Transesophageal Echocardiography Research Articles

The Evolving Epidemiology of Infective Endocarditis: An Observational Study from Western India

Background: Over the last few decades, the epidemiology and the management of infective endocarditis (IE) is undergoing significant evolution and advancements respectively. Many studies from the developed world and some from India have brought this to light. Objective: To study demography, risk factors, microbiological spectrum, clinical profile, management, and outcome of IE in a tertiary care setup in western India. Materials and Methods: This is a retrospective observational study of 90 patients diagnosed with definite as well as possible IE and admitted to the intensive care units (ICU) and wards in our institute from April 2015 to May 2022. Demographics, signs and symptoms, laboratory results, echocardiography, radiological findings, treatment, and outcomes were studied. Results: 73 (81.1%) were definite and 17 (18.9%) were possible cases of IE. 93.3% cases were community-acquired, 6.7% were hospital acquired. Mean age of the patients was 43.3 + or - 18.8 years. Male: female ratio was 4.3:1. 62.2% had an underlying cardiac illness, with congenital heart disease (CHD) being the most common (18.9%) followed by rheumatic heart disease (RHD) (16.5%). Fever, weight loss, dyspnea, and cough were the common presenting symptoms. 69 (76.7 %) patients had native valve IE, 13 (14.4%) had prosthetic valve IE, 6 (6.7%) had vegetations on the endothelium without involvement of the valves, 2 (2.2%) patients had vegetations on the prosthetic material used for repair of congenital heart defects. About 48% of patients had a history of prior receipt of antibiotics. Blood cultures were positive in 48 (53.3%) patients. Most common valve infected was the mitral valve (MV) and the most common organisms isolated were the viridans group of streptococci (VGS), with penicillin (Pn) MIC <0.5 mcg/ml of all but one isolate. Transesophageal echocardiography (TEE), done in 17 patients, improved the pick-up of abnormal echo findings from 83.3% to 91.1%. Ceftriaxone was the most common antibiotic used. Surgery was done in 22 (24.4%) patients. 67 (74.4%) patients were cured, 14 (15.6%) patients died and 9 (10%) patients were lost to follow-up. Conclusion: The increasing age of patients, absence of any underlying cardiac ailment, the importance of TEE in patients with high suspicion of IE, and the trend towards early surgery were the important aspects highlighted with respect to the changes happening in the field of IE. Almost all the strains of VGS, the most common isolated organisms, retained their sensitivity to Pn and ceftriaxone, making the treatment possible with once-a-day dosing of ceftriaxone monotherapy, highlighting the utilization of outpatient antibiotic therapy (OPAT).

Simultaneous beating-heart mitral valve replacement and aortic repair following Bentall procedure via double right mini-thoracotomies: a case report

BackgroundRedo mitral valve surgery by re-sternotomy approach has challenges such as bleeding and organ injury due to adhesion dissection, sternal bone infection, and poor field of view of mitral valve. On the other hand, redo mitral valve surgery via a right mini-thoracotomy approach appears to address these challenges. We successfully performed a double right mini-thoracotomies approach for mitral valve replacement and pseudoaneurysm repair under the beating-heart condition. Herein, we report the effectiveness and the safety of this technique and detailed procedure.Case presentation.The patient is a 71-year-old man with a history of Bentall procedure using a mechanical valve at another hospital 30 years ago. He developed acute heart failure due to severe mitral valve regurgitation. After medication, he was referred to our department for the purpose of surgery for mitral valve regurgitation. Preoperative transesophageal echocardiography showed extensive degenerative change of the both leaflets and chordae tendineae rupture at the P3 segment. Both left atrium and ventricle dilated, and left ventricle contractility reduced. Aortic mechanical valve had no problem. In addition, preoperative contrast enhanced computed tomography revealed a pseudoaneurysm at the distal anastomotic site of Bentall procedure. We performed mitral valve replacement by mechanical valve and repair of distal anastomotic cite under beating heart condition, utilizing a double right mini-thoracotomies approach for mitral valve and ascending aortic pseudoaneurysm respectively. The postoperative course was uneventful, the patient was discharged without complications.ConclusionThe right mini-thoracotomies approach efficiently accessed mitral valve and ascending aorta in reoperations, reducing the adhesion dissection risks and ensuring clear exposure. Moreover, concomitant use of beating-heart technique minimized adhesion dissection for aortic cross-clamp, preserved cardiac function.

Influencing factors and predictive model for left atrial appendage emptying velocity in nonvalvular AF patients.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of death and stroke. The left atrial appendage (LAA) plays a crucial role in the development of AF. Reduced left atrial appendage emptying velocity (LAAEV) is an important indicator of nonvalvular AF, associated with thrombosis and recurrence after catheter ablation. This study aims to identify factors influencing LAAEV and construct a predictive model for LAAEV in nonvalvular AF patients. This retrospective cohort study included 1,048 nonvalvular AF patients hospitalized at the Second Hospital of Hebei Medical University from January 1, 2015, to December 31, 2021. Patients underwent transthoracic and transesophageal echocardiography and had complete laboratory data. Statistical analyses included binary logistic regression and multiple linear regression to identify independent predictors of reduced LAAEV and construct a predictive model. Patients were divided into two groups: reduced LAAEV (<40 cm/s) and normal LAAEV (≥40 cm/s). The reduced LAAEV group included 457 patients (43.61%), with significant differences in age, gender, alcohol consumption, heart failure (HF), ischemic stroke, AF type, resting heart rate, CHA2DS2-VASc score, serum creatinine (SCR), serum uric acid (SUA), estimated glomerular filtration rate (eGFR), glycated hemoglobin (HbA1C), β2 macroglobulin (B2M), left atrial diameter (LAD), and left ventricular ejection fraction (LVEF) compared to the normal LAAEV group. Logistic regression analysis identified age (OR 0.974, 95% CI 0.951-0.997, P = 0.028), HF (OR 0.637, 95% CI 0.427-0.949, P = 0.027), AF type [Persistent AF vs. PAF (OR 0.063, 95% CI 0.041-0.095, P = 0) Long-standing Persistent AF vs. PAF (OR 0.077, 95% CI 0.043-0.139, P = 0)], LAD (OR 0.872, 95% CI 0.836-0.91, P < 0.001), and LVEF (OR 1.057, 95% CI 1.027-1.089, P = 0) as independent predictors of reduced LAAEV. Multiple linear regression analysis included age, AF type, LAD, and LVEF in the final predictive model, explaining 43.5% of the variance in LAAEV (adjusted R² = 0.435). Age, HF, type of AF, LAD, and LVEF are independent predictors of reduced LAAEV. The predictive model (LAAEV = 96.567-15.940 × AFtype-1.309 × LAD-0.18 × Age + 37.069 × LVEF) demonstrates good predictive value, aiding in the initial assessment and management of nonvalvular AF patients.

Aorto-Right Atrial and Aorto-Right Ventricular Fistulas as a Complication of Subacute Infective Endocarditis.

Aortic fistulas are a rare, potentially fatal, complications of subacute infective endocarditis.Early recognition is greatly assisted by transesophageal echocardiography.

Cardiac Output Directly Influences Intracardiac Air After Venous Air Embolism: An Echocardiographic Model Comparing Position Change on Intracardiac Air Bubble Clearance.

Venous air embolism (VAE) can cause significant morbidity and mortality. Prevention and management of VAE include cessation of air entrainment, positioning changes, and hemodynamic support. The degree to which position change and cardiac output (CO) moderate resolution of intracardiac air has not been rigorously studied using contemporary transesophageal echocardiography (TEE). This observational cohort-type study aimed to identify the effect of supine vs sitting positioning on the movement and resolution of intracardiac air. In 20 patients undergoing seated neurosurgery, central venous air aspiration catheters were placed through the median basilic vein. TEE was used to estimate the time required for clearance of agitated microbubbles from the right atrium and ventricle in both the supine and sitting position. Estimates of CO were also obtained echocardiographically in each position. Average clearance time was faster in the sitting vs the supine position with no significant difference in CO. A negative correlation between CO and right atrial clearance time across all patients was demonstrated with a Pearson coefficient of -0.4 (95% CI -0.07, -0.65) with P = .02. During VAE, both patient position and CO can significantly affect how bubbles move through intracardiac chambers. However, augmenting CO during VAE may be clinically more feasible, efficient, and productive than changing positioning-especially during crises unless the changing in position is intended to halt the entrainment of air. Further TEE studies of intravascular air movement affected by other position changes (lateral, reverse Trendelenburg) and vasopressors should be considered.

Application of Echocardiography in Anaesthesia: From Preoperative Risk Assessment to Postoperative Care.

Echocardiography has carved out a fundamental niche in anaesthesiology, revolutionizing the monitoring and management of cardiac function during surgery. Clinical practice has changed from simple 2D and 3D echocardiography to more sophisticated applications such as incorporating artificial intelligence. Echocardiography provides detailed real-time information about cardiac anatomy and function, helping anaesthesiologists make better decisions regarding tailoring anesthetic interventions and optimizing patient outcomes. From optimizing hemodynamic management in patients with severe aortic stenosis to fine-tuning fluid and vasopressor therapy in patients with right heart dysfunction, echocardiography has improved the care provided in the perioperative period. These applications permit the demonstration of not only technical advantages that could accrue from echocardiography but are also a part of individualized care to improve the outcomes of patients. The challenges in integrating echocardiography with anaesthesia include operator dependency, a steep learning curve in acquiring echocardiographic skills, and limitations due to patient factors and technological limitations, which lead to poor echocardiographic performance. Additionally, transoesophageal echocardiography (TEE) is an invasive procedure with several potential risks that must be considered cautiously. Continuing education, certification recommendations, and skill development are prerequisites for this echocardiography tool to remain robust and reliable in anaesthesiology. Technological innovation, especially in improving 3D imaging and integration with artificial intelligence, is where a very bright future lies ahead for echocardiography. It would further accelerate the process of echocardiographic evaluation and improve diagnostic accuracy. All these would turn out to be more person-centered for each patient. Anaesthesiologists must, therefore, pace themselves with such developments so these can be appropriately applied in the clinics. In summary, echocardiography became so integrally ingrained into anaesthesia that it propelled the specialty with essential tools anaesthesiologists use to manage patients for optimum outcomes. Its application has difficulties and limitations, but continued professional development and development of echocardiographic technology will make sure that its benefits are maximized. Quickly, echocardiography is becoming central to anaesthesiology's role in optimizing patient care and surgical success as we move into the application of evermore sophisticated echocardiographic techniques.

Role of interatrial block in modulating cryptogenic stroke risk in patients with patent foramen ovale: a retrospective study

BackgroundThe patent foramen ovale (PFO) and interatrial block (IAB) are associated with cryptogenic stroke (CS). However, the role of the interaction between PFO and IAB in CS remains unclear.MethodsThis case–control study enrolled 256 patients with CS and 156 individuals without a history of stroke or transient ischemic attack. IAB was defined as P wave duration > 120 ms. PFO was evaluated by contrast transesophageal echocardiography, and classified as no-PFO, low-risk PFO and high-risk PFO. Multiplicative and additive interaction analysis were used to assess the interaction between PFO and IAB in CS.ResultsMultiplicative interaction analysis unveiled a significant interaction between IAB and low-risk PFO in CS (OR for interaction = 3.653, 95% CI, 1.115–12.506; P = 0.037). Additive interaction analysis indicated that 68.4% (95% CI, 0.333–1.050; P < 0.001) of the increased risk of CS related to low-risk PFO was attributed to the interaction with IAB. The results were robust in multivariate analysis. However, but no significant multiplicative or additive interaction was observed between IAB and high-risk PFO. When stratified by IAB, high-risk PFO was associated with CS in both patients with IAB (OR, 4.186; 95% CI, 1.617–10.839; P = 0.003) and without IAB (OR, 3.476; 95% CI, 1.790–6.750; P < 0.001). However, low-risk PFO was only associated with CS in patients with IAB (OR, 2.684; 95% CI, 1.007–7.149; P = 0.048) but not in those without IAB (OR, 0.753; 95% CI, 0.343–1.651; P = 0.479).ConclusionThe interaction between IAB and PFO might play an important role in CS, particularly in cases with low-risk PFO.

The relationship between tricuspid annular plane systolic excursion on transesophageal echocardiography and the incidence of postoperative acute kidney injury in patients undergoing coronary artery bypass grafting surgery: a multicenter prospective cohort study

BackgroundTo date, the relationship between the Transesophageal Echocardiography (TEE) monitoring indicator tricuspid annular plane systolic excursion (TAPSE) and the incidence of postoperative acute kidney injury (AKI) in Coronary Artery Bypass Grafting(CABG) patients remains unknown. The main objective of this study was to explore the relationship between the TAPSE and the incidence of AKI in CABG patients.MethodsThis was a multicenter prospective cohort study was conducted between September 2021 and July 2022. Among 266 patients aged at least 18 years who underwent elective CABG, 140 were included.ResultsWe measured TAPSE via M-mode TEE via the mid-esophageal (ME) right ventricle(RV) inflow-outflow view (60°). All echocardiographic measurements were performed three separate times at each time point: T0 (before the start of CABG), T2 (approximately 5 ∼ 10 min after neutralization of protamine) and T3 (before leaving the operating room), and then averaged. Serum creatinine was measured 1 day before and within 7 days after CABG. There was no statistically significant association between the TEE-monitoring indicator TAPSE and the incidence of postoperative AKI in patients who underwent CABG.ConclusionsThe TAPSE was not significantly correlated with postoperative AKI incidence and could not predict the early occurrence of postoperative AKI in CABG patients. TEE needs more evaluation for clinical efficacy of predicting the early occurrence of postoperative AKI in isolated CABG.

Transcranial Doppler With Microbubbles: Screening Test to Detect and Grade Right-to-Left Shunt After an Ischemic Stroke: A Literature Review.

Right-to-left shunt, mainly due to patent foramen ovale (PFO), is likely responsible for ≈5% of all ischemic strokes and 10% of those occurring in young and middle-aged adults. Randomized clinical trials demonstrated that, in selected young and middle-aged patients with otherwise cryptogenic acute ischemic stroke and high-risk PFO, percutaneous PFO closure is more effective than antiplatelet therapy alone in preventing recurrence. However, PFO is generally a benign finding and is present in about one-quarter of the population. Therefore, in clinical practice, identifying PFOs that are likely to be pathogenetic is crucial for selecting suitable patients for PFO closure to prevent recurrent stroke and to avoid potentially harmful and costly overtreatment. Contrast transthoracic echocardiography has a relatively low sensitivity in detecting PFO, whereas transesophageal echocardiography is currently considered the gold standard for PFO detection. However, it is a relatively invasive procedure and may not always be easily feasible in the subacute setting. Contrast transcranial Doppler is a noninvasive, inexpensive, accurate tool for the detection of right-to-left shunt. We conducted a literature review on the use of contrast transcranial Doppler to detect and grade right-to-left shunt after an acute ischemic stroke and present a clinical workflow proposal for young and middle-aged patients.

Correlations between intraoperative and postoperative echocardiographic measurements in patients undergoing aortic bioprosthetic valve replacement: a prospective observational study.

Patient-prosthesis mismatch (PPM) should be avoided during surgical aortic valve replacement because PPM would worsen the mortality and morbidity. Diagnosis of PPM could be made using various parameters measured by intraoperative transesophageal echocardiography. However, few studies have examined which parameters correlate most accurately between intraoperative and postoperative values. This single-center prospective observational study analyzed 46 patients who underwent surgical aortic valve replacement (SAVR). Echocardiography was performed at the following 3-time points: preoperatively, intraoperatively, and 1month postoperatively. The correlation between intraoperative and postoperative measurement values, including peak velocity (PV), mean pressure gradient (MPG), effective orifice area (EOA), and effective orifice area index (EOAI), were assessed using Pearson's correlation coefficient. Moreover, to evaluate whether a multivariable linear regression model with intraoperative and postoperative stroke volume added as an explanatory variable improves the correlation, the multiple correlation coefficients were calculated. PV, MPG, EOA, and EOAI measured intraoperatively and 1month postoperatively were significantly correlated. The r values of each measurement were 0.35, 0.344, 0.411 and 0.323, respectively. The multivariable linear regression model showed that the multiple correlation coefficients for MG and EOA were 0.491 and 0.663, respectively. Intraoperative and postoperative PV, MPG, EOA, and EOAI were significantly correlated in patients undergoing SAVR with a bioprosthetic valve. The r value for EOA was 0.441, the largest among the measured values. Adjustment for stroke volume improved the strength of the correlation. Intraoperative evaluation of prosthetic valve function was considered most appropriate using EOA. University Hospital Medical Information Network Clinical Trials Registry, registration number UMIN000046164, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052695 .

Predictive indicators in peripheral blood and left atrium blood for left atrial spontaneous echo contrast in atrial fibrillation patients

ObjectivesThe purpose of this study was to demonstrate the discriminating predictive indicators in peripheral blood and left atrium blood for predicting the risk of left atrial spontaneous echo contrast (LASEC) in atrial fibrillation patients underwent catheter ablation.MethodsA total of 108 consecutive AF patients treated with radiofrequency ablation between July 2022 and July 2023 were enrolled and divided into two groups based on preprocedural transesophageal echocardiography: the non LASEC group (n = 71) and the LASEC group (n = 37). Circulating platelet and endothelial- derived MPs (PMPs and EMPs) in peripheral blood and left atrial blood were detected. Plasma soluble P-selectin (sP-selectin) and von Willebrand factor (vWF) were observed. Diagnostic efficiency was measured using receiver operating characteristic (ROC) curve.ResultsPeripheral sP-selectin, vWF and EMPs expressions elevated in all subjects when compared to those in left atrium blood. Levels of sP-selectin and vWF were significantly higher in peripheral blood of LASEC group than those of non LASEC group (p = 0.0018,p = 0.0271). Significant accumulations of peripheral PMPs and EMPs were documented in LASEC group by comparison with non LASEC group (p = 0.0395,p = 0.018). The area under curve(AUC) of combined PMPs and sP-selectin in predicting LASEC was 0.769 (95%CI: 0.678–0.845, sensitivity: 86.49%, specificity: 59.15%), significantly larger than PMPs or sP-selectin alone.ConclusionsExpressions of PMPs, sP-selectin, EMPs and vWF Increased in NVAF patients with LASEC and that might be potential biomarkers for LASEC prediction.

Hematological Complications From Transcatheter Aortic Valve Replacement (TAVR): Recognition and Treatment.

Transcatheter aortic valve replacement (TAVR) has emerged as a pivotal intervention for patients with severe aortic stenosis who are at high or prohibitive surgical risk. Although TAVR is a minimally invasive procedure, it is linked to serious hematological problems, most notably thrombosis and bleeding. Numerous factors, such as procedural features, patient comorbidities, and anticoagulation management techniques, contribute to these complications. Bleeding complications can be major, minor, or life-threatening. They can be caused by problems with the vascular access site, anticoagulation medication, or coexisting conditions like renal dysfunction and frailty. Hemoglobin drop, overt bleeding, and hematoma signs must all be closely watched to identify bleeding. Careful selection and modification of anticoagulation medication, the use of vascular closure devices, and timely attention to bleeding sites are examples of management techniques. Thrombotic consequences, which include cerebrovascular accidents and valve thrombosis, are caused by endothelial injury, stent implantation, and patient hypercoagulability. Imaging modalities such as computed tomography and transesophageal echocardiography are used in the crucial process of detection. The goal of preventive care is to maximize anticoagulation regimens that are customized to each patient's risk profile, frequently striking a balance between the risk of thrombosis and bleeding. A multidisciplinary strategy that integrates surgical, hematological, and cardiology expertise is necessary for the effective management of these hematological complications. To improve patient outcomes, ongoing research attempts to improve risk stratification and create safer anticoagulation protocols. This review emphasizes how critical it is to identify bleeding and thrombotic events as soon as possible and treat them promptly to reduce the risk of negative outcomes for TAVR patients.

Tissue Oedema Following Pulsed Field Ablation Recognized during a Concomitant Left Atrial Appendage Closure Procedure. A Case Report

Abstract Background In patients with non-valvular atrial fibrillation (AF), at high stroke risk and who are ineligible for long-term oral anticoagulation the left atrial appendage closure (LAAC) could be an alternative to anticoagulation. Pulsed field ablation (PFA) is a new nonthermal method for cardiac ablation modality based on high-voltage electrical energy for irreversible electroporation. We first report a case of a concomitant PFA pulmonary vein isolation and LAAC. Case Summary A 74-year-old female patient was referred to our department for pulmonary vein isolation (PVI) for persistent AF (CHA2DS2-VASc Score 5). A concomitant percutaneous LAAC was proposed because of a history of previous cerebellar transient ischemic attack despite continuous oral anticoagulation therapy. PVI was achieved with a pentaspline PFA catheter, LAAC performed with a WATCHMAN FLXTM device (Boston Scientific, Plymouth, MN, USA). After PVI, a swelling of the left atrial ridge was observed, yet a 27 mm LAAC device was successfully implanted. The follow-up transesophageal echo (TEE) after 6 weeks showed complete resolution of the oedema, no device related thrombus but a slight proximal tilting of the LAAC device without leakage could be observed. The 6-month follow-up demonstrated a stable sinus rhythm, no stroke or bleeding events were recorded. Discussion In this case of synchronous PFA-PVI procedure in AF and Watchman FLXTM device implantation, the electroporation created an acute oedema at the ridge level which at the TEE follow-up after 6 weeks was resolved. This resulted in a slightly tilted Watchman device position which was nevertheless stable and showed no leakage.

Pearls and Pitfalls of Epicardial Echocardiography for Implantation of Impella CP Devices in Ovine Models.

The Impella CP is a percutaneously inserted temporary left ventricular assist device used in clinical practice and in translational research into cardiogenic shock, perioperative cardiac surgery, acute cardiac failure and mechanical circulatory support. Fluoroscopic guidance is usually used for insertion of an Impella, thus limiting insertion to within catheterization laboratories. Transthoracic, transoesophageal and intracardiac echocardiography have been reported to guide Impella CP implantation with identified specific limitations stemming from the surgical, anatomical and equipment factors. We conducted translational prospective descriptive feasibility investigation as a part of two other hemodynamic Impella studies. It showed the successful application of epicardial echocardiographic scanning for implantation of Impella CP devices in ovine models, from which details of the technique and identified pitfalls are described with practical solutions for future investigators and clinicians. Many described findings are relevant to any other echocardiographic techniques when adequate imaging of the Impella and relevant anatomical structures is achievable.

Intracardiac Ectopic Thyroid Tissue: A Case Report

We present the case of a 36-year-old female who visited the OPD of a local hospital in Lahore, Pakistan, with history of chest pain, shortness of breath and palpitations. Echocardiogram and transesophageal echocardiography revealed right ventricular outflow tract mass, dilated coronary sinus and atrial septal defect. Surgery was advised, and successful excision of the mass was done and the specimen later sent to Chughtai Institute of Pathology for histopathological evaluation and diagnosis. The results revealed benign thyroid tissue with no evidence of malignancy. The patient was symptom-free on follow up after 6 months.

Pulmonary Artery Endograft Implantation Using a Parallel Stent Grafting Technique to Enable the Treatment of a Bronchial Anastomosis Complication After Lung Transplantation.

Bronchial stenosis associated with bronchial anastomosis dehiscence after lung transplantation is a catastrophic complication following lung transplantation with a paucity of therapeutic solutions. To describe an adaptation of the parallel stent grafting technique in the pulmonary arterial territory to treat this challenging situation. This is a case report of a 52-year-old patient who presented bronchus stenosis and bronchial anastomosis dehiscence after lung transplantion. Bronchial stenting and lung retransplantation were contraindicated. Therefore, an endovascular approach using pulmonary artery endograft placement to prevent bleeding during repeated right bronchial balloon dilation was propposed. The technique consists of the deployment of an aortic extender endoprosthesis in the right main pulmonary artery and a balloon expandable stent in the upper lobe pulmonary artery (using a parallel graft configuration) through the common femoral and right internal jugular veins, respectively. Intraoperative transesophageal echocardiogram and one-lung ventilatory ventilation are needed. The patient underwent a new bronchoscopy 16 days after the procedure, that showed epithelization at the previous eroded zone, enabling bronchocopic balloon dialtion to be safely performed. A post-operative contrast-enhanced CT scan revealed an adequate positioning of the stent grafts. Despite all eforts, the patient succumbed to ventilator associated pneumonia on postoperative day 108. The technique's advantages include its feasibility even in situations in which other techniques may be contraindicated and its potential use in emergencies. Its limitations include the need for experienced interventionists to perform it, and the potential risk of acute tricuspid regurgitation. This study illustrates the early feasibility of the parallel stent grafting technique applied to the pulmonary artery territory. However, it's safety profile regarding infectious risk was not demontrated.

Hereditary hemorrhagic telangiectasia - pediatric review.

Hereditary hemorrhagic telangiectasia (HHT) diagnostic and management approach for pediatrics underwent significant advances over the last couple of years. In 2020, new guidelines for HHT were published that included a pediatric section thus attracting special focus into the childhood presentation. Curacao criteria are specific, but not sensitive enough in children. Genetic testing is encouraged for all family members even if asymptomatic. Standardized scoring for epistaxis is strongly encouraged, as it allows monitoring and can stratify therapeutic approaches. Early screening for pulmonary and brain visceral arteriovenous malformations (AVMs) in pediatric patients with confirmed genetic alterations of HHT should be instituted. Graded trans-esophageal echocardiogram with agitated saline contrast can be used as screening method for pulmonary AVMs. As pulmonary AVMs can develop throughout lifetime, guidelines recommend repeated screening even in asymptomatic patients at least every 5 years. Signs of stroke in childhood are more subtle than in adults. Cerebral imaging in early childhood can identify brain AVMs that may benefit from early intervention. Embolization of high-risk pulmonary and cerebral AVMs should be performed at specialized centers even at pediatric age. One or two classic HHT telangiectasia can be considered diagnostic in children. Antibiotic prophylaxis with dental procedures continues to be recommended.

Genetic insights and clinical implication of inherited hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is one of the most common inherited genetic diseases of myocardium. It is the leading cause of unexpected mortality among young people and athletes. H.C.M. has been regarded as a sarcomere illness for the past few decades, usually with incomplete penetrance and varied expressivity arising from autosomal dominance. For the purpose of risk and treatment stratification, all diagnostic techniques—such as tissue biopsy, genetic counselling, magnetic resonance imaging, transthoracic and transoesophageal echocardiography, heart catheterization, and genetic counselling—must be used. Additionally, each patient's results should be customized based on their genotype and phenotype. About one-third of people have left ventricular outflow tract blockage at rest, and another third may be prompted to develop it. Interstitial fibrosis and myocyte hypertrophy and disarray are among the histological characteristics of H.C.M. Another common complication of the hypertrophy is left ventricular diastolic dysfunction. The pathogenesis of H.C.M is complex, and its clinical profile is variable. Functional disability resulting from heart failure and stroke (induced by atrial fibrillation) is also attributed to H.C.M. The goal of the current treatments for H.C.M., which include medication, myectomy, alcohol septal ablation, and implanted cardiac defibrillators (I.C.Ds) to avoid SCD, is to slow down the disease's progression and relieve symptoms. Multidisciplinary approaches are best suited for the diagnosis and treatment of patients with H.C.M. More individualized care and better results for this patient population have been made possible by this, as well as the enhanced safety and effectiveness of medicinal, percutaneous, and surgical therapy for H.C.M. In this review the molecular pathophysiology of H.C.M will be reviewed in light of current knowledge. In addition, describing how genetic testing is used for diagnosis and outlining the range of clinical manifestations.

What Important Information Does Transesophageal Echocardiography Provide When Performed before Transvenous Lead Extraction?

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality.

Left Atrial Appendage Thrombus as a Marker of Disease Severity in 500 Patients with Atrial Fibrillation on Oral Anticoagulation: A 13-Year Follow-Up Study.

Background/Objective: Whether left atrial appendage thrombus (LAAT) in patients with atrial fibrillation (AF) on chronic anticoagulation significantly increases cardiovascular risk is unknown. This study aimed to assess LAAT prevalence and its predictive role in cardiovascular events among consecutive anticoagulated patients with AF admitted for electrical cardioversion. Methods: This prospective study included 500 patients. The primary outcome was LAAT on transesophageal echocardiography. Patients were followed up for a median of 1927.5 (interquartile range 1004-2643) days to assess cardiovascular events. Results: LAAT was detected in 65 (13%) patients. No significant differences in stroke, transient ischemic attack, systemic thromboembolic events, or myocardial infarction prevalence were observed between patients with AF with and without LAAT. Hospitalization for heart failure (HF) was more frequent in patients with LAAT than in those without LAAT; however, the effect of LAAT on HF hospitalization was not statistically significant. Patients with LAAT had a significantly higher risk of cardiovascular death than those without LAAT. LAAT and greater left atrial (LA) diameter were associated with higher rates of cardiovascular death. The independent HF hospitalization predictors were greater LA diameter, lower left ventricular ejection fraction (LVEF), and estimated glomerular filtration rate (eGFR). Conclusions: Patients with AF who received anticoagulation therapy showed a high prevalence of LAAT. LAAT and greater LA diameter were associated with significantly higher rates of cardiovascular death. LAAT, greater LA diameter, lower LVEF, and lower eGFR were associated with poor prognosis in anticoagulated patients with AF and were predictors of disease severity.