Septal Bulge Research Articles

Comparative Evaluation of Alcohol Septal Ablation: Left Anterior Descending Versus Non-left Anterior Descending Artery Approaches

Alcohol septal ablation (ASA) is performed for symptomatic drug-refractory hypertrophic obstructive cardiomyopathy to reduce the left ventricular outflow tract pressure gradient (LVOTPG) by injecting ethanol into a septal branch that perforates the septal bulge. The target septal branches usually arise directly from the left anterior descending (LAD) artery; however, vessels from a non-LAD artery can be selected in some cases. This study aimed to compare effectiveness and safety between ASA performed using a septal branch arising from a non-LAD artery and a branch arising from the LAD artery. This single-center, retrospective, observational cohort study comprised patients with hypertrophic obstructive cardiomyopathy who underwent ASA at the Gifu Heart Centre between 2011 and 2022. The effectiveness and safety of ASA using the 2 artery types were compared. The primary endpoints were LVOTPG and procedure success, determined as LVOTPG <30 mmHg after 1 year. Of 33 patients (mean age: 66.4 ± 13.0 years; 13 males), 18 patients who underwent ASA using only LAD branches and 15 patients who underwent ASA using only non-LAD branches demonstrated no significant difference in the decrease in LVOTPG during the follow-up period (−99.1 ± 47.4 mmHg/year vs. −75.7 ± 39.2 mmHg/year, respectively, P = 0.19). The procedure success at 1 year was not significantly different between the 2 groups (93.3% and 84.6%, respectively, P = 0.58). ASA performed using septal branches from non-LAD arteries could be an alternative treatment approach when appropriate septal branches are missing or desirable effects cannot be obtained from ASA using LAD branches.

Ratio of left ventricular outflow tract area to aortic annulus area and complete atrioventricular block after transcatheter aortic valve replacement for aortic stenosis

BackgroundMechanical compression of cardiac conduction system by transcatheter heart valves leads to complete atrioventricular block (CAVB) after transcatheter aortic valve replacement (TAVR). Bulging of ventricular septum in the left ventricular outflow tract (LVOT) may be associated with greater compression of conduction system, leading to irreversible CAVB. ObjectiveThis study aimed to investigate the association of ventricular septal bulging with TAVR-related CAVB and permanent pacemaker implantation (PPI). MethodsAmong 294 consecutive patients with severe aortic stenosis who underwent TAVR between July 2017 and February 2023, 271 were included in the analysis. As a quantitative evaluation of bulging of the ventricular septum, the ratio of LVOT area to aortic annulus area (L/A ratio) was measured at the systolic phase of computed tomography images. ResultsTAVR-related CAVB occurred in 64 patients (23.6%). Twenty-eight patients (10.3%) required PPI. The optimal thresholds of L/A ratio for predicting TAVR-related CAVB and PPI were 1.0181 and 0.985, respectively. Patients with less than the cut-off values had higher rate of TAVR-related CAVB and PPI than those above (28.3% vs 13.1%, p = 0.0063; 14.7% vs 4.4%, p = 0.0077, respectively). A multivariate analysis showed that L/A ratio < 1.0181 was an independent predictor of TAVR-related CAVB (odds ratio [OR] 2.65, p = 0.011), in addition to prior right bundle branch block (OR 3.76, p = 0.0005), use of a self-expanding valve (OR 1.99, p = 0.030), and short membranous septum length (OR 0.96, p = 0.037). Only L/A ratio < 0.985 was independently associated with PPI (OR 3.70, p = 0.011). ConclusionLow L/A ratio is a predictor of TAVR-related CAVB and PPI.

Isolated discrete upper septal thickening in a non-referral cat population of senior and young cats

Introduction/objectivesDiscrete upper septal thickening (DUST) is a phenotype of elderly people. The cardiac phenotype in senior cats has been incompletely described. We aimed to characterize the echocardiographic phenotype of senior cats, specifically to determine prevalence of DUST and hypertrophic cardiomyopathy (HCM). AnimalsOne hundred and forty-nine healthy, normotensive cats. Materials and methodsProspective cross-sectional study. Senior (≥9 years) and young (<6 years) cats were recruited from non-referral population. We defined DUST as an isolated basilar septal bulge, and HCM as left ventricular wall thickness ≥6 mm. An interventricular septum ratio (basal-to-mid septal thickness ratio) was calculated. We assessed for associations between clinical and echocardiographic variables and DUST. Data are presented as mean (±SD), median (range), or frequency (percentage). ResultsOne-hundred and two senior and 47 young cats were enrolled. Aortoseptal angle (AoSA) was steeper in senior cats (137° (±14.5) vs. 145° (±12.3) in young cats, P=0.002). Eighteen cats had DUST (18/149, 12%), fourteen senior, and four young cats (P=0.4). Cats with DUST had steeper AoSA (125° (±8.3) vs. 142° (±13.7), P<0.0001) and higher interventricular septum ratio (1.4 (1.2–2.0) vs. 1.0 (0.7–1.8)). Univariable analysis showed decreased odds of DUST with greater AoSA (OR 0.9, P<0.0001), age was not associated with DUST. Twenty-nine senior cats had HCM (28.4%). Discussion/conclusionsPrevalence of DUST was 12%. There was no association between age and DUST. Smaller/steeper AoSA was the main factor associated with DUST. There was a high prevalence of HCM in this senior population.

Is Congenital Muscular Mitral-Aortic Discontinuity Another Feature of Obstructive Hypertrophic Cardiomyopathy? A Pathology Validation Study

Hypertrophic cardiomyopathy (HCM) is an inherited myocardial disease at risk of sudden cardiac death and heart failure, even requiring heart transplantation. A “muscular mitral-aortic discontinuity” has been reported during surgery in the obstructive form. We aimed to validate these findings through pathological analysis of HCM heart specimens from the cardiovascular pathology tissue registry. Hearts with septal asymmetric HCM from sudden cardiac death, other causes of death, or heart transplantation were included. Sex-matched and age-matched patients without HCM served as controls. Gross and histologic analysis of the mitral valve (MV) apparatus and the mitral-aortic continuity were performed. Thirty HCM hearts (median age, 29.5 years; 15 men) and 30 controls (median age, 30.5 years; 15 men) were studied. In HCM hearts, a septal bulging was present in 80%, an endocardial fibrous plaque in 63%, a thickening of the anterior MV leaflet in 56.7%, and an anomalous insertion of papillary muscle in 10%. All cases but 1 (97%) revealed a myocardial layer overlapping the mitral-aortic fibrous continuity on the posterior side, corresponding to the left atrial myocardium. A negative correlation between the length of this myocardial layer and the age and the anterior MV leaflet length was found. The length did not differ between HCM and controls.Pathologic study of obstructive HCM hearts does not confirm the existence of a "muscular mitral-aortic discontinuity". An extension of left atrial myocardium, overlapping posteriorly the intervalvular fibrosa, is rather visible, and its length decreases with age, possibly as a consequence of left atrial remodeling. Our study highlights the fundamental role of thorough gross examination and the value of organ retention for further analysis in order to validate new surgical and imaging findings.

366 RIGHT HEART FAILURE IN CARCINOID HEART DISEASE: A MULTIDISCIPLINARY APPROACH

Abstract Introduction Carcinoid heart disease occurs in more than 50% of patients with neuroendocrine gastrointestinal tumors, and it is the initial presentation of carcinoid syndrome in up to 20% of patients. The disease is characterized by pathognomonic plaque-like deposits of fibrous tissue in the endocardium of valvular cusps, cardiac chambers, and occasionally, the intima of the pulmonary arteries or aorta. The tricuspid and the pulmonary valve are most often affected by carcinoid disease, with several combinations of valve dysfunction (usually pulmonic stenosis + tricuspid regurgitation). Valvular dysfunction can lead to peripheral edema, ascites and right-sided heart failure, extreme cases may present with low cardiac output syndrome. Valve surgery may relieve symptoms and it should be considered in patients with controlled neoplasia. Case report a 47-years-old man with a history of operated neuroendocrine gastrointestinal tumor (ileal resection+right hemicolectomy+mesenteric lymphadenectomy) was admitted to our department for right heart failure. His clinical examination was remarkable for ankle swelling, flushing, liver congestion, ascites; moreover the patient reported progressive compromise of functional capacity and weight loss due to anorexia. Laboratory findings were in the normal range except for BNP 184 pg/ml (UNL &amp;lt;100 pg/dl). ECG: sinus rhythm 80 bpm, diffuse repolarization abnomarlities. Transthoracic echocardiography showed: severe right chambers remodeling with RV+RA dilatation associated with systo-diastolic septal bulge (pressure + volume overload), torrential tricuspid regurgitation (secondary to fibrotic retraction of valve leaflets and severe coaptation deficiency with apical tethering), moderate-to-severe pulmonic regurgitation associated with valve stenosis; on the left side: mitral and aortic valves were normal, there was mild reduction of left ventricle ejection fraction secondary to ventricular interdipendence. The patient was discussed in Heart Team: right sided valves were both considered responsible for patient's symptoms, so he was scheduled for surgical intervention after achieving adeguate haemodinamic stability. Pre-surgery right catetherization showed normal pulmonary pressures. Coronary arteries were normal. Before, during and after surgery he was treated with octreotide to reduce the risk of Carcinoid Crisis in the perioperative period. The patient underwent surgical replacement of tricuspid and pulmonary valves with biological prosthesis Mosaic n°33 and Avalus n°23 respectively. Histological examination of the valves showed extensive deposits of fibrous tissue in the valvular endocardium. Post-surgical hospital stay was uneventful, the patient was discharged 14 days after surgery on normal sinus rhythm and in good clinical conditions. In order to prevent thromboembolic events anticoagulant therapy with Warfarin was introduced. Conclusion this is the report of a rare cardiac condition responsible for right heart failure symptoms. Heart Team discussion and multidisciplinary approach involving surgeons and oncologist are mandatory in order to establish the best treatment strategy and timing for interventions. However, since this is a rare condition, more evidence is needed to better understand long term clinical outcomes and treatment options (including future percutaneous perspectives).

Abstract P2021: Blockade Or Deletion Of The Thromboxane/Prostanoid Receptor Reduces Right Ventricular Stiffness To Maintain Function In Right Ventricular Pressure Overload

The increased afterload of pulmonary arterial hypertension (PAH) impairs right ventricular function, as the RV struggles to adapt to increased pressure with remodeling and fibrosis. RV failure is the primary cause of death in PAH, and a frequent cause of death in pulmonary hypertension secondary to pulmonary embolism, emphysema, pulmonary fibrosis, and left-heart failure. There is currently no RV-specific therapeutic to maintain function and prolong patient life. During PAH, cardiomyocytes upregulate cell-surface expression of the G αq /IP 3 -coupled thromboxane/prostanoid receptor (TPr), which is activated by multiple endogenous ligands increased in PAH, and leads to calcium influx. TPr activation is also pro-fibrotic in multiple cell types and models. Previous studies have shown reduced fibrosis following TPr antagonism in mouse models of short-term pulmonary hypertension; however this effect has been variable in long-term studies. To more precisely determine the functional effects of TPr activation in RV pressure overload, we used pulmonary arterial banding (PAB) for a direct, sustained increase in pressure, antagonism or deletion of the TPr, and murine cardiac MRI for simultaneous evaluation of the RV and LV. TPr antagonism in a long-term PAB model improved RV ejection fraction and restored LV volume and output by preventing septal bulging and LV eccentricity. This occurred with even short-term antagonism, and was associated with decreased fibrosis in the septum and RV insertion points. Similar results were seen following PAB of universal or cardiomyocyte-specific TPr knockout mice; in all cases, decreasing TPr activation during RV pressure overload reduced RV stiffness even when RV fibrosis remained unchanged. In long-term pressure overload, the improved compliance with antagonism normalized expression of Yap/Taz-associated genes. These results suggest that TPr activation contributes to cardiomyocyte mechanotransduction and deleterious remodeling in response to the RV pressure overload of pulmonary hypertension, and that antagonism of the TPr may preserve RV function to prolong life in PAH patients.

Specific deformation pattern in hypertensive patients with septal bulge and preserved systolic function.

A wide range of subclinical changes in left ventricular (LV) geometry and function can be observed, even in the early course of arterial hypertension (HTN). Aim of the study was to investigate if the appearance of isolated basal septal hypertrophy (BSH, septal bulge) in asymptomatic young and middle-aged adults with HTN could be a marker of incipient LV systolic dysfunction when other measures of global LV function are still normal. A total of 138 patients with primary arterial hypertension, aged less than 65years, with no comorbidities and with preserved LV ejection fraction (EF) were included. Complete 2D transthoracic echocardiography study was preformed according to standardized protocol, as well as deformation study using speckle tracking echocardiography. Global and regional longitudinal strain was measured in apical 4-, 2- and 3-chamber views according to 18-segments model. Global and regional circumferential and radial strains were measured in short axis view. Average was taken from each of the six basal, middle and apical LV segments. Patients were divided into two groups according to BSH presence and values were compared. Basal septal hypertrophy was found in half of the patients (53.6%). The whole cohort had altogether normal LV global systolic function, as well as global indices of radial strain (GRS 43.86 ± 10.75%) and longitudinal strain (GLS - 19.73 ± 2.19%), while global circumferential strain (GCS) was mildly reduced (GCS - 19.5 ± 2.81%). BSH patients had more expressed LV geometry changes (LV mass: 89.19 ± 24.59g/m2 vs 109.15 ± 25.33g/m2, p < 0.001; relative wall thickness: 0.3 ± 0.08 vs 0.38 ± 0.11, p < 0.001) and also revealed a specific pattern of longitudinal deformation impairment in three LV segments (basal and mid interventricular septum, basal anteroseptum). "Strain gradient" from LV base to apex (basal < mid < apical) was observed in the whole population for longitudinal and circumferential strain, and it was more pronounced in the BSH group. This group had more impaired basal LS, while apical CS was improved. Subendocardial longitudinal strain was also more impaired in the BSH group. This study brings new meaning to basal septal hypertrophy (BSH) occurrence in hypertensive patients with discrete global concentric remodeling. Regional systolic dysfunction of the basal and mid LV segments is found, while apical segments increase in deformation. This specific "strain gradient" pattern was found to be more pronounced in patients with BSH. The recognition of BHS in apparently healthy hypertensive patients with no impairment in global systolic function may suggest latent target organ damage with regional impairment of systolic function and the need to imply more aggressive treatment approach.

STRESSED HEART MORPHOLOGY AND NEUROLOGIC STRESS SCORE EFFECT BEYOND HEMODYNAMIC STRESS ON FOCAL GEOMETRY

Objective: Recent work have emphasized the importance of adaptive cardiac emodelling (Plos One, IJCCRP, Am J Cardiovasc Dis., 2021). In addition to hemodynamic stress in hypertension, novel cardiac imaging have shown that stressed heart morphology (SHM: basal septal hypertrophy, the early imaging biomarker in hypertension, J Applied Physiol 2019) could be affected by emotional stress and aortic stenosis (B Press Monitor 2020, ATCS 2021). Design and method: The aim of the study was to explore the potential effect of chronic emotional and mental overdrive in addition to chronic hemodynamic stress due to chronic hypertension. Therefore, we planned to determine imaging data as well as neurologic stress scores in SHM and compare them in terms of geometric details and severity of stress scores. Results: SHM was diagnosed in 50 chronic patients with systemic hypertension using the universal criteria (thicker than 1.4 cm septal base on the parasternal long axis). Then, we decided to detect quantitative scores of neurologic stress for all patients of the study group. The patients with SHM with irregular septal basal emodelling with septal bulging were associated with high neurologic stress score, while the other SHM patients with regular emodelling had lower score (p &lt; 0.05). Conclusions: SHM seems like a quite complex phenomenon which possibly affected by emotional and mental overdrive beyond pure hemodynamic stress due to hypertension. Complex imaging findings also are consistent with adaptive phase SHM (J Clinic Med 2022, J of Hypertension 2022) showing irregular nature of human SHM which is likely to depend on cognitive function compared to regular emodelling in animals.

PO-717-05 PROPHYLACTIC AND PREVENTIVE RADIOFREQUENCY SEPTAL ABLATION TO REDUCE THE POSSIBILITY OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION POST-MITRAL VALVE REPLACEMENT

The patients who have severe mitral annulus calcification leading severe mitral stenosis often are eldery and have comorbidities which increase surgical risk of stroke, embolization, and bleeding complications. Radiofrequency ablation is another prophylactic and preventive option for reducing the possibility of left ventricular outflow tract obstruction (LVOTO) post-mitral valve replacement patients who are not suitable for surgical myomectomy or alcohol septal ablation. N/A We report on a 78-year-old woman with a history of symptomatic severe mitral valve stenosis with a mean gradient of 20 mmHg. She was not a surgical candidate for mitral valve and preparing for a valve-in-valve percutaneous mitral valve replacement. Computer tomography revealed left ventricular septal bulge appeared to have a significant LVOTO post-valve replacement. However she was not a candidate for surgical myomectomy due to her age and comorbidities, and she also had no anatomical option to consider for alcohol septal ablation. Heart team discussion decided to do radiofrequency ablation (RFA) to reduce the possibility of LVOTO post-valve replacement. RFA was performed in the left ventricular outflow tract (LVOT) using an irrigated-tip ablation catheter; the target site was identified along the LV septal hypertrophy using intracardiac echocardiography (ICE) and electroanatomical CARTO mapping. ICE demonstrated thinning of the ablated regions. The LV electrograms were noted during ablation and the size was decreasing from 0.63 mV to 0.15 mV. After RFA, she underwent minimally invasive open left-atrial transcatheter mitral valve replacement-in-MAC via right minithoracotomy with a 29-mm Edwards Sapien 3 bioprosthetic valve. Transthoracic echocardiography after surgery showed normal left ventricular systolic function with a mean mitral valve pressure gradient of 5.63 mmHg and no paravalvular leakage. The LVOT resting gradient of 17 mmHg. LVOTO could be one of the complications after valve replacement. Radiofrequency septal ablation is a novel prophylactic and preventive procedure in reducing the possibility of the left ventricular outflow tract obstruction post-mitral valve replacement and decreasing the risk of morbid and mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Sex-specific echocardiographic phenotypes in left ventricular outflow tract obstruction

Abstract Funding Acknowledgements Type of funding sources: None. Background Previous studies have reported major sex differences in prevalence, demographics, and timing of intervention in left ventricular outflow tract (LVOT) obstruction. Whether the observed differences are related to LVOT anatomy is less explored. Purpose The aim of this study was to assess the anatomic substrate for LVOT obstruction by echocardiography to identify sex-specific phenotypes. Methods We included 76 patients (37% women) with symptomatic LVOT obstruction referred to a tertiary care centre between 2005-2020 to be considered for septal ablation or myectomy. A standardized echocardiography was extended with systematic measurements of parasternal LVOT dimensions at 5, 10 and 15 mm below the aortic valve, proximal septal thickness at 10, 20 and 30 mm, subaortic septal bulge radius and aortoseptal angle in all patients prior to intervention (Image). Measurements were also adjusted for body surface area (BSA). A total of 3 patients had to be excluded from analysis due to poor image quality. Results Women were older (p &amp;lt; 0.001, Table), while there were no differences in body mass index (27.6 v.s. 27.5, p = ns), systolic and diastolic blood pressure (133 v.s 133 mmHg, p = ns and 75 v.s 80 mmHg, p = ns, respectively), or prevalence of hypertension (24% v.s. 29%, p = n.s). Left ventricular end-diastolic diameter, LVOT diameters and septum thickness measured 30 mm from the aortic valve were lower in women (Table). However, in all these measurements the differences disappeared after adjusting for BSA. There were no sex differences in posterior wall thickness. Furthermore, the aortoseptal angle was steeper among women, and the septum bulge radius smaller, remaining so even after adjustment for BSA(Table). Conclusion In women with LVOT obstruction, the septum bulge radius adjusted for BSA was smaller, and the aortoseptal angle steeper. Our findings suggest that there may be important sex differences in the echocardiographic phenotype in LVOT obstruction. Abstract Table Abstract Figure. Image

Diversity and determinants of the sigmoid septum and its impact on morphology of the outflow tract as revealed using cardiac computed tomography.

The sigmoid septum has been generally evaluated subjectively and qualitatively, without detailed examination of its diversity, impact on the morphology of the left ventricular outflow tract (LVOT), and anatomical background. We enrolled 100 patients without any background cardiac diseases (67.5 ± 12.8 years old; 43% women) who underwent cardiac computed tomography. Basal septal morphology was evaluated using antero-superior and medial bulging angles (bidirectional angulation of the basal septum relative to the LVOT). The eccentricity index of the LVOT, area narrowing ratio (LVOT/virtual basal ring area), aortic-to-left ventricular axial angle (angulation of the aortic root relative to the left ventricle), and wedged height (non-coronary aortic sinus to inferior epicardium distance) were also quantified. The antero-superior bulging, medial bulging, aortic-to-left ventricular axial angles, LVOT eccentricity index, area narrowing ratio, and wedged height were 76° ± 17°, 166° ± 27°, 127° ± 9°, 1.8 ± 0.5, 1.0 ± 0.2, and 41.2 ± 9.1mm, respectively. Both bulging angles were correlated with each other and contributed to the narrowing and deformation of the LVOT. Angulated aortic root was not correlated with either bidirectional septal bulge or LVOT narrowing. Clockwise rotation of the aortic root rotation was an independent predictor of prominent antero-superior septal bulge. Deeper aortic wedging was a common independent predictor of bidirectional septal bulge. The extent of septal bulge varies in normal hearts. Along with deep aortic wedging, the bidirectional bulge of the basal septum deforms and narrows the LVOT without affecting the virtual basal ring morphology.

Systolic anterior motion of the mitral valve associated with acute type A aortic dissection: a case report describing one-step surgery of ascending aortic replacement and interventricular septal myectomy

BackgroundSystolic anterior motion of the mitral valve associated with acute type A aortic dissection is rare in daily clinical practice. The prevention of systolic anterior motion is important, because once it occurs, the hemodynamics may become unstable, leading to a critical situation. In the surgical procedure to treat systolic anterior motion, the prevention of new iatrogenic aortic intimal tears is important in the context of acute type A aortic dissection.Case presentationWe present a case of systolic anterior motion in a 68-year-old woman with an acute type A aortic dissection and suspected acute relative adrenal insufficiency. Preoperative transthoracic echocardiography revealed left ventricular outflow tract obstruction due to systolic anterior motion without left ventricular hypertrophy and interventricular septal bulging due to a narrow aorto-mitral angle. We successfully performed a one-step surgery for ascending aortic replacement and interventricular septal myectomy using the needle stick technique for the treatment of systolic anterior motion.ConclusionsConcomitant interventricular septal myectomy using the needle stick technique with thoracic aortic replacement is a safe and feasible technique. Interventricular septal myectomy may be effective in preventing postoperative unstable hemodynamics due to systolic anterior motion in the management of acute aortic dissection.

Serum Cardiac Biomarkers in Asymptomatic Hemodialysis Patients: Role of Soluble Suppression of Tumorigenicity-2

Introduction: Cardiovascular events (CVE) remain the leading cause of mortality in hemodialysis (HD) patients. The ability to assess the risk of short-term CVE is of great importance. Soluble suppression of tumorogenicity-2 (sST2) is a novel biomarker that better stratifies risk of CVE than troponins in patients with heart failure. Few studies have investigated the role of sST2 in the HD population. The aim of this single-center study was to assess the predictive ability of sST2 on CVE in comparison to high-sensitive cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) in HD patients. Methods: This study used a prospective, observational cohort design. We enrolled 40 chronic HD patients asymptomatic for chest pain and without recent history of acute coronary syndrome. We tested sST2 pre-/post-HD, hs-cTnI, and BNP. Demographic/dialytic/echocardiographic data were evaluated. We recorded the number of CVE for 12 months. The patients were classified into 2 groups: those who developed CVE and those who did not. Results: Ten of the 40 patients (25%) developed CVE during a 12-month follow-up. Increased sST2 levels (p < 0.0001) as well as hs-cTnI and BNP are predictive of CVE. When analyzing biomarkers as binary variables for values above or below the normal range, the correlation remained significant only for sST2 (p = 0.001). A small variation in sST2 levels before and after HD sessions was found (−2.1 ng/mL). sST2 was correlated with left ventricular (LV) echocardiographic data: LV mass index (p = 0.0001), LV ejection fraction (p = 0.01), and diastolic bulging of septum (p = 0.015). BNP and sST2 combination increased the prediction of CVE in a statistical model. Conclusion: Our study confirms that sST2 is useful for stratifying CV risk in the HD population. sST2 can be evaluated simply as a dichotomous value higher or lower than the normal range, making it easily interpretable. Dialysis and residual diuresis did not affect significantly sST2. A multimarker approach that incorporates sST2 and BNP may improve the prediction of CVE.

Haemodynamic collapse immediately after transcatheter aortic valve implantation due to dynamic intraventricular gradient: a case report and review of the literature.

BackgroundDynamic intraventricular obstruction after transcatheter aortic valve implantation (TAVI) has been previously reported. There is a risk of haemodynamic collapse in the case of left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion (SAM) of the mitral valve.Case summaryAn 83-year-old woman with aortic stenosis (AS) was referred to our hospital for TAVI. Transthoracic echocardiography revealed a severely calcified aortic valve with a peak velocity of 6.3 m/s across the valve. Acceleration of blood flow (peak velocity 2.6 m/s) at the LVOT due to a septal bulge was also seen. Transfemoral TAVI was performed, and a 29 mm Evolut PRO was implanted under general anaesthesia. After the implantation, a complete atrioventricular block with junctional rhythm developed, and refractory hypotension occurred immediately. Transoesophageal echocardiography revealed LVOT obstruction due to SAM of the mitral valve associated with severe mitral regurgitation (MR), which was not observed preoperatively. Fluid infusion and catecholamine administration were not effective. However, after performing temporary pacing from the right ventricular (RV) apex, the LVOT obstruction and severe MR improved. Her haemodynamics stabilized, and we could complete the procedure. A dual-chamber permanent pacemaker with beta-blocker administration as a longer-term treatment further improved the LVOT obstruction. The patient was finally discharged to a rehabilitation hospital.DiscussionAlertness and recognition of potential LVOT obstruction after TAVI are important. Pacing from the RV apex, as well as dual-chamber pacing, comprise a less invasive and feasible therapeutic option in such cases.

Genotype-phenotype association by echocardiography offers incremental value in patients with Noonan Syndrome with Multiple Lentigines.

Noonan Syndrome with Multiple Lentigines (NSML) and Noonan Syndrome (NS) can be difficult to differentiate clinically in early childhood. This study aims to describe characteristics of the ventricular septum that may differentiate NSML from NS. We hypothesize that the shape of the ventricular septum determined by echocardiography correlates with genotype and may distinguish patients with NSML from those with NS. We analyzed data from 17 NSML and 67 NS patients. Forty normal and 30 sarcomeric hypertrophic cardiomyopathy (HCM) patients were included as controls. Septal morphology was qualitatively evaluated, and septal angle was measured quantitatively at end diastole. We recorded the presence of a ventricular septal bulge (VSB) and reviewed genetic testing results for each patient. The most important findings were a sigmoid septum (71%) and VSB (71%) in NSML. NSML septal angle was decreased compared to the normal and sarcomeric HCM control groups, respectively (149 ± 13 vs. 177 ± 3, p < 0.001; 149 ± 13 vs. 172 ± 7, p < 0.001). NS septal angle was similar to the controls (176 ± 6 vs. 177 ± 3, p > 0.5; 176 ± 6 vs. 172 ± 7, p > 0.5). NSML-linked pathogenic variants were associated with sigmoid septum and VSB. These findings provide novel phenotypic evidence to clinicians that may offer incremental diagnostic value in counseling families in ambiguous NSML/NS cases. Characteristics of the ventricular septum are linked to specific gene variants that cause NSML and NS. Sigmoid septum and VSB are associated with NSML. This novel echocardiographic association may help clinicians distinguish NSML from NS in ambiguous cases. Early distinction between the two may be important, as syndrome-specific therapies may become available in the near future. This study may encourage further research into genotype-phenotype associations in other forms of HCM.

Effect of Regional Upper Septal Hypertrophy on Echocardiographic Assessment of Left Ventricular Mass and Remodeling in Aortic Stenosis

Transthoracic echocardiography (TTE) is the reference method for evaluation of aortic stenosis (AS), and it is extensively used to quantitate left ventricular (LV) mass and volumes. Regional upper septal hypertrophy (USH) or septal bulge is a frequent finding in patients with AS and may lead to overestimation of LV mass when using linear measurements. The objective of this study was to compare estimates of LV mass obtained by two-dimensional transthoracic echocardiographic LV dimensions measured at different levels of the LV cavity with those obtained by cardiovascular magnetic resonance (CMR). One hundred six patients (mean age, 63±15years; 68% men) with AS were included in this subanalysis of the PROGRESSA study. Two-dimensional transthoracic echocardiographic measurements of LV dimensions were obtained at the basal level (BL; as recommended in guidelines), immediately below the septal bulge (BSB), and at a midventricular level (ML). Regional USH was defined as a basal interventricular septal thickness ≥ 13mm and >1.3 times the thickness of the septal wall at the ML. Agreement between transthoracic echocardiographic and CMR measures was evaluated using Bland-Altman analysis. The distribution of AS severity was mild in 23%, moderate in 57%, and severe in 20% of patients. Regional USH was present in 28 patients (26%). In the whole cohort, two-dimensional TTE overestimated LV mass (bias: BL,+60±31g; BSB,+59±32g; ML,+54±32g; P=.02). The biplane Simpson method slightly but significantly underestimated LV end-diastolic volume (bias -10±20mL, P<.001) compared with CMR. Overestimation of LV mass was more marked in patients with USH when measuring at the BL and was significantly lower when measuring LV dimensions at the ML (P<.025 vs BL and BSB). Two-dimensional TTE systematically overestimated LV mass and underestimated LV volumes compared with CMR. However, the bias between TTE and CMR was less important when measuring at the ML. Measurements at the BL as suggested in guidelines should be avoided, and measurements at the ML should be preferred in patients with AS, especially in those with USH.

Transesophageal echocardiographic predictors of intraventricular conduction delay in patients undergoing transcatheter aortic valve replacement

Introduction Patient anatomical features, such as shorter membranous septum (MS) length, on computed tomography have been shown to predict conduction abnormalities after transcatheter aortic valve replacement (TAVR). This relationship has not yet been evaluated using transesophageal echocardiography (TEE). Our hypothesis is that the distance from the aortic annulus to the septal bulge, a surrogate of MS distance and length, will be associated with a new interventricular conduction delay and heart block post-TAVR. Likewise, we hypothesize an implantation depth of the valve closer to the septal bulge will also predict post-TAVR interventricular conduction delay. Methods Comprehensive intraprocedural echocardiographic data were analyzed retrospectively on 88 patients who underwent TAVR under general anesthesia with TEE. Pre-procedural MS distance and post-procedural implantation depth (quantified as the inferior border of valve to septal bulge) were measured in the mid-esophageal long axis view of the aortic valve in mid-systole. EKGs were evaluated pre-TAVR and immediately post-valve deployment. Univariate logistic regression was used to identify predictors of a need for post-operative pacemaker (PM) implantation and new bundle branch block (BBB). Results The population consisted of 88 patients undergoing TAVR with TEE from 2017-2018 at our institution. The median age was 84, 45/88 (51.1%) were female. After TAVR, 7/88 (7.9%) had PPM placed and 21/88 (23.8%) had a new bundle branch block, transient or permanent. MS length was inversely associated with the risk of developing an interventricular conduction delay after TAVR (OR=0.19, CI 0.05-0.75, p=0.018). As shown in Table 1, the implantation distance was inversely associated with the need for a pacemaker or developing a new interventricular conduction delay after TAVR (OR=0.19, Cl 0.06-0.6, p=0.006). Discussion MS length and valve implantation depth on intraprocedural TEE are inversely associated with the risk of developing conduction abnormalities post-TAVR. TEE assessment may be comparable to CT in predicting post-TAVI high-grade atrioventricular block, and has the additional benefit of being performed intraprocedurally in selected patients.

Identifying Electrocardiogram Pattern Changes and Their Association with Echocardiography among Malaysian Footballers Attending PreParticipation Evaluation

Introduction: Sudden cardiac death is the most common medical cause of death in athletes. The aim of this study was to identify the electrocardiogram (ECG) pattern changes and its association with echocardiography among Malaysian footballers during a pre-participation evaluation (PPE). Methods: A retrospective study was conducted on footballers attending a PPE at a primary care centre. Secondary data collection was conducted and the proforma included clinical history, physical examination, ECG, Echocardiogram and cardiovascular riskfactors assessment such as heart rate, blood pressure, lipid profile, fasting blood sugar and creatinine. Data were extracted from the medical records, echocardiogram report and the original ECG. The ECG patterns were analysed according to the International consensus for ECG interpretation in athletes to determine physiological versus pathological changes. The data was analysed using SPSS v24. Results: This study included 85 male Malaysian footballers with a mean age of 20.1 ± 3.0 years. The mean resting heart rate was 55.2 ± 9.3beats per minute. Abnormal ECG changes were found in 20% of the participants, which were higher compared to that reported in other studies (14% – 17.3%). The normal ECG findings in athletes were sinus bradycardia (76.5%), J-point elevation (68.2%), prolonged PR interval (3.5%) and incomplete right bundle branch block (4.7%). The abnormal ECG changes were multiple T wave inversions (5.9%), hypertrophy (2.4%), and deep Q-waves (8.2%). Four abnormal ECGs were consistent with abnormal echocardiography findings and out of these,two ECGs with hypertrophic changes were consistent with mild inter atrial septal bulging and apical hypertrophy. Conclusions: Malaysian footballers have ECG changes that are consistent with physiological changes in athlete’s heart. The positive association between ECG and Echocardiogram findings are useful in confirming pathological ECG changes. Physicians should be trained in PPE protocol and ECG interpretation in athletes in order to improve identification of those at risk of sudden cardiac death.

Infraorbital groove correction by microfat injection after lower blepharoplasty

Blepharoplasty alone cannot completely correct deep infraorbital grooves because of its limited ability to improve anatomical volume loss. As the concept of resolving periorbital fat atrophy to improve the infraorbital groove was introduced, several methods to properly fill the groove have been attempted. The purpose of this study was to present a new technique, involving the use of autologous fat from periorbital compartments, for infraorbital groove correction after lower blepharoplasty. Fifty patients (mean age, 55.9 years; range, 41-75 years) underwent transcutaneous lower blepharoplasty between December 2016 and August 2018. Infraorbital septal fat was harvested during the operation; after lower blepharoplasty, transcutaneous microfat was injected into the infraorbital groove. One month after the procedure, 46 patients were satisfied or very satisfied with the results. One patient complained of an unsolved prominent infraorbital groove; additional microfat graft harvesting was performed from the abdomen after 6 months. Two patients complained of remnant septal bulging; additional transconjunctival fat was removed after 6 months. Five patients developed mild ectropion and recovered without any additional treatments. None of the patients developed infection, hematoma, lid retraction or any other complications. Microfat injection after lower blepharoplasty has become popular. The method described in this study has certain advantages: the amount of correction is accurate, there is no donor-site morbidity and both subcutaneous and submuscular layers can be corrected simultaneously.

How Does Regional Hypertrophy Affect Strain Measurements With Different Speckle-Tracking Methods?

In this study, we evaluate the impact of abnormal myocardial shapes, such as regional hypertrophy, on longitudinal strain measurements with different tracking approaches. We selected 40 patients with normal ejection fraction and prominent septal bulge. We assessed longitudinal strain with full wall (FW) tracking, (GE EchoPAC) as well as endo-, mid-, and epicardial (EME) tracking (Tomtec ImageArena), on the same image acquired with a GE machine (using raw data and full frame rate DICOM data, respectively). We used a region of interest (ROI) which follows precisely the endo- and epicardial contours (true contour ROI) and one where the bulging region was excluded (straight ROI). In segments with bulge, absolute segmental longitudinal strain values were in all myocardial layers significantly higher with a straight ROI compared to a true contour ROI, both with FW tracking and EME tracking. The highest difference was found in the endocardial layer (3.4 ± 2.5% and 7.7 ± 7.1%, respectively, both P < 0.001). In the bulged segments, the effect of ROI shape was more pronounced in EME tracking software compared to FW tracking software. Bulged segments also influenced global longitudinal strain measurements, mostly in the endocardial layer (P < 0.001). Global longitudinal strain values obtained with the straight ROI correlated better with longitudinal fractional shortening of the LV. Regional bulging has a significant effect on both global and segmental strain measurements. Endocardial strain values obtained with EME tracking and a true contour ROI were most sensitive to bulging. Midwall strain values derived from FW tracking using a straight ROI were most robust.