Septal Shift Research Articles

Impella 5.5 Support for Delayed Surgical Ventricular Septal Defect Repair-A Paradigm Shift?

Ventricular septal defects (VSDs) remain a rare but life-threatening complication of myocardial infarction. Although the incidence has decreased due to better treatment options, the mortality rate remains high. The timing of VSD repair remains critical to outcome. The use of mechanical circulatory support is rarely described in the literature, although it may help to delay repair to allow tissue stabilization. While Impella is currently considered contraindicated due to the potential worsening of the right-to-left shunt and possible systemic embolization of necrotic debris, there is no comprehensive evidence for this. Therefore, we aimed to analyze whether the use of Impella 5.5 as a first choice for patients undergoing VSD repair should be considered for discussion. This retrospective study analyses four consecutive patients who underwent delayed ventricular septal repair after prior implantation of Impella 5.5 (Abiomed Inc., Danvers, Massachusetts, United States). A total of 75% of patients (n = 3) presented with acute right heart failure prior to implantation with a mean systolic pulmonary artery pressure of 64 ± 3.0 mmHg. Implantation was performed under local anesthesia in three cases. The mean time to surgery was 9.8 ± 3.1 days. All patients remained on the Impella 5.5 device postoperatively. Weaning from Impella 5.5 was successful in 75% (n = 3). The mean length of stay in the intensive care unit was 22.3 ± 7.5 days. Preoperative implantation of the Impella 5.5 device is a safe and feasible option for patients undergoing VSD repair. Outcomes may be improved by performing Impella implantation under local anesthesia and continuing Impella support after VSD repair. However, it is important to note that these patients represent a high-risk cohort and the mortality rate remains high.

Successful management of HeartMate 3 in a patient with arrhythmogenic right ventricular cardiomyopathy.

The management of right heart failure during durable left ventricular assist device (LVAD) support remains an unsolved issue so far. We had a 44-year-old male patient who was diagnosed with arrhythmogenic right ventricular cardiomyopathy and received HeartMate 3 LVAD (Abbott, USA) implantation as a bridge-to-transplant indication. The pump speed was adjusted as low as 4500rpm to avoid the left ventricular narrowing and interventricular septal leftward shift. Riociguat was administered to decrease the afterload of the right ventricle and increase the preload of the left ventricle, in addition to the combination of neurohormonal blockers. Frequent low-flow alarm events eventually disappeared after amlodipine administration, and he was successfully returned to work. We here present a unique management in a patient with right heart failure due to arrhythmogenic right ventricular cardiomyopathy during HeartMate 3 LVAD support.

Abstract 14114: An Extreme Case of Calcific Constrictive Pericarditis

Introduction: Constrictive pericarditis (CP) can lead to cardiac dysfunction and a range of clinical symptoms. However, differentiating it from conditions like restrictive cardiomyopathy can be challenging due to the overlapping features. Case Presentation: We present a case of a 61-year-old female with a history of atrial flutter and subsequent atrial fibrillation, experiencing worsening dyspnea on exertion, lip cyanosis, and upper abdominal constriction. Extensive diagnostic workup, including Echo, CT scan, and cardiac MRI, revealed severe biatrial enlargement, ventricular interdependence, elevated filling pressures, reduced cardiac output, and extensive pericardial thickening and calcifications ( Figures 1.a and 1.b ). These findings supported the diagnosis of extensive CP. Discussion: CP is often missed and delayed in diagnosis due to its complex hemodynamics and the non-specific symptoms. Typically, the initial imaging modality to be performed is an Echo. Specific findings such as dilated vena cava, preserved tissue velocity with annuls paradoxus, abnormal respiratory septal shift, and respiratory variations in mitral/tricuspid inflow should be first clues for potential diagnosis. Furthermore, evaluation of the hepatic vein with diastolic flow reversal during expiration is a key finding. Lack of respiratory variation in the SVC is also important. Cardiac CT will assess pericardial thickness and calcification, while cardiac MRI is key for the diagnosis by showing the pericardial thickness and fibrosis as well as the septal respiratory shift and venous congestion. An invasive hemodynamic study might be required if imaging is inconclusive. this patient’s presentation, imaging findings, exercise test results and collectively supported considering radical pericardiectomy. Conclusions: This report highlights the diagnostic challenges related to CP and the importance employing a multimodality imaging approach for accurate diagnosis.

P398 ACUTE PERICARDITIS COMPLICATED BY RAPID DEVELOPMENT OF CONSTRICTION: A CASE REPORT

Abstract A 57–years–old man with no previous cardiovascular history presented with fever, hypotension, dyspnoea at rest and chest pain. The electrocardiogram showed sinus tachycardia, PR–segment depression and diffuse concave–upwards ST–segment elevation. Elevated C–reactive protein and low pro–BNP level were found at lab tests, procalcitonin and troponin were negative. Chest X–ray showed bilateral pleural effusion. Transthoracic echocardiogram (TTE) revealed mild–to–moderate serofibrinous pericardial effusion with initial diastolic collapse of right chambers, suggesting cardiac pre–tamponade. Because of the exiguity of liquid component, pericardiocentesis was not performed, patient was stabilized by fluid–challenge with hypertonic solution. Ibuprofen and colchicine were started. Left thoracentesis was performed removing one liter of fluid overall compatible with transudate. Cytological and microbiological examinations were negative. Despite of initial clinical improvement, the patient showed kidney failure and worsening of lung failure; perianal abscess was detected causing sepsis and requiring surgical drainage and antibiotic therapy with vancomycin and piperacillin/tazobactam. Culture exams were negative. After ibuprofen replacement with indomethacin a repeated TTE showed reduced pericardial effusion, but also respiratory variation in ventricular filling with signs of interventricular dependence. Cardiac magnetic resonance showed thickening and high signal intensity of pericardial layers on T2 weighted imaging and ventricular septal shift on free–breathing cine sequences, suggesting effusive–constrictive pericarditis. Left and right cardiac catheterization demonstrated ventricular “dip and plateau” pattern and ventricular discordance. Considering the lack of clinical improvement on medical therapy, off–bypass pericardiectomy was performed. Incomplete adhesion between the two pericardial layers and thick gelatinous material were found. After surgery patient experienced rapid clinical improvement; cardiac index increased from 1.5 to 3.5 L/min/m2. Effusive–constrictive pericarditis is a rare and dreaded complication of acute pericarditis. Surgery, when appropriated, is crucial for prognosis. In our case initial response to anti–inflammatory therapy with reduced pericardial effusion unmasked constrictive physiology in an effusive–constrictive pericarditis. Clinical management was complicated by sepsis which could have played a role in constriction developing.

28 CONSTRICTIVE PERICARDITIS: A ROOM FOR MULTI-MODALITY IMAGING

Abstract Introduction The diagnosis of constrictive pericarditis can be challenging through conventional imaging. Novel imaging techniques have been proposed to improve it. Clinical Case A 74-year-old man with a previous diagnosis of heart failure with preserved ejection fraction and permanent atrial fibrillation (AF) was admitted because of worsening dyspnea, peripheral edema, and ascites refractory to diuretics therapy. ECG revealed low QRS voltages and AF with normal heart rate and laboratory exams detected increased values of BNP and hepatic stasis indices; blood count and CRP were normal. Echocardiography revealed mildly reduced bi-ventricular pump function (left ventricular ejection fraction = 52%, right ventricular fractional area change = 25%) and slightly increased wall thickness. Atria were moderately dilated (left and right atrium 46 and 44 ml/mq, respectively) and mitral and tricuspid annuli were dilated too. There was inferior vena cava plethora, moderate atriogenic tricuspid regurgitation and mild-to-moderate atriogenic mitral regurgitation. A paradoxical interventricular septal motion and significant respiratory changes on trans-mitral (>25%) and trans-tricuspid (>30%) pulsed Doppler were noted; however, there was no "annulus reversus" (lateral and septal e’ 13 and 11 cm/sec, respectively) at TDI analysis. In contrast, 2D-speckle-tracking global longitudinal strain showed impaired deformation ​​of the lateral segments with relative sparing of the septal segments. The latter pattern has been recently described as "strain reversus" or "hot septum sign". The findings were suspected of constrictive pericarditis, but a chest Computed Tomography excluded pericardial calcifications. Cardiac magnetic resonance (CMR) was then performed revealing a "septal shift" at cine-real time sequences analysis. The pericardium was slightly thickened (4-5 mm) with widespread late gadolinium enhancement but without signs of acute inflammation at T2-weighted imaging. Tricuspid regurgitation was confirmed to be "moderate" after phase-contrast imaging. Cardiac catheterization finally revealed normal coronary arteries and confirmed the diagnosis of constrictive pericarditis (square root sign, equalization of bi-ventricular end-diastolic pressures). The patient underwent pericardiectomy and tricuspid and mitral valve repair and was asymptomatic at 6-months follow-up. Conclusions Constrictive pericarditis represents a potentially reversible cause of heart failure but can be easily missed through conventional imaging. In the present case, advanced echocardiography and CMR were essential to come up with an accurate diagnosis, guiding the patient's clinical management with excellent outcome.

Abstract 15557: Missed Diagnosis of Constrictive Pericarditis: Importance of Multimodality Imaging

Introduction: Constrictive pericarditis is a potentially reversible cause of hypotension that is diagnostically challenging. Multimodality imaging is important in the evaluation of patients for constrictive pericarditis to ensure timely management. Case Presentation: A 68-year-old female with a history of chronic hypotension controlled with midodrine and fludrocortisone, end-stage renal disease, and rheumatoid arthritis was admitted to our hospital following a ground-level fall leading to left femur fracture. At admission, her blood pressure was 100/72 mmHg and heart rate was 84 per minute. No pericardial rub, murmurs, or jugular venous distension were present. Laboratory evaluation revealed normal serum electrolytes, thyroid-stimulating hormone, and morning cortisol levels. A routine transthoracic echocardiogram was performed as part of her perioperative cardiac evaluation that demonstrated a beat-to-beat septal diastolic shudder and annulus reversus suggestive of constrictive pericarditis. These findings were confirmed with cardiac magnetic resonance imaging (CMR) that showed pericardial thickening, tubular-shaped right ventricle with impaired filling, septal bounce as well as respirophasic early diastolic septal flattening. Cardiothoracic surgery was consulted however definitive management with pericardiectomy is pending at the time of this report. Conclusion: With recent advances in tissue Doppler imaging, echocardiography can be used in clinical practice to diagnose constrictive pericarditis. Reversal of the relationship between lateral and medial e` velocities (annulus reversus) and respiration-related ventricular septal shift (septal shudder) are suggestive of constrictive pericarditis.

Resonantly Coupled High-Efficiency Sensors for Assessment of Ventricular Chamber Size for Autonomous Control of Left Ventricular Assist Device.

Current left ventricular assist devices (LVADs) are set to a fixed rpm and are unable to adjust to physiological demands irrespective of preload or afterload. Autonomous control of LVADs has the potential to reduce septal shift, preserve right ventricle function, and meet physiological demands. A highly innovative resonantly coupled regimen is presented which can achieve this goal. We introduce sensors based on a highly sensitive relationship between transmission coefficient and spatial separation in a resonantly coupled regimen. This relationship represents a polynomial regression. A regimen of an apical sensor and multiple outflow sensors is investigated. A range of separations varying from 50-200 mm was systematically investigated. These ranges consider anatomical & physiological variation(s) in cardiac chamber size. Validation was obtained in porcine heart preparation. The polynomial regression model predicted distance between the sensors with a mean absolute percentage error of 0.77%, 1.07%, and 5.75% for the three putative positions of the outflow sensors and apical sensor when compared with experimental results. A high degree of accuracy (95%) between the predicted and observed distance was obtained. Continuous measurements were done over 90 days to examine drift, with no statistically detectable change in measurements over million sampling cycles. We have demonstrated a reliable sensor methodology without drift for assessing ventricular chamber size in an LVAD setup. This has the potential to allow autonomous control of LVAD based on ventricular chamber size to address some of the adverse events.

Staged Ventricular Septation in Double-Inlet Ventricle - A Strategy to Avoid Fontan?

Single-stage ventricular septation for double-inlet left or right ventricle (DILV or DIRV) has historically been associated with poor outcomes. We hypothesize that staged ventricular septation may demonstrate favorable clinical outcomes to be an alternative to Fontan palliation. This single-center retrospective study reviewed patients with DILV or DIRV who underwent staged ventricular septation between 2015-2021. The strategy involves pulmonary artery banding or Norwood procedure during infancy (stage 1), followed by partial ventricular septation to anchor the septum, while maintaining systemic RV pressure to avoid septal shift (stage 2). Residual septal defects are closed with pulmonary artery band removal at stage 3. Results are reported as median (interquartile range). Twelve patients underwent partial ventricular septation. At a median follow-up time of 17 months (8-30) after stage 2, there were no interstage deaths or cardiac transplants; LV dysfunction was observed in one patient. Hemodynamic evaluation after stage 2 demonstrated median left atrial pressure of 9.5 mm Hg (8.9-11.5), cardiac index of 3.4 L/min/m2 (3.2-3.6), and RV and LV indexed end-diastolic volumes of 52 ml/m2 (41-67) and 105 ml/m2 (81-115), respectively. Five patients have progressed to stage 3; one required pacemaker for complete heart block. Unplanned reintervention was required in 4 patients after stage 1, 2 patients after stage 2, and 3 patients after stage 3. Staged ventricular septation is an alternative to single-ventricle palliation in a subset of double-inlet ventricle patients and is associated with acceptable early outcomes. Further studies are necessary to determine long-term outcomes.

Association of Right Ventricular–to–Left Ventricular Diameter Ratio at End-Systole With Outcomes in Children Who Underwent Repair of Tetralogy of Fallot

RATIONALE: Tetralogy of Fallot (TOF) is a right-sided dominant cardiac lesion with a stenotic right ventricular (RV) outflow tract and hypertrophied RV, which could result in septal shift and RV dilation. This study evaluated the RV/left ventricular (LV) diameter ratio at end-systole in association with clinical outcomes in children who underwent repair of TOF. The main aim of this study was to determine the association of RV/LV diameter ratio at end-systole with the outcomes of TOF repair. The specific objectives were to determine whether the preoperative (demographic and echocardiographic data) parameters were associated with the clinical outcomes of TOF repair and to determine whether the intraoperative (cardiopulmonary bypass time and aortic cross-clamp time) parameters were associated with the clinical outcomes of TOF repair. METHODOLOGY: This prospective cohort single-center study enrolled 112 TOF patients aged 1 to 18 years admitted for surgical repair. The RV/LV ratio was measured using echocardiography preoperatively, indexed to patient’s weight and body surface area, and associated with its postoperative cardiac complications using logistic regression analysis. RESULTS: Cumulative incidence of cardiopulmonary complications was at 28.7% (32 of 112). Reperfusion lung injury had the most cases (11.6%), followed by low cardiac output syndrome (9.8%) and postpericardiotomy syndrome (5.4%). Both RV and LV diameters, indexed to patient’s weight and body surface area, (P = 0.0051, P < 0.001), RV/LV ratio (P < 0.001), and LV end diastolic size with z scores (P < 0.001), showed statistically significant results. Increase in RV/LV ratio is associated with adverse postoperative clinical outcomes in pediatric patients who underwent repair of TOF (P < 0.001). Significant preoperative parameter showed that stunting is associated with complications postoperatively (P = 0.017), whereas for the intraoperative parameters, prolonged cardiopulmonary bypass time and aortic cross-clamp time were also associated with postoperative complications. CONCLUSION: The increased value of RV/LV end-systolic diameter ratio at 1.63 (±0.256), which incorporates both pathologic septal shift and RV dilation, is associated with higher incidence of postoperative cardiac complications among patients with tetralogy of Fallot.

Using the Septal Shift Technique to Correct Crooked Nose Deformity.

Crooked nose deformity is defined as any degree of deviation of the anatomical structures involving the nasal bone, the upper and lower lateral cartilages, and the septum from the midsagittal plane of the face, in any direction. This study introduces a new technique to correct crooked nose deformity. Twenty-six with I-shaped, C- and reverse C-shaped, and S-shaped crooked nose deformity underwent open approach rhinoplasty. After performing in-out fracture osteotomy, L-strut septoplasty was preferred. Initially, the L-strut was sutured through the hole that opened to the maxillary spine and then passed to the dorsal section. In the dorsal part of the L-strut, a spreader graft with the appropriate thickness and length was sutured opposite to the deviated side, only at the keystone area. The L-strut was then incised vertically to form a cranial and caudal segment. The caudal portion was sutured by shifting to the other side of the spreader, beginning at the caudal end of the cranial portion. The upper lateral cartilages were sutured to the newly formed L-strut. Finally, tip-plasty was performed, and the procedure was terminated. The septal shift technique is an effective method for treating crooked nose deformity. The septal shift technique is a new technique without complications used in the author's routine practice as an effective method for treating crooked nose deformity. Therapeutic, IV.

AN INTERESTING CASE OF CARDIAC ARREST DURING THE CREATION OF AV FISTULA

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: We present an intersting case of cardiac arrest due to hemodynamic compromise occurring soon after AV fistula creation. CASE PRESENTATION: 45-year-old woman with medical history of ESRD on hemodialysis and pulmonary hypertension presented for left-arm AV fistula creation. Initial parts of the procedure went uneventful. However, towards the end of procedure, 10 minutes after unclamping of the graft, patient became hypotensive and suffered from cardiac arrest secondary to pulseless ventricular tachycardia progressing to torsades. Patient received CPR and multiple defibrillator shocks, epinephrine, IV magnesium sulfate and amiodarone boluses. Blood gas showed pH of 7.05 and lactate 6.5 mmol/L. Potassium, magnesium and phosphate levels were normal. She was started on epinephrine drip for hemodynamic support and heparin drip due to concern of PE. STAT TTE showed severe LVH with LVEF of 55 to 60%, moderate pulmonary hypertension, normal RV size and function. CTA of chest did not show any evidence of pulmonary embolism therefore heparin was stopped. Patient was transferred to ICU where she remained stable and had a full neurologic recovery. DISCUSSION: AV fistula creation in patients with pre-existing pulmonary hypertension and RV dysfunction could result in increased venous return and RV preload leading to acute RV dilatation. This could cause septal shift towards the left resulting in decreased LV preload, leading to decreased cardiac output, potentially resulting in hypotension. Decreased coronary and systemic perfusion could also result in myocardial ischemia and RV failure leading to arrhythmias and death. CONCLUSIONS: Physicians should be aware of this potentially fatal acute complication of AV fistula creation. DISCLOSURE: Nothing to declare. KEYWORD: Cardiac Arrest, AV Fistula, hemodynamic effects, dialysis access, high output cardiac failure

P63: Resonantly Coupled High-Efficiency Sensors for Assessment of Ventricular Chamber Size in LVADs

Study: Current left ventricular assist devices (LVAD) are set at a fixed RPM; and are unable to adjust to physiological demands irrespective of preload or afterload. An autonomous control of LVADs has the potential to reduce septal shift, preserve right ventricle function, and meet physiological demands. A highly innovative resonantly coupled regimen is presented which can achieve this goal. Methods: We introduce resonantly coupled sensors to measure the ventricular chamber size. A decrease in transmission coefficient (S21) is observed as the distance between the sensors increases. Ventricular chamber size is predicted using a 2nd-degree polynomial regression model. A regimen of an apical epicardial sensor (SA) and outflow graft sensors (SO1, SO2, and SO3) is investigated Fig. 1(a-c). The minimum and maximum distances are 50-150 mm, 100-200 mm, and 50-150 mm, respectively. These ranges account for anatomical variation in heart size. A porcine model was used for experimentation. Results: Our polynomial regression model predicted distance between the sensors with a mean absolute percentage error of 2.1%, 1.24%, and 2.4% for the three positions of the outflow graft sensor when compared with experimental results, as shown in Fig. 1(d-f). A high degree of accuracy (98%) between predicted and observed size was obtained. Conclusion: We have demonstrated a reliable sensor methodology without drift for assessing ventricular chamber size in an LVAD patient. This will pave way for autonomous control of LVAD based on ventricular size. This method of prediction has the potential to prevent adverse outcomes for LVAD patients with physiological perturbations that would otherwise go unnoticed until their next hospital visit.

Right-sided heart reperfusion ("Berlin bridge technique") for right ventricle support during left ventricular assist device (LVAD) implantation.

Right-sided heart reperfusion ("Berlin bridge technique") for right ventricle support during left ventricular assist device (LVAD) implantation.

Characteristics and Clinical Outcomes of Cancer Patients who Developed Constrictive Physiology After Pericardiocentesis.

This study aimed to identify the characteristics and clinical outcomes of cancer patients who developed constrictive physiology (CP) after percutaneous pericardiocentesis. One-hundred thirty-three cancer patients who underwent pericardiocentesis were divided into 2 groups according to follow-up echocardiography (CP vs. non-CP). The clinical history, imaging findings, and laboratory results, and overall survival were compared. CP developed in 49 (36.8%) patients after pericardiocentesis. The CP group had a more frequent history of radiation therapy. Pericardial enhancement and malignant masses abutting the pericardium were more frequently observed in the CP group. Fever and ST segment elevation were more frequent in the CP group, with higher C-reactive protein levels (6.6±4.3mg/dL vs. 3.3±2.5mg/dL, p<0.001). Pericardial fluid leukocytes counts were significantly higher, and positive cytology was more frequent in the CP group. In baseline echocardiography before pericardiocentesis, medial e' velocity was significantly higher in the CP group (8.6±2.1cm/s vs. 6.5±2.3cm/s, p<0.001), and respirophasic ventricular septal shift, prominent expiratory hepatic venous flow reversal, pericardial adhesion, and loculated pericardial fluid were also more frequent. The risk of all-cause death was significantly high in the CP group (hazard ratio, 1.53; 95% confidence interval,1.10-2.13; p=0.005). CP frequently develops after pericardiocentesis, and it is associated with poor survival in cancer patients. Several clinical signs, imaging, and laboratory findings suggestive of pericardial inflammation and/or direct malignant pericardial invasion are frequently observed and could be used as predictors of CP development.

639 A case of acute transient constrictive pericarditis—an unusual presentation

Abstract Aims Transient constrictive pericarditis (TCP) is a rare manifestation which can occur in up to 15% of cases of acute pericarditis and most have resolution after 3 months of anti-inflammatory therapy. Methods and results We present the case of a young guy who showed up at our emergency department complaining of pericarditic chest pain and fever up to 39 °C degrees since the previous 4 days. After physical examination, electrocardiogram, blood tests, chest X-ray, and echocardiography acute pericarditis with severe pericardial effusion (more than 20 mm of thickness) were diagnosed and an empiric anti-inflammatory therapy with ibuprofen and colchicine was started. After 2 weeks of therapy, patient was not clinically improving with a worsened pericardial effusion and only a mild reduction of inflammatory markers. During an echocardiographic examination, features of constrictive physiology were discovered: respirophasic interventricular septal shift, increased respiratory variation of the mitral and tricuspidal inflow, plethoric inferior vena cava, and ‘annulus reversus’ and ‘annulus paradoxus’ on Tissue Doppler Imaging (TDI). Cardiac magnetic resonance (CMR) was also performed to confirm the diagnosis of acute pericardial constriction: it revealed increased T2-weighted imaging signal and increased Delayed Gadolinium Enhanced (DGE) signal, respectively consistent with oedema and with neovascularization, both suggestive of acute pericardial inflammation. Therefore, oral low doses corticosteroid was started After 2 weeks course of ‘triple therapy’ the patient was clinically improved and the echocardiographic features of constrictive physiology were no longer present thus allowing his discharge and the continuation of therapy at home. Conclusions This case was remarkable because it showed that constrictive pericarditis may present in a reversible form with medical therapy, this meaning it is due to pericardial oedema, inflammation and fibrin deposition similar to acute pericarditis rather than the pericardial fibrosis and calcification more commonly seen in chronic pericardial constriction.

Features on cardiac magnetic resonance imaging and accuracy of echocardiographic findings for diagnosing constrictive pericarditis.

Constrictive pericarditis is a rare disease with a difficult diagnosis. Cardiac magnetic resonance (CMR) imaging data of Aga Khan University Hospital from January 2011 to March 2020 was retrospectively reviewed and patients with the diagnosis of constrictive pericarditis were included. A total of 22 patients were included with the mean age of 46±16 years and majority 17(77%) were male. The most common findings on transthoracic echo were significant respiratory variation in mitral and tricuspid inflow velocities in 20(91%), and septal annular e'>9 in 10 (86%). The most common finding on CMR was respiratory septal shift in 22(100%), followed by septal bounce in 21(95%) and thickened pericardium in 18(82%). Nearly two-third of the patients, 15(70%) were considered for pericardiectomy but it was deferred in 5 patients due to high surgical risk. Ten patients underwent pericardiectomy, with no mortality on a mean follow up of 4±2 years.

844 A Case of Pulmonary Artery Banding for Future Anatomical Repair in Congenitally Corrected Transposition of the Great Arteries (ccTGA)

Abstract This is a case of a patient prenatally diagnosed with ccTGA. Immediately after birth, postnatal transthoracic echocardiography diagnosed ccTGA with concomitant Ebstein’s anomaly of the tricuspid valve, without a ventricular septal defect (VSD). Initially, this dysplastic tricuspid valve had mild tricuspid regurgitation. However, by 12 months follow up, the patient was becoming symptomatic, and their tricuspid regurgitation had become severe. Due to the patients worsening symptoms and regurgitation, clinical intervention was pursued. The patient had Cardiovascular Magnetic Resonance performed to assess for myocardial fibrosis and to measure the size of each ventricle. After imaging and MDT discussion, the patient was deemed suitable for a double switch operation, a form of anatomical repair. However, since this patient did not have pulmonary stenosis (PS), they required a pulmonary artery (PA) band before anatomical repair. This procedure has dual benefits: to retrain the morphological left ventricle (mLV) to cope with systemic pressures, and to induce a septal shift, which can reduce the severity tricuspid regurgitation. At 18 months of age, this patient had their PA band placed. The patient immediately had a reduction in the severity of their tricuspid regurgitation. In the future, this patient will have cardiac catheterisation performed to measure mLV pressures and assess when the patient is ready for anatomical repair. The morphology of this patient is rare, as most patients with ccTGA have an associated VSD. This case describes a potential management pathway for a ccTGA patient without VSD and an Ebstenoid tricuspid valve. It also demonstrates the benefits of PA banding in a ccTGA patient with this morphology. This is a unique contribution, due to the rarity of this specific morphology and the limited evidence and guidance for its successful management.

COVID-19 and the Risk of Pulmonary Embolism: ECG Findings Can Help

We appreciate the kind invitation to provide an update on an aspect of our study published before [1]. Therefore, we decided to further discuss the Pulmonary Embolism (PE) in patients with COVID-19. COVID-19 pandemic has affected many countries and their health-care system. COVID-19 also imposes significant diagnostic challenges because of its wide range of complications [2]. Evidence shows that COVID-19 can cause a hypercoagulable state and increases the risk of thromboembolism [3]. The radiological appearance of PE in patients with COVID-19 might differ from COVID-19 (-) patients, and the clots are dominantly seen in peripheral zones [4,5]. This fact supports the idea that COVID-19 can cause PE by in-situ immune thrombosis, and the clots might originate from lung vessels rather than deep veins [6]. There is an overlap between signs and symptoms of COVID-19 infection and pulmonary embolism, making the diagnosis of pulmonary embolism challenging [7]. Elevated D-dimer levels may come to our help and increase our suspect for PE, but it is still not specific to the diagnosis of Venous Thromboembolism (VTE) [8]. Anticoagulant therapy may increase the patients’ survival rate [9]. Dyspnea, chest pain, and tachypnea are common in both PTE and COVID-19 infection. Hemoptysis has also been described as a rare COVID clinical symptom (0-5 %) [10], while this number is 13% for patients with PE [11]. In the case reported by Casey et al. [7], a 42 years old COVID-19 positive male presented with pleuritic chest pain, dyspnea, and hemoptysis. In the physical exam, he was tachypneic, and auscultation revealed bibasilar rhonchi. Electrocardiography demonstrated right axis deviation and an S1Q3T3 pattern with flattening of the T-waves in the II, III, aVL and aVF. These findings increased the probability of PE. Also, Laboratory evaluation showed a D-dimer of 4.8μg/dl. So a Computerized Tomography Angiography (CTA) of the chest was obtained. CTA demonstrated bilateral segmental pulmonary emboli and peripheral ground-glass opacities caused by COVID-19 pneumonia. However, sometimes everything becomes more complicated. In the case reported by Ioan et al. [12], a 61 years old male with a history of hypertension treated with Angiotensin-Converting Enzyme Inhibitor (ACEI) presented with dyspnea and cough. His blood pressure was normal, his heart and respiratory rates were 136 and 30, and oxygen saturation was &lt;85% on room air. His Electrocardiogram (ECG) showed sinus tachycardia, ST depression in I, aVL, and V2-V4, and ST-segment elevation in II, III, aVF. An Echocardiography was obtained, which showed RV dilatation, interventricular septal shift, RV lateral wall akinesia, and a pulmonary arterial systolic pressure of &gt;60mmHg. His hypoxemia was refractory to invasive mechanical ventilation, so he was intubated and underwent invasive mechanical ventilation without response. For this patient thrombolytic treatment was started due to suspicion of PE. The patient started improving. CTA confirmed PE with a finding of diffuse bilateral ground-glass opacities consistent with COVID-19 pneumonia. A coronary angiogram showed no significant coronary stenosis. In this case, no obvious sign or symptom, such as pleuritic chest pain or hemoptysis, could lead to PE diagnosis at first. In ECG, there was no flattening of the T-waves or S1Q3T3 pattern, and the patient had a normal axis. Although PE can present with an ST-segment elevation in anteroseptal leads (V1-V4) [13], it is a rare finding that can be mistaken for ST-elevation myocardial infarction. However, in the discussed patient, RV overload and severe pulmonary hypertension with refractory hypoxemia could lead us to PE diagnosis [12]. Conclusion In conclusion, diagnosing COVID-19 complications such as PE can be challenging as COVID-19 can mask their sign and symptoms. We should be aware of any signs or symptoms that can lead us to diagnose these complications. ECG is a low-cost and widely available tool that may give valuable clues to help us diagnose PE. Some ECG signs raise suspicions for PE, such as right axis deviation, S1Q3T3 pattern, or the flattening of T waves. As we saw in an above-discussed case, even an ST-segment elevation in anteroseptal leads can lead us to PE diagnosis.

Abstract 16631: Predictors of Left Ventricular Dysfunction in Patients After Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries

Introduction: After anatomic repair (AR) of congenitally corrected transposition of the great arteries (ccTGA), the left ventricle (LV) is re-established as the systemic ventricle. As such, LV dysfunction is an important factor in long-term patient morbidity. While predictors exist for successful AR, little is known regarding measures of LV function before and after AR, and no known predictors exist of worsening global longitudinal strain (GLS). Methods: All patients with ccTGA who survived to discharge after AR at a single institution from 2000-2018 were included. Pre-operative and discharge echocardiograms were reviewed and GLS analysis was performed. LV sphericity index was measured to determine the degree of ventricular septal shift; a lower index denotes more septal bowing into the LV. Logistic regression was used to identify factors associated with worsened GLS after AR. Results: Of 91 survivors (65% male), 51 underwent Senning/arterial switch (ASO) and 40 had Senning/Rastelli. Mean LV ejection fraction (EF) decreased from 66% to 61% after AR (p = 0.0003) with 26% having LVEF less than or equal to 55% (increased from 4% pre-op, p = 0.0003). Mean LV GLS was normal pre-op (-20.0% ± SD 4.1%) but worsened following AR (-16.5% ± 4.6%; p &lt;.0001); abnormal LV GLS (&gt; -18%) increased to 62% (vs 32% pre-op, p &lt;.0001). More patients undergoing Senning/ASO (78%) had abnormal LV GLS at discharge compared to those with a Senning/Rastelli (22%) (odds ratio [OR] 9.3, p &lt;.0001). Abnormal pre-op GLS (OR 5.8, p = 0.002) and lower LV sphericity index (OR 1.05, p = 0.01) were also significantly associated with worsening GLS at discharge. In multivariable analysis, all three remained independently associated with worsened LV GLS. Age at AR, ventricular looping, LV posterior wall thickness, and reintervention prior to discharge were not associated with changed LV GLS at discharge. Conclusions: Following AR of ccTGA, LVEF decreases but remains in the normal range, while LV GLS detects abnormalities. Risk factors for worsening GLS include abnormal pre-op LV GLS, lower LV sphericity index, and a Senning/ASO repair. Lower LV sphericity index, or more septal shift into the LV, may represent a “less trained” LV, highlighting the need for careful patient selection for AR.

High-intensity interval training improves interventricular synchrony and strain under hypoxic stress in sedentary males

Abstract Background Interventricular interactions in increased RV afterload such as hypoxia stress, which affects both synchrony and function in an in-series effect as well as a parallel effect arising from leftward septal shift. Improved myocardial contractility is a critical circulatory adaptation to exercise training, however, the types of exercise that can improve interventricular synchrony under hypoxic environment have not yet been established. Purpose This study investigates how high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) influence on the interventricular synchrony in response to normobaric hypoxia in sedentary men. Methods Fifty-four sedentary males were randomized to perform HIIT (3-minute intervals at 40% and 80% VO2peak, n=18), MICT (sustained 60% VO2peak, n=18) for 30 minutes/day, 5 days/week for 6 weeks and the control group (CTL, n=18). Synchrony measurements at apical 4-chamber view including (1) intra-delay, the difference in time to peak strain (TS) between segmental septal-to-lateral ventricular or atrial walls, and (2) inter-delay, the difference in TS between RV or RA free wall and LV or LA lateral wall. The data were acquired by 2-dimensional speckle tracking echocardiography at rest under hypoxic condition (12% FIO2, simulated an altitude of 4,500 m) before and after the interventions. Results HIIT had significantly elevated radial and longitudinal strains in both LA and LV (p&amp;lt;0.05). As the results showed, HIIT was superior than MICT in improvement of longitudinal intra-delay of LV; furthermore, only HIIT simultaneously ameliorated both radial and longitudinal synchrony at apex. Although the HIIT enhanced intraventricular synchrony in both motions, whereas the interventricular synchrony deteriorated at radial motion. In atrium synchrony, although both groups augmented the intra-LA synchrony, however, only HIIT reduced the inter-delay between LA and RA at the roof motion. LV end-systolic volume (ESV) significantly correlated with the longitudinal inter-delay of ventricle (r=−0.53, p&amp;lt;0.05), whereas the LV end-diastolic volume (EDV) correlated with the inter-delay of atrium in roof motion (r=0.40, p&amp;lt;0.05). Conclusion We found differences between HIIT and MICT in segmental intra- and inter- synchrony. HIIT enhanced both ventricular or atrial synchrony, and further increased the EDV coupled with decreased ESV. These findings give new insight into cardiac adaptation to difference endurance training and the long-term impact of such changes warrants future study in cardiac diseases. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Science Council of Taiwan