Regurgitant Jet Research Articles

Exercise behavior of degenerative mitral stenosis.

Mitral annular calcification (MAC) is increasingly encountered, particularly among the elderly and those with chronic kidney disease, and is often associated with a transvalvular gradient. In contrast to rheumatic mitral stenosis relatively little is known about mitral stenosis due to MAC. We aimed to clarify whether exercise limitation in this group is primarily due to valvular obstruction or ventricular dysfunction resulting from multiple comorbidities. 20 patients with severe MAC (bulky calcium deposits which restricted leaflet motion) were submitted to supine bicycle exercise, measuring Doppler and echocardiographic parameters at baseline and during exercise. They were compared 1:1 to subjects matched for age, sex, and left ventricular wall thickness. At baseline MAC subjects had higher mean mitral valve gradients (MVG) than comparison subjects (7.5 ± 3.8 vs 1.6 ± 0.8mm Hg, p < 0.0001), along with larger indexed left atrial volumes (54.4 ± 14.9 vs 34.0 ± 11.7mL, p < 0.0001) and reduced left atrial strains (reservoir, conduit, and booster pump). With exercise MAC subjects reached higher levels of MVG (17.3 ± 8.4 vs 5.5 ± 2.5mm Hg, p < 0.0001), and pulmonary artery systolic pressure (estimated from tricuspid regurgitant jet [TR] velocity) and displayed a moderate correlation between ΔMVG and ΔTR velocity (r2 = 0.57). MAC subjects whose exercise MVG was ≥ 15mm Hg all had a peak pulmonary artery systolic pressure > 60mm Hg. MAC subjects also had relative chronotropic incompetence. Patients with severe MAC and a transvalvular gradient experience large increases in MVG and pulmonary pressure with exercise, similar to what has been described in rheumatic mitral stenosis. MAC may be an under-recognized cause of dyspnea and exercise intolerance in older patients.

Added value of three-dimensional transesophageal echocardiography in management of mitral paravalvular leaks.

Prosthetic paravalvular leak (PVL) is a well-known serious complication following surgically as well as percutaneously implanted prosthetic valves. It usually happens due to incomplete sealing of the prosthetic ring to the native cardiac tissue whether immediately postoperative or considerably later as a complication of infective endocarditis, etc Surgery has been always the treatment of choice for clinically significant PVLs. However, percutaneous transcatheter closure therapy has become a successful alternative in carefully selected group of patients. Echocardiography is a cornerstone in the initial diagnosis, assessment of the severity and location of the PVL. Furthermore, it plays a crucial role in the assessment of the feasibility for percutaneous closure and during intra-procedural guidance. Transesophageal echocardiography (TEE) has the advantage over transthoracic echocardiography (TTE) of not being affected by the acoustic shadow of the mitral prosthesis that usually hides the regurgitation jets and makes TTE evaluation difficult. Three-dimensional (3D) TEE has been shown to provide better diagnostic accuracy compared to two-dimensional (2D) TEE as regard to evaluation of PVLs especially in patients with more than one PVL. This is due to better delineation of the location, shape, and size of the PVL and equally important during guiding the transcatheter percutaneous closure.

Comparative therapeutic effect of the L-arginine and sildenafil on beta-thalassemia children with increased tricuspid regurgitant jet velocity

BackgroundSecondary pulmonary hypertension (PH) is emerging as a significant cause of mortality and morbidity in patients with thalassemia. Tricuspid Regurgitant Jet Velocity (TRJV) can identify patients at risk for PH. Aim of the workTo study the effect of the L-arginine and Sildenafil on patients with β -thalassemia complicated by increased Tricuspid Regurgitant Jet Velocity. Patients and methodsA randomized controlled clinical trial was carried out on 60 children with β-thalassemia major, selected with high TRJV (TRJV>2.5 m/s). The children were selected from Hematology Unit, Pediatric Departments, Tanta University Hospital. They were classified into 3 groups: Group (I): Twenty children received L-arginine, group (II): Twenty children received Sildenafil therapy and group (III): Twenty children did not receive either L-arginine or sildenafil therapy as a control group. All Patients were matched in ethnicity, age and sex distribution. They underwent to full history taking and complete clinical examination. Investigations include; complete blood count, aspartate transaminase (AST), alanine transaminase (ALT), serum ferritin and Color Doppler Echocardiography to measure TRJV. Results: There was no statistically significant difference between three groups as regard platelet count, serum ferritin, serum ALT, AST. There was a significant decrease of TRJV after Sildenafil therapy and/or L-arginine therapy, with no statistically significant differences between group (I) and group (II) as regard to TRJV after treatment. ConclusionPediatric patients with thalassemia complicated by PH can get benefit from therapy with Sildenafil and/or arginine therapy.

Additional cleft mitral valve diagnosed by a combination of 2-D and 3-D echocardiography using transesophageal echocardiography during mitral valve prolapse: a case report

BackgroundA mitral cleft may be an important etiological factor for significant mitral regurgitation. We diagnose an additional cleft mitral valve by a combination of 2-dimensional (2-D) and 3-dimensional (3-D) echocardiography.Case presentationWe describe the case of a severe mitral regurgitation due to posterior leaflet prolapse (P2). In the 2-D view, which is obtained after turning the probe clockwise from the mid-esophageal long-axis view, TEE showed a moderate central regurgitation jet. In the 3-D en face view, a cleft between P2 and P3 was identified, and we found that the cause of mitral regurgitation was not only P2 prolapse but also a cleft between P2 and P3.ConclusionA complex mitral valve lesion was detected by a combination of 2-D and 3-D TEE. The presence of a cleft could affect the surgical procedure because of the possibility that an enlarged cleft would increase with leaflet resection.

Pulmonary Artery Aneurysm in a Child

A 12-year-old boy was diagnosed with an asymptomatic 3 × 3 cm right pulmonary artery aneurysm (PAA) (Figures 1A and 1B). Echocardiography demonstrated a bicuspid aortic valve with a mild-to-moderate regurgitation. The peak velocity of the tricuspid valve regurgitation jet indicated mild pulmonary hypertension. Given the presence of pulmonary hypertension, valvular pathology, and the family’s history of unreliable follow-up, we recommended an operation. A plan was implemented to follow the aortic regurgitation annually with an echocardiography.

Myocardial strain on admission predicts disease severity in infants hospitalized for bronchiolitis.

To assess cardiac function in infants with bronchiolitis and the association with disease severity and outcomes. Cardiac function may be impaired in bronchiolitis and represent an early predictor of disease severity. A prospective cohort study. Infants with suspected bronchiolitis were included. All cases received antigen detection and viral genome detection from nasal lavage or swabs and echocardiography within 24 hours from admission. Systolic and diastolic function in left ventricle (LV) and right ventricle (RV) were assessed using longitudinal strain (LS), a measure of myocardial deformation. Pulmonary artery pressures were estimated using tricuspid regurgitation jet (TR), when present, and end-systolic eccentricity index (EI ES). Main outcomes (duration of respiratory support, length of stay [LOS], and type of respiratory support) were collected. Data were compared to normative existing data, and a group of healthy infants, matched in age. Twenty-eight infants with bronchiolitis and 10 healthy comparators were included. Cases with bronchiolitis showed significantly lower values of RV LS and LV LS compared to healthy comparators (LV: p0.04 and RV: P < .001). Ten infants (36%) had a normal biventricular function, nine (32%) had LV impairment, and nine (32%) had a biventricular impairment. No significant differences were found in TR and EI ES. Infants with biventricular impairment demonstrated a significant increase in LOS (p0.04) and higher levels of respiratory support compared to the healthy comparators (P = .03). Bronchiolitis is associated with myocardial impairment. Cardiac function is related to disease severity and outcome.

Association of increased arterial stiffness with diastolic dysfunction in ischemic stroke patients: the Norwegian Stroke in the Young Study.

Young and middle-aged ischemic stroke survivors have a high prevalence of hypertension, increased arterial stiffness and abnormal left ventricular (LV) geometry, which all are associated with the presence of LV diastolic dysfunction. However, the prevalence and covariates of diastolic dysfunction in these patients have not been reported. To explore diastolic dysfunction in ischemic stroke patients aged 15-60 years included in the Norwegian Stroke in the Young Study. Data from 260 patients with acute ischemic stroke was analyzed. Diastolic dysfunction was assessed by combining transmitral peak early flow (E), early diastolic mitral annular velocity (e'), E/e' ratio, left atrial volume index and peak tricuspid regurgitant jet velocity, following current European guidelines. Carotid-femoral pulse wave velocity at least 10 m/s by aplanation tonometry was defined as increased arterial stiffness. Prevalent diastolic dysfunction was found in 20% of patients (13% with diastolic dysfunction grade 1 and 7% with diastolic dysfunction grades 2-3). Patients with diastolic dysfunction were older and more likely to have hypertension, overweight, increased arterial stiffness, higher LV mass and less percentage nightly reduction in mean blood pressure (BP) (all P < 0.001). In a multivariable logistic regression analysis, diastolic dysfunction was associated with increased arterial stiffness [odds ratio 2.86 (95% confidence interval 1.05-7.79), P < 0.05] independent of age more than 45 years, overweight, hypertension, night-time BP reduction and LV mass. Among young and middle-aged ischemic stroke survivors, diastolic dysfunction was found in 20%. The presence of diastolic dysfunction was associated with increased arterial stiffness independent of higher age, overweight, hypertension, night-time BP reduction and LV mass.

Myocardial strain in newborn infants with tracheomalacia due to vascular rings, a pilot study

Background Vascular rings (VR) may cause severe tracheomalacia and upper airway obstruction (UAO). Increased pulmonary artery pressure and cardiac dysfunction have been described in patients with chronic UAO, but has not been investigated in infants with obstruction associated with VR. The aim of this study is to evaluate myocardial strain in infants with UAO due to VR. Method Demographic characteristics, respiratory symptoms, percentage of tracheal obstruction measured and classified using Computer Tomography, and lung function testing (LFT) were collected. Left (LV) and right ventricle (RV) systolic functions were measured using speckle tracking echocardiography longitudinal strain analysis (LS). Pulmonary artery pressure was evaluated using maximal tricuspid regurgitation jet velocity (TR) and LV end-systolic eccentricity index (EI). Results Fifteen cases were included in the study, six had mild tracheal obstruction (<50%), nine moderate-severe obstruction (≥50%). LV LS and RV LS were significantly reduced in cases with moderate to severe airway obstruction cases compared to those with mild airway obstruction (LV LS −15.9 versus −19.9%; RV LS −15.7 versus −20.5%, p = .04 and p = .02, respectively). Respiratory symptoms were more pronounced in moderate-severe cases. No significant differences in TR, EI, and LFT were observed. Conclusions In cases of VR with severe tracheomalacia RV and LV myocardial strain is reduced, suggesting secondary cardiac dysfunction.

Distinct pressure half-time values by transthoracic echocardiography for grading of paravalvular regurgitation after transcatheter aortic valve replacement

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = −0.293; p = 0.138) than in patients without LVH (r = −0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.

Left atrial dysfunction in sickle cell anemia is associated with diffuse myocardial fibrosis, increased right ventricular pressure and reduced exercise capacity

Increased extracellular volume (ECV) by CMR is a marker of interstitial myocardial fibrosis and is associated with diastolic dysfunction in sickle cell anemia (SCA). Left atrial (LA) dysfunction and stiffness contribute to the development of diastolic heart failure in other settings. We aimed to evaluate LA function and stiffness associations with ECV, tricuspid regurgitation jet velocity (TRV) and exercise abnormalities in SCA. In a prospective study, individuals with SCA underwent CMR, echocardiography and exercise test. ECV was measured using MOLLI sequence. Atrial strain was studied in the 4- and 2-chamber views. LA stiffness was calculated as the ratio of echocardiographic E/e’-to-LA reservoir strain. Twenty-four participants with SCA were included (median age 20 years). ECV was increased in participant with SCA compared to our lab normal values (mean 0.44 ± 0.08 vs 0.26 ± 0.02, P < 0.0001). Six (25%) had LA LGE. ECV positively correlated with LA stiffness (r = 0.45, p = 0.04). There was a negative correlation between LA stiffness and %predicted VO2 (r = −0.50, p = 0.04). LA stiffness was moderately associated with increased TRV (r = 0.55, p < 0.005). LA stiffness is associated with ECV, exercise impairment and increased TRV. This study sheds insights on the interaction between LA function, RV hypertension, and myocardial fibrosis in SCA.

Clinical Utility of Echocardiography in Former Preterm Infants with Bronchopulmonary Dysplasia

The clinical utility of echocardiography for the diagnosis of pulmonary vascular disease (PVD) in former preterm infants with bronchopulmonary dysplasia (BPD) is not established. Elevated pulmonary vascular resistance (PVR) rather than pulmonary artery pressure (PAP) is the hallmark of PVD. We evaluated the utility of echocardiography in infants with BPD in diagnosing pulmonary hypertension and PVD (PVR >3 Wood units×m2) assessed by cardiac catheterization. A retrospective single center study of 29 infants born ≤29weeks of gestational age with BPD who underwent cardiac catheterization and echocardiography was performed. PVD was considered present by echocardiography if the tricuspid valve regurgitation jet peak velocity was >2.9m/sec, post-tricuspid valve shunt systolic flow velocity estimated a right ventricular systolic pressure >35mm Hg, or systolic septal flattening was present. The utility (accuracy, sensitivity, and positive predictive value [PPV]) of echocardiography in the diagnosis of PVD was tested. Subgroup analysis in patients without post-tricuspid valve shunts was performed. Echocardiographic estimations of right ventricular pressure, dimensions, function, and pulmonary flow measurements were evaluated for correlation with PVR. The duration between echocardiography and cardiac catheterization was a median of 1day (interquartile range, 1-4days). Accuracy, sensitivity, and PPV of echocardiography in diagnosing PVD were 72%, 90.5%, and 76%, respectively. Accuracy, sensitivity, and PPV increased to 93%, 91.7%, and 100%, respectively, when infants with post-tricuspid valve shunts were excluded. Echocardiography had poor accuracy in estimating the degree of PAP elevation by cardiac catheterization. In infants without post-tricuspid valve shunts, there was moderate to good correlation between indexed PVR and right ventricular myocardial performance index (rho=0.89, P=.005), systolic to diastolic time index (0.84, P<.001), right to left ventricular diameter ratio at end systole (0.66, P=.003), and pulmonary artery acceleration time (0.48, P=.05). Echocardiography performs well in screening for PVD in infants with BPD and may be diagnostic in the absence of a post-tricuspid valve shunt. However, cardiac catheterization is needed to assess the degree of PAP elevation and PVR. The diagnostic utility of echocardiographic measurements that correlate with PVR should be evaluated prospectively in this patient population.

Successful catheter ablation of persistent atrial fibrillation is associated with improvement in functional tricuspid regurgitation and right heart reverse remodeling.

Atrial fibrillation (AF) is a common disease that changes cardiac morphology, especially in the left atrium (LA). It is now known that certain categories of functional mitral regurgitation (MR) are associated with AF; however, the influence of AF on right cardiac morphology is not fully understood. Our aim in this study was to investigate the association between AF and right cardiac morphology. This was a retrospective cohort study of 86 patients with persistent AF without other cardiac disease who underwent catheter ablation (CA). Seventy-one patients had sustained sinus rhythm (SR) (SR Group) and 15 patients had sustained AF (AF Group) during the study period. We compared the changes in the right cardiac dimensions and tricuspid regurgitation (TR) between the groups 12months after CA. Patients' baseline echocardiographic assessments revealed that the LA volume index was significantly smaller in the SR group than in the AF group (46.8 ± 11.9ml/m2 vs 59.3 ± 12.8ml/m2, respectively; p < 0.01). Comparing baseline data with the 12-month follow-up data, in the SR group, right atrial area (RAA, cm2), tricuspid annular diameter (mm), and tricuspid regurgitant jet area (cm2) were significantly decreased compared with the AF group (19.5 ± 4.5-15.5 ± 3.6 vs 20.7 ± 3.6-19.7 ± 2.3; 30.5 ± 4.9-26.4 ± 3.9 vs 28.7 ± 4.0-28.8 ± 3.1; and 1.4 [interquartile range (IQR) 0.7-2.6]-0.6 [IQR 0.2-1.2] vs 1.2 [IQR 1.1-1.5]-0.9 [IQR 0.4-1.3], respectively). On multivariate analysis, change in RAA correlated with the reduction in tricuspid regurgitant jet area (R = 0.51, p < 0.001). In conclusion, successful CA for persistent AF led to right heart reverse remodeling, and our findings suggested that persistent AF was associated with RAA dilatation and TR.

P228 Mitral valve aneurysm in the context of post-infective endocarditis in hypertrophic cardiomyopathy: an issue of inflammation or pressure gradients?

Abstract Mitral valve aneurysms (MVA) are uncommon and usually develop acutely in the setting of infective endocarditis (IE). We present a case report of a patient with a ruptured aneurysm of the mitral valve (MV) leaflet and obstructive hypertrophic cardiomyopathy (HCM), previously treated for IE. Echocardiography is essential for diagnosis, highlighting the importance of imaging for early identification and timely intervention. CASE REPORT 68-year-old male patient with type 2 diabetes mellitus and dyslipidemia was admitted to hospital with a 3-week history of malaise, fever and recent left-sided abdominal pain. No past relevant history. Physical examination revealed a grade II/VI systolic heart murmur at the cardiac apex, fever, abdominal tenderness in the left upper quadrant and purpuric lesions in the inferior limbs. Neutrophilia, CPR 211mg/L. Positive blood cultures for Staphylococcus aureus methicillin-sensitive. Spleen embolization, with no abcess on abdominal CT. Transthoracic (TTE) and transesophageal echocardiography (TEE) disclosed a highly mobile polypoid mass in the atrial side of the anterior MV leaflet, septal left ventricular hypertrophy and systolic anterior motion (SAM) of the MV. Mild mitral regurgitation (MR). No evidence of abcess, aneurysm or valve perforation. The diagnosis of IE was established and the patient completed 42 days of Flucloxaciline. Favorable clinical evolution, residual lesions on the MV. TTE and TEE were repeated on follow-up. Besides HCM and SAM of the MV, an aneurysm of the anterior leaflet of the MV was identified and two regurgitant jets: one due to incomplete coaptation of the leaflets; other through the perforated aneurysm. Mild global MR. A strategy of close follow-up was adopted. Beta blocker dose was increased. Maintenance of the characteristics of the aneurysm. DISCUSSION MVA are rare, with perforation and significant MR development as the most serious complications. They mostly develop in the acute setting of IE of the aortic valve (AV), due to the "jet lesion" from the regurgitant jet or direct extension of the infection. In this case, MVA developed as a late complication of IE of the MV. Previous infection and inflammation lead to increased susceptibility of the valve leaflet, with possible persistent chronic inflammation. In the setting of obstructive HCM, the lesioned endothelium is exposed to significant intraventricular pressure gradients, which have probably raised its propensity to bulge towards the atrium, resulting in aneurysm formation and perforation. Optimal approach to MVA has not been defined. If the setting of perforation with severe MR, surgery must be performed in order to avoid a fatal outcome. In small aneurysms with mild MR, a conservative approach seems reasonable. The purpose of this case is to highlight potential complications of IE, which should be actively investigated, with echocardiography playing a central role in the diagnosis and follow-up.

P1693 Mitral valve aneurysm complicating infective endocarditis

Abstract Funding Acknowledgements Nothing to disclose Background Mitral valve aneurysm is an uncommon sequelae of infective endocarditis (IE), early diagnosis and timely intervention is of paramount importance to prevent aneurysm rupture and hemodynamic deterioration. Clinical presentation A 25-years old gentleman with no known past medical history, presented with a history of unexplained fever for the past month partially responding to antipyretics along with exertional dyspnea. On examination he had a blood pressure of 120/80 mmHg, a heart rate of 110 bpm, a temperature of 39oC, a harsh pansystolic murmur over the apex and early diastolic murmur over the second aortic area. Laboratory results revealed anaemia, leukocytosis elevated ESR and CRP and blood cultures were positive for streptococcus viridians. Electrocardiography showed sinus tachycardia. Methods and results Trans-Thoracic Echocardiography (TTE) revealed the presence of an echolucent cavity measured 1.6x1.6 cm overlying a perforation of the anterior mitral valve leaflet (AML) a long with two small vegetations attached to the AML at the perforation edge, largest measures 0.8cm. There was a severe mitral valve regurgitation. The aortic valve is thickened trileaflet with lack of diastolic cooptation and evidence of severe regurgitation. The left ventricle dimensions were dilated and function was reduced, estimated LVEF = 50%. 3DTrans-esophageal Echocardiography(TEE) was done for better visualization of the mitral valve. The cavity involved A2 scallop, it was perforated and communicating with the LA with an additional regurgitation jet. The aortic valve showed no detectable masses or abscesses. Accordingly, patient was diagnosed with infective enfocarditis complicated with AML perforation and aneurysm formation, anti-biotics were commenced and patient was referred for double valve replacement. Discussion Mitral valve aneurysm most commonly occurs secondary to infective endocarditis of the aortic valve, while our patient does not demonstrate evidence of vegetations at the aortic valve but he had an unhealthy valve with severe regurgitation jet that hits AML and might by a cause of hit lesion at the AML and eventually complicated by aneurysm formation. Discussion Echocardiography is a crucial imaging modality in patient with long standing fever and underlying valvular heart disease to rule out infective endocarditis. 3D-TEE is of added value along with TTE in better definition of vegetations, detection of infective endocarditis complication and it has a crucial role in proper diagnosis and surgical planning for better clinical outcomes. Abstract P1693 Figure. Mitral valve aneurysm

P835 Mitral valve abscess complicating infective endocarditis

Abstract Funding Acknowledgements n/a Background Health care associated infective endocarditis (HAIE) accounted for u to 30% of infective endocarditis (IE) cases, it tends to affect patients with a poor clinical condition and represents a considerable in-hospital mortality. Case A 75-years old gentleman with end-stage renal failure secondary to polycystic kidney disease had commenced hemodialysis via a tunneled hemodialysis catheter 3 months ago, presented for pre-operative evaluation before vascular surgery for acute left lower limb ischemia, patient gave history of fever for the past month partially responding to antipyretics along with recent ischemic cerebrovascular stroke with no residual neurological deficits. On examination he had a blood pressure of 110/70 mmHg, a heart rate of 100 bpm, a temperature of 38oC, and a harsh pansystolic murmur over the apex. Laboratory results revealed leukocytosis elevated CRP and blood cultures were positive for staphylococcus aureus. Electrocardiography showed sinus tachycardia. Methods and Results 2D-Trans-Thoracic Echocardiography (TTE) revealed the presence of echogenic rounded mobile mass measured 2x2 cm attached to the atrial surface of the posterior mitral valve leaflet. There was a severe mitral valve regurgitation and the regurgitant jet was directed anteriorly swirling around the mass. The left ventricle dimensions and function were normal. 2D-Trans-esophageal Echocardiography(TEE) was done for better visualization of the mass and it"s attachment. The mass was overlying the atrial surface of the posterior leaflet middle P2 scallop with a small echo-lucent cavity (abscess formation) in the leaflet in addition to another smaller mass at the atrial surface of the anterior leaflet. The aortic, tricuspid and pulmonary valves were normal in structure and function Discussion Echocardiography is a crucial imaging modality in a patient with multiple systemic emboli to rule out cardio-embolic source of embolization. TEE is of added value along with TTE in better definition of masses and detection of IE related complication. While the patient was prepared for the vascular surgery to secure the ischemic limb his sensorium was disturbed and became unconscious immediate brain computed tomography showed severe intracranial hemorrhage and the patient died. Conclusions Patient with chronic kidney disease and on hemo-dialysis are highly vulnerable to health care related infective endocarditis and high clinical suspicion should be given in a situation of prolonged fever and embolic events. Mitral valve abscess is a rare complication of infective endocarditis and if occurs it leads to increase mortality. TEE should be an integral part of management of patients with IE to role out serious complications. Abstract P835 Figure. Mitral valve infective endocarditis

91 Mitral fracking: an unusual complication of infective endocarditis

Abstract The conglomerate of microorganisms, inflammatory cells, fibrin and platelets that constitutes the characteristic lesion of infectious endocarditis, that is, vegetation, was considered as a major criterion of infectious endocarditis in the 90s thanks to the development of ultrasound. Ecocardiography allows the diagnosis of complications derived from the infection, such as valvular perforation, prosthetic dehiscence, fistula or abscesses. One of the most infrequent complications is the mitral pseudoaneurysm. It has its origin in the impact of a jet of aortic regurgitation on the anterior leaflet of the mitral valve, which is why we have called it mitral fracking. A 60-year-old man who had a recent history of pneumonia and for whom he was still receiving antibiotic treatment, debuted suddenly with dyspnea of minimal effort. He went to a cardiology clinic where he was found to have severe mitral regurgitation. He was directly derived to cardiac surgery of our hospital. Prior to the intervention, a transesophageal ultrasound study was performed in our department, which showed the following findings: a bicuspid aortic valve with a small vegetation on its aortic surface (Figure A, surgical piece), a protuberance on the anterior mitral leaflet (Figure B) with internal flow that caused systolic expansion towards the atrium (Figure C) and diastolic collapse towards the ventricle (figure D): the mitral pseudoaneurysm. The therapeutic action was based on the replacement of both valves with mechanical prostheses. The blood cultures were negative, but the surgical piece revealed unequivocal histological findings of infectious endocarditis. Currently, the patient is stable and the valves are normofunctional in the regular follow-up controls. Abstract 91 Figure.

552 Natural history of bivalvular functional regurgitation

Abstract Introduction Bivalvular functional regurgitation (BVFR) defined as concomitant mitral and tricuspid insufficiency has not been described or systematically assessed before. The present study therefore sought to define incidence, impact and natural history of BVFR in heart failure with reduced ejection fraction (HFrEF) to provide the foundation for risk assessment and directions for potential treatment strategies. Methods We enrolled 1021 consecutive patients with HFrEF under guideline-directed medical therapy and performed comprehensive echocardiographic and neurohumoral profiling. Mitral and tricuspid regurgitation was quantified by an integrated approach comprising valve morphology, width of the proximal regurgitant jet, proximal flow convergence, and pulmonary venous flow. All-cause mortality during a five-year follow up served as the primary endpoint. Results Thirty percent of patients suffered from moderate or severe BVFR. Long-term mortality increased with the presence and severity of FR with severe BVFR representing the highest risk-subset (P &amp;lt; 0.001). Severe BVFR patients were more symptomatic and displayed an adverse remodeling and neurohumoral activation pattern (all P &amp;lt; 0.05). Severe BVFR was associated with excess mortality (Figurel 1, Panel A) independently of clinical (adj.HR 1.52, 95%CI 1.39-1.84;P &amp;lt; 0.001) and echocardiographic (adj.HR 1.31, 95%CI 1.11-1.54;P = 0.001) confounders, guideline-directed medical therapy (adj. HR 1.55, 95%CI 1.35-1.79;P &amp;lt; 0.001) and neurohumoral activation (adj.HR 1.31, 95%CI 1.07-1.59;P = 0.009). Moderate BVFR (n = 99) comprised equal baseline characteristics and similar risk as isolated severe FR. (Figure 1, Panel B) (HR 0.95, 95%CI 0.69-1.30;P = 0.73). Conclusion This long-term outcome study shows the multi-faceted nature of FR and defines BVFR as an important clinical entity associated with impaired functional class, adverse cardiac remodeling and excess risk of mortality. Moderate BVFR conveys similar risk as isolated severe FR reflecting the deleterious impact of the global regurgitant load on the failing heart and the need of an integrated understanding for risk-assessment. Abstract 552 Figure 1 (Panel A and B)

P627 Step by step valve destruction in infective endocarditis with no apparent vegetations

Abstract Background Infective endocarditis can present without evident vegetation, diagnosis is challenging and prognosis very poor. We present an illustrative case where natural evolution of the mitral valve destruction with no evident vegetations was followed with frequent consecutive transthoracic (TTE) and transesophageal echocardiography (TOE). Case presentation 71-year old male with known dilated cardiomyopathy presented with dyspnoea, ankle swelling and severe kidney failure with hyperkalemia. During short hospitalization he was recompensated with haemodialysis, parenteral diuretics and inotropes. TTE showed dilated left ventricle with severe systolic dysfunction and no evidence of valvular disease. Few days after discharge he was readmitted with malaise and febrile state with no obvious site of infection. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated immediately. Weekly TTEs and TOEs were performed (Figure 1, column A-D): Week 1: TTE was performed due to congestive heart failure. There was no suspicion on disease and TTE showed no obvious mitral valve pathology. Week 3: Second TTE showed only light thickening of posterior mitral leaflet with mild mitral regurgitation. Week 4: Follow-up TOE was performed showing posterior leaflet discontinuity with small eccentric regurgitation jet and no vegetation. Week 6: Symptoms of congestive heart failure persisted despite antibiotic treatment. A progressive destruction of posterior leaflet with evident perforation of P1 scallop and consequent severe mitral regurgitation. Patient was referred for urgent mitral valve replacement. Conclusions Staphylococcus aureus is a destructive pathogen and can cause severe destruction of native valve even without obvious vegetations. This case presents echocardiographic features of natural course of infective endocarditis on mitral valve. Despite antibiotic therapy progressive valve destruction is possible. Abstract P627 Figure.

P670 RV function in adult patients with repaired tetralogy of Fallot: assessment by three-dimensional echocardiography, comparison to CMR findings and relationship to pulmonary artery distensibility

Abstract Purpose The purpose of this study was to examine right ventricular (RV) function by three-dimensional speckle-tracking echocardiography (3DSTE) in patients after correction of tetralogy of Fallot (TF), the accuracy of 3DSTE compared to cardiovascular magnetic resonance (CMR) findings and assess pulmonary arterial (PA) distensibility in order to achieve a more comprehensive understanding of the matching between RV performance and PA load. Methods Twenty-one patients (mean age 39 ± 16 years) with repaired TF and twenty-one age-matched healthy subjects selected as controls were studied. CMR findings were available in 14 patients. RV volumes, RV ejection fraction (RVEF) and RV longitudinal and circumferential strains were calculated by three-dimensional echocardiography and three-dimensional speckle tracking echocardiography. The main pulmonary artery was interrogated by color, pulsed, and continuous-wave Doppler. Pulmonary regurgitation (PR) was assessed by color-flow mapping and graded as none, mild, or greater than mild using the measurement of the regurgitant jet width in relation to the outflow tract diameter. Right pulmonary artery (PA) was visualized from suprasternal view by two-dimensional echocardiography. Tissue Doppler Imaging (TDI) mode was activated in B-mode imaging to examine arterial motion, then mode was changed to color-mode with the beam line aligned perpendicular to the superior and inferior walls of the right PA. PA distensibility and strain were determined. Data analysis was performed offline. Results Overall, 3D RVEF and RV longitudinal strain were reduced in TF patients compared to the control group. Nine patients had moderate or moderate-to-severe PR. PA strain and distensibility were decreased (p = 0.003) compared with controls, both in the presence and absence of PR. PA strain had a positive correlation with RVEF (r = 0.79, p &amp;lt; 0.005) and RV strain (r = 0.82, p &amp;lt; 0.001). RV end-diastolic and end-systolic volumes by 3DE correlated with the respective parameters by CMR (r = 0.88,p &amp;lt; 0.001 and r = 0.87,p &amp;lt; 0.005 respectively). Patients with moderate-to-severe PR had more prominent PA strain changes (p = 0.02). Conclusions Three-dimensional right ventricular ejection fraction and RV strain are impaired in patients with repaired TF, in agreement with CMR data. Reduced PA strain is associated with reduced RV 3DSTE parameters and is more pronounced in the presence of pulmonary regurgitation.

503 Unlocking the mystery of haemolytic anaemia after mitral valve repair

Abstract Hemolytic anemia is an uncommon complication after mitral valve repair. All possible causes should be excluded before making a diagnosis. Echocardiography is an important tool. Transthoracic echocardiography may underestimate the severity and direction of regurgitation jets. Transesophageal echocardiography is the helpful imaging modality helping identify an accurate mechanism. A 55-year-old female with a history of mitral valve repair 5 years earlier presented with shortness of breath for 2 months. She noticed that she had intermittent jaundice and dark urine for 5 months but these symptoms were worsening and persistent for 2 months. She had no fever and abdominal pain. She did not take any medication. The physical examination revealed mark pale conjunctiva and icteric sclera. The apex of heart was palpated at 6th intercostal space lateral to the midclavicular line. The pan-systolic murmur was audible along the mitral valve area. The lung was clear and no pedal edema. Her complete blood count showed hematocrit of 13% with fragmented red blood cell and polychromasia in a blood smear. The level of aspartate transaminase, direct bilirubin, and lactate dehydrogenase was elevated with low haptoglobin level. A chest X-ray showed cardiomegaly without pulmonary edema. The diagnosis of autoimmune hemolytic anemia was made but her symptom was not improved after corticosteroid treatment. Transthoracic echocardiography cannot explain the cause of hemolytic anemia, so the transesophageal echocardiography was performed. The echocardiography revealed severe mitral regurgitation and paravalvular leak. The turbulent flow was seen across the mitral annuloplasty ring. She underwent mitral valve replacement to treat her symptoms. After an operation, her symptoms were significantly improved without any jaundice. The hemolytic anemia was resolved. This case demonstrated an important role of transesophageal echocardiography, especially in post heart valve surgery patient. Although hemolytic anemia after mitral valve surgery is rare, it should be considered in every hemolytic anemia patient without other explainable causes. An accurate diagnosis is a crucial role in treatment. Abstract 503 Figure.