

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients

BackgroundThe physiological response of the right ventricle (RV) following left ventricular assist device (LVAD) implantation is difficult to predict. We aimed to investigate RV geometric and functional changes after LVAD insertion and their effects on clinical outcomes. MethodsWe retrospectively reviewed 188 patients who underwent HeartMate 3 implantation at our center between November 2014 and September 2021. The RV end-diastolic diameter (RVEDD) and area (RVEDA) were measured on preoperative and pre-discharge transthoracic echocardiography. The non-adapted group included patients with increased RVEDD and RVEDA at discharge. The composite outcome was defined as death or readmission due to worsening right heart failure. ResultsThere were 82 patients (44%) who had a non-adapted and 106 (56%) who had an adapted RV. Preoperatively, the non-adapted group had smaller RVEDD (46 vs. 49 mm, p < 0.001) and RVEDA (27 vs. 31 cm2, p < 0.001). At discharge, the non-adapted group had larger RVEDD (51 vs. 43 mm, p < 0.001) and RVEDA (33 vs. 27 cm2, p < 0.001). Kaplan-Meier analysis demonstrated worse 3-year survival (77% vs. 91%, p = 0.006) and freedom from composite outcome (58% vs. 85%, p < 0.001) in the non-adapted group. A multivariable Cox proportional hazards model showed that non-adaption (HR 3.09, 95% CI 1.29–7.40 p = 0.01) and age (HR 3.73, 95% CI 1.42–9.77, p = 0.007) were independent predictors of composite outcome. ConclusionsAcute RV dimensional changes after LVAD insertion may represent intrinsic RV function and may be a useful prognostic marker.

Anomalous papillary muscle insertion into the mitral valve leaflet in hypertrophic obstructive cardiomyopathy: a lip nevus sign in echocardiography.

Anomalous papillary muscle (APM) insertion into the mitral valve leaflet is rare but clinically important in hypertrophic obstructive cardiomyopathy (HOCM). In this study, we report the detection rate of APM insertion into the mitral valve using preoperative imaging modalities and the surgical outcomes of the patients. By retrospectively reviewing the clinical records of patients with HOCM who underwent surgical treatment by a single operation group at our center from January 2020 to June 2023, patients with APM insertion into the mitral valve leaflet were identified. Baseline data, image characteristics, and surgical outcomes were analyzed. The incidence of APM insertion into the mitral valve leaflet was 5.1% (8/157). The insertion site was located at A3 in six cases, which was more common than at A2 (n = 2). Preoperative echocardiography was used to identify two patients (25%) with APM insertion. We observed a particular echocardiographic feature for APM in HOCM patients, which was noted as a "lip nevus sign", with a higher detection rate (62.5%). All patients successfully underwent septal myectomy with concomitant APM excision or mitral valve replacement via the transaortic (n = 5) or transmitral (n = 3) approach. The mean age was 49.0 ± 17.4 years and seven patients (87.5%) were female. Interventricular septum thickness (17.0 mm vs. 13.3 mm, P = 0.012) and left ventricular outflow gradient (117.5 mmHg vs. 7.5 mmHg, P = 0.012) were significantly decreased after surgery. Residual outflow obstruction, systolic anterior motion, and ≥3+ mitral regurgitation were negative. During the follow-up of 26.2 ± 12.2 months, there were no reported operations, adverse events, mitral regurgitation aggravations, recurrences of outflow obstruction, or instances of SAM. Papillary muscles inserted into the mitral valve leaflet are a subtype of subvalvular malformation in HOCM that requires surgical correction. The lip nevus sign on echocardiography is a characteristic of APM insertion in HOCM and may improve the preoperative detection rate. Adequate myectomy with anomalous papillary muscle excision has achieved good results in reducing the outflow gradient and eliminating mitral regurgitation, with good outcomes at short-to-intermediate follow-up.