Takotsubo cardiomyopathy in the case of 72-year-old teacher after work-related psychological stress. Evolution of left ventricular longitudinal strain - Delayed but complete recovery in automated function imaging (AFI)

Takotsubo cardiomyopathy (TC) is related to a transient systolic dysfunction of left ventricle (LV), accompanied by clinical and electrocardiographic symptoms of myocardial ischemia in the absence of hemodynamically significant coronary artery disease. Takotsubo cardiomyopathy is usually provoked by a psychologically or/and physically stressful event which may be related to occupational activities. Although visually assessed evolution of LV function is well documented, the data concerning strain changes is sparse and various patterns of deformation abnormalities are suggested. We have described a 72-year-old woman with chest pain related to a lecture given at the meeting of the Senior University, fulfilling all the Mayo Clinic criteria of the TC. The longitudinal strain analysis with automated function imaging (AFI) documented severe impairment and stepwise recovery of regional and global LV contractility. The case described confirms that accurate diagnosis, treatment and documenting of functional improvement in takotsubo cardiomyopathy may enable the return to occupational activities even for elderly persons. Int J Occup Med Environ Health 2017;30(4):681-683.

Metastatic pulmonary artery sarcoma presented with tamponade: a case report

Pulmonary artery sarcoma is a rare tumor with varying presentations including pericardial effusion and pulmonary metastasis. Single‐nucleotide polymorphism array is a novel method that can be used to define tumor genome and be used as a guidance to choose the proper treatment regimen.

Persistent left superior vena cava in atrial septal defect sinus venosus type: diagnosis with saline contrast echocardiography-a case series

Persistent Left Superior Vena Cava (PLSVC) should be suspected if we find dilatation of coronary sinus. Sophisticated imaging is not always available in each health care provider. Transthoracic echocardiography (TTE) with agitated saline injections through the left and right antecubital veins provides a simple, and inexpensive, but effective study for a rapid bedside diagnosis of PSLVC.

The prognostic significance of preoperative left ventricular diastolic dysfunction and left atrial enlargement on acute coronary syndrome in kidney transplantation

Echocardiography is commonly performed as a screening test to evaluate perioperative risks before kidney transplantation. However, only limited data are available on echocardiographic parameters of left ventricular diastolic dysfunction (LVDD) and left atrial enlargement (LAE) on acute coronary syndrome and mortality in kidney transplant recipients. We reviewed 2779 adult recipients who underwent pretransplant echocardiography from 1997 to 2012. We divided the patients into two and four groups by two categories: LVDD grades 0-1 vs. 2-3, and left atrial size quartile groups. During a mean follow-up of 4.5 years, acute coronary syndrome occurred in 89 (3.2%) patients. The recipients with LVDD grades 2-3 (P = 0.005 for non-fatal, P = 0.02 for fatal/non-fatal) and LAE (P = 0.001 for non-fatal, P = 0.03 for fatal/non-fatal) had a higher incidence of acute coronary syndrome after kidney transplantation. All-cause mortality did not differ significantly between the groups. In a multivariate analysis, LVDD of grades 2-3 (hazard ratio 2.98, 95% confidence interval 1.535-5.787; P = 0.001), and LAE (hazard ratio 1.052, 95% confidence interval 1.006-1.101; P = 0.03) were independently associated with non-fatal acute coronary syndrome. In patients who are kidney transplant candidates, pretransplant LVDD and LAE were independently associated with a higher incidence of acute coronary syndrome after kidney transplantation.

Assessment of Paravalvular Leak After Transcatheter Aortic Valve Replacement: Transesophageal Echocardiography Compared With Transthoracic Echocardiography

OBJECTIVES

Determine whether moderate or greater paravalvular leak (PVL) after transcatheter aortic valve replacement quantified using intraoperative transesophageal echocardiography (TEE) is associated with mortality and investigate the correlation between PVL grading using intraoperative TEE and postoperative transthoracic echocardiography (TTE).

DESIGN

Retrospective, observational study.

SETTING

Single academic institution.

PARTICIPANTS

The study comprised adult patients undergoing elective transcatheter aortic valve replacement between April 2011 and February 2014.

INTERVENTIONS

Patients were grouped by amount of PVL on intraoperative TEE into "significant" (moderate or greater) and "nonsignificant" (no, trivial, or mild) PVL groups. Demographics and patient characteristics were compared. Continuous variables were assessed with t-tests or Wilcoxon rank sum tests and categorical variables with the chi-square or Fisher exact test. A Cox proportional hazards model adjusted for EuroSCORE was used to test the independent association of PVL with late mortality, and covariate-adjusted survival curves were constructed. A Fleiss-Cohen-weighted kappa value was used to assess agreement between PVL grading using intraoperative TEE and postoperative TTE.

MEASUREMENTS AND MAIN RESULTS

One hundred ninety-six patients were grouped into the "significant" (n = 22) or "nonsignificant" (n = 174) PVL group. Twenty patients (10%) died during the follow-up period. Significant PVL on either TTE (p = 0.62, hazard ratio 1.68, 95% confidence interval [CI] 0.22-12.85) or TEE (p = 0.49, hazard ratio 0.49; 95% CI 0.06-3.68) was not associated with a survival difference. Modest agreement was found between PVL on intraoperative TEE and postoperative TTE (kappa = 0.47, CI 0.37-0.57, p < 0.0001).

CONCLUSIONS

Larger studies are needed to evaluate the association of PVL graded on intraoperative TEE with survival. There is modest agreement between the degree of PVL found on TEE and TTE.

Dissection of the interventricular septum: Echocardiographic features

Dissection of the interventricular septum (IVS) is an extremely rare entity. An institutional echocardiographic database was retrospectively reviewed; 13 patients with a diagnosis of IVS dissection were found and confirmed by cardiac surgery. The purposes of the study were: to determine the value of transthoracic echocardiography (TTE) in establishing the diagnosis of IVS dissection, and to detail the TTE features of IVS dissection.Thirteen patients with IVS dissection diagnosed by TTE, 8 males and 5 females were taken from 789,114 TTE studies performed between 1985 and 2014. All underwent cardiac surgery during which their diagnosis was confirmed. The etiology, location, 2-dimensional morphology, and color Doppler findings of IVS dissection were noted.The right sinus of Valsalva (SOV) was involved in 11 of the 13 patients. In 5 patients, a single aneurysm of the right SOV was seen dissecting into the IVS. One patient with a combination of a bicuspid aortic valve and a right SOV aneurysm dissected into the IVS. In 4 patients, aortic valve infective endocarditis resulted in IVS dissection. In 1 patient, mechanical aortic valve prosthetic replacement was complicated by annular detachment and a severe paravalvular leak causing IVS dissection. In all 11 patients, TTE showed a dissecting cystic-like mass in the IVS from the base to the mid-septum or confined to the septal base. The path of the dissection in these 11 patients was traced to the right SOV and communications between the IVS dissection and the aortic root were identified. In the remaining 2 patients, IVS dissection followed septal rupture due to a myocardial infarction, and communication was seen between the IVS dissection and the right ventricle.The study showed that most of the dissections of the IVS commence in the right SOV, due to either congenital anomalies or infective endocarditis, or following aortic valve replacement or myocardial infarction. The TTE characteristic of IVS dissection is a cystic-like mass seen in the IVS.

Severe tricuspid regurgitation due to valvular entrapment of an inferior vena cava stent

Endovascular venous stenting is increasingly performed for a variety of conditions. Inferior vena cava stent migration has been reported up to 6 months after placement; stent migration 6 months after implantation is uncommon. To our knowledge, this is only the second reported case of late stent migration with valve entrapment 1.

Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope

BACKGROUND

Syncope is a common reason for outpatient transthoracic echocardiography (TTE). We studied the applicability of pediatric appropriate use criteria (AUC) on initial outpatient evaluation of children (≤18 years) with syncope.

METHODS

Data were obtained before (Phase I, April-September 2014) and after (Phase II, January-April 2015) the release of the AUC document from six participating pediatric cardiology centers. Site investigators determined the indication for TTE and assigned appropriateness rating based on the AUC document: Appropriate (A), May Be Appropriate (M), Rarely Appropriate (R), or "unclassifiable" (U) if it did not fit any scenario in the AUC document.

RESULTS

Of the total 4562 TTEs, 310 (6.8%) were performed for syncope: 174/2655 (6.6%) Phase I and 136/1907 (7.1%) Phase II, P=.44. Overall, 168 (50.5%) were for indications rated A, 63 (18.9%) for M, 79 (23.7%) for R, and 23 (6.9%) for U. Release of AUC did not change the appropriateness of TTEs [A=51.6% vs 49.0%, P=.63, R=20.2% vs 28.3%, P=.09]. Overall syncope-related R indications formed 15.7% of R indications for all the echocardiograms performed in the entire Pediatric Appropriate Use (PAUSE) study (11.9% Phase I and 22.4% Phase II, P=.002). TTEs were normal in majority of the patients except 7 that had incidental findings.

CONCLUSIONS

In conclusion, syncope is a common reason for indications rated R and release of the AUC document did not improve appropriate utilization of TTE in syncope. Targeted educational interventions are needed to reduce unnecessary TTEs in children with syncope.

The Evolving Role and Use of Echocardiography in the Evaluation of Cardiac Source of Embolism

This report will review the role of echocardiography in the diagnosis of cardiac sources of embolism. Embolism of cardiac origin accounts for around 15%–30% of ischemic strokes. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthonous cerebrovascular occlusive disease. Transthoracic and/or transesophageal echocardiography serves as a cornerstone in the evaluation, diagnosis, and management of these patients. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism.

Clinical application of point of care transthoracic echocardiography in perioperative period

Transthoracic echocardiography (TTE) has established its role for diagnosis and management in cardiology and is used by various other specialities in medicine, but it is not routinely practised by anaesthesiologists in the perioperative period including the pre-admission clinic/outpatient clinic. The last decade has seen the emerging role of anaesthesiologist as a 'Perioperative physician'. This review article highlights the potential role and clinical utility, education, teaching and limitations of point of care (POC) TTE modality in perioperative care. Various echocardiography society guidelines and endorsements, diagnostic protocols and limitations are enumerated. This article also discusses some of the possibilities for future education and development related to clinical ultrasound including POC TTE in anaesthetic training curriculum.

Validation of maternal cardiac output assessed by transthoracic echocardiography against pulmonary artery catheterization in severely ill pregnant women: prospective comparative study and systematic review

OBJECTIVE

Most severe pregnancy complications are characterized by profound hemodynamic disturbances, thus there is a need for validated hemodynamic monitoring systems for pregnant women. Pulmonary artery catheterization (PAC) using thermodilution is the clinical gold standard for the measurement of cardiac output (CO), however this reference method is rarely performed owing to its invasive nature. Transthoracic echocardiography (TTE) allows non-invasive determination of CO. We aimed to validate TTE against PAC for the determination of CO in severely ill pregnant women.

METHODS

This study consisted of a meta-analysis combining data from a prospective study and a systematic review. The prospective arm was conducted in Pretoria, South Africa, in 2003. Women with severe pregnancy complications requiring invasive monitoring with PAC according to contemporary guidelines were included. TTE was performed within 15 min of PAC and the investigator was blinded to the PAC measurements. Comparative measurements were extracted from similar studies retrieved from a systematic review of the literature and added to a database. Simultaneous CO measurements by TTE and PAC were compared. Agreement between methods was assessed using Bland-Altman statistics and intraclass correlation coefficients (ICC).

RESULTS

Thirty-four comparative measurements were included in the meta-analysis. Mean CO values obtained by PAC and TTE were 7.39 L/min and 7.18 L/min, respectively. The bias was 0.21 L/min with lower and upper limits of agreement of -1.18 L/min and 1.60 L/min, percentage error was 19.1%, and ICC between the two methods was 0.94.

CONCLUSIONS

CO measurements by TTE show excellent agreement with those obtained by PAC in pregnant women. Given its non-invasive nature and availability, TTE could be considered as a reference for the validation of other CO techniques in pregnant women. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

RESUMEN OBJETIVO

Las complicaciones del embarazo más graves se caracterizan por trastornos hemodinámicos serios, debido a los cuales existe la necesidad de sistemas validados de monitorización hemodinámica para mujeres embarazadas. Aunque la cateterización de la arteria pulmonar (CAP) mediante termodilución es el patrón de referencia clínico para la medición del gasto cardíaco (GC), este método se usa con poca frecuencia debido a su naturaleza invasiva. La ecocardiografía transtorácica (ETT) permite la determinación no invasiva del GC. El objetivo de este estudio fue validar la ETT frente al CAP para determinar el GC en mujeres embarazadas gravemente enfermas. MÉTODOS: Este estudio consistió en un metaanálisis que combinó datos de un estudio prospectivo y una revisión sistemática. El estudio prospectivo se llevó a cabo en Pretoria (Sudáfrica) en 2003. Se incluyeron mujeres con complicaciones graves en el embarazo que requerían una monitorización invasiva mediante CAP según las directrices de ese momento. Se realizó una ETT en un plazo de 15 minutos de haber realizado el CAP y el investigador no tuvo acceso a las mediciones del CAP. Las mediciones comparativas se extrajeron de estudios similares obtenidos a partir de una revisión sistemática de la literatura y se añadieron a una base de datos. Se compararon las mediciones simultáneas del GC mediante ETT y CAP. La concordancia entre métodos se evaluó a través del método estadístico de Bland-Altman y de coeficientes de correlación intraclase (CCI).

RESULTADOS

Se incluyeron treinta y cuatro mediciones comparativas en el metaanálisis. Los valores medios del GC obtenidos mediante CAP y ETT fueron de 7,39 l/min y 7.18 l/min, respectivamente. El sesgo fue de 0,21 l/min, siendo los límites inferior y superior de la concordancia de -1,18 l/min y 1.60 l/min; el error porcentual fue del 19,1%, y el CCI entre ambos métodos fue de 0,94.

CONCLUSIONES

Las mediciones del GC en mujeres embarazadas mediante ETT muestran una excelente concordancia con las obtenidas mediante CAP. Dada su naturaleza no invasiva y su disponibilidad, la ETT podría considerarse como referencia para la validación de otras técnicas relacionadas con el GC en mujeres embarazadas. : ,。(pulmonary artery catheterization,PAC)(cardiac output,CO),,。(transthoracic echocardiography,TTE)CO。PACTTECO。 : meta。2003。PAC。PAC 15 minTTE,PAC。,。TTEPACCO。Bland-Altman(intraclass correlation coefficients,ICC)。 : meta34。PACTTECO7.39 L/min7.18 L/min。-1.18 L/min、1.60 L/min0.21 L/min,19.1%,ICC0.94。 : TTECOPACCO。,TTECO。.

Comparative Effectiveness of Intranasal Dexmedetomidine-Midazolam versus Oral Chloral Hydrate Targeting Moderate Sedation during Pediatric Transthoracic Echocardiograms

Objective  To compare efficacy and safety of two moderate sedation regimens for transthoracic echocardiography (TTE): intranasal dexmedetomidine-midazolam (DM) versus oral chloral hydrate (CH) syrup. Method  This was a retrospective cohort of 93 children under 4 years of age receiving moderate sedation with either DM or CH for TTE from January 2011 through December 2014. Measurements and Main Results  Forty-nine patients received oral CH and 44 received the intranasal combination of DM. The demographics between groups were similar except the DM patients were slightly older and heavier (each p  < 0.05). Failure rate between groups did not reach statistical significance (CH 14.3% vs. DM 6.8%; p  = 0.324). Total sedation to discharge time was similar between groups (CH 89.4 minutes vs. DM 89.6 minute; p  = 0.97). Cardiopulmonary data did reveal a significantly lower heart rate (101.9 vs. 91.7; p  < 0.001) and respiratory rate (23.4 vs. 21.0, p  = 0.03) in the DM group, but no difference in blood pressure measurements or echo determined shortening fraction. Conclusion  These data support the use of intranasal DM as a safe and efficacious method of moderate sedation for children undergoing TTE.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery

OBJECTIVES

The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery.

DESIGN

Prospective observational study.

SETTING

Tertiary university hospital.

PARTICIPANTS

The study comprised 51 patients aged 18 years or older presenting for cardiac surgery.

INTERVENTIONS

Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01).

CONCLUSIONS

Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view

OBJECTIVES

The tricuspid annular plane systolic excursion (TAPSE) is a validated measure of right ventricular function; however, the apical echocardiographic window varies and has limitations in intensive care unit (ICU) patients receiving mechanical ventilation or those with underlying disease and air entrapment. We aimed to evaluate the subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) as an alternative to TAPSE in critically ill patients.

METHODS

To measure SEATAK, we obtained the subcostal inferior vena cava view and used M-mode to measure excursion of the tricuspid annulus (kick). Analysis was performed with JMP for Bland-Altman and Spearman correlations.

RESULTS

We evaluated 45 patients, 26 (57.8%) of whom were women, with a mean age of 60.8 years. We were not able to obtain the apical view to measure TAPSE in 8.9% of the patients. In contrast, SEATAK was measured in all patients. The mean SEATAK and TAPSE were 1.62 cm and 1.93 cm, respectively, with a mean pairwise difference of -0.26 cm (95% CI: -0.19 to -0.35), with the SEATAK value being lower than TAPSE. The overall correlation was strong and significant (ρ = .86, P=.03). The graphical correlation was maintained between TAPSE and SEATAK and the degree of RVF.

CONCLUSION

In patients presenting with RVF in the ICU (or in situations where the apical echocardiographic view is suboptimal for tricuspid annular assessment), SEATAK can be an alternative to TAPSE. Further research is needed to validate and determine the sensitivity and specificity of SEATAK for RVF prognostication.

Usefulness of bubble study in echocardiographic diagnosis of contained rupture of hydatid cyst in the right ventricular outflow tract

We describe an adult female presenting with dyspnea in whom both transthoracic and transesophageal echocardiography detected a mobile sac-like structure in the right ventricular outflow tract (RVOT) containing a heterogenous echogenic mass. This sac-like structure markedly changed its shape and size during the cardiac cycle. These findings and the fact that the patient lived in a rural area raised the possibility that this was a hydatid cyst. A bubble study using normal saline was useful in detecting a contained rupture of the cyst. Bubble echoes were noted within the sac-like structure but did not penetrate the inner wall of the cyst which contained echogenic material, indicating that the rupture was confined only to the outer layers. At surgery, a 0.5 cm communication was noted between the cyst and the RVOT and pathology confirmed the diagnosis of hydatid cyst.

Sonography and Transthoracic Echocardiography for Diagnosis of Systemic Cardiovascular Metastatic Tumor Thrombi

Sonography and transthoracic echocardiography (TTE) are seldom used for assessment of metastatic tumor thrombi in the cardiovascular system in routine clinical practice. We performed this retrospective study to evaluate the combination of sonography with TTE for diagnosis of metastatic tumor thrombi in heart and systemic vessels. Vascular, abdominal, pelvic, and small-part sonography was applied in 18 patients, and TTE was conducted simultaneously in 14 patients. Tumor thrombi invaded into the inferior vena cava system in 12 patients, superior vena cava system in 5 patients, and aorta in 1 patient; they extended to the right cardiac chambers in 11 patients. Six patients had diagnoses by pathologic examination. The primary neoplasms were identified by conventional imaging in 17 patients. The morphologic and echogenic characteristics of the tumor thrombi were diverse and depended on their original tumors. The thrombi were either contiguous or discrete from the original tumors. The neoplastic vascularity of the thrombi and the invasive extension were the primary characteristics that distinguished them from bland thrombi. Simultaneous application of sonography and TTE is a feasible way to comprehensively evaluate cardiovascular metastatic tumor thrombi in most patients.

Simulation-based training in echocardiography

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

Early detection of right ventricular dysfunction using transthoracic echocardiography in ARDS: a more objective approach

PURPOSE

Right ventricular (RV) dysfunction is an independent predictor of morbidity and mortality in acute respiratory distress syndrome (ARDS). Our goal was to describe morphologic changes in the RV using objective measures on transthoracic echocardiography (TTE) that occur following ARDS.

METHODS

We retrospectively measured changes in the following RV parameters from a pre-ARDS TTE to an ARDS TTE: tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), fractional area change (FAC), systolic pulmonary artery pressure (SPAP), peak tricuspid regurgitant (TR) velocity, and septal shift.

RESULTS

Over 24 months, 14 patients met inclusion/exclusion criteria. Mean TAPSE decreased from 22.4 mm pre-ARDS to 16.3 mm during ARDS, P<.001. Mean MPI increased from 0.19 to 0.38, P=.001. Mean FAC decreased from 60.8% to 41.2%, P=.003. Peak TR velocity increased from 2.67 m/s pre-ARDS to 3.31 m/s during ARDS, P=.02. SPAP and septal shift demonstrated trends but not statistically different between pre-ARDS and ARDS states. TAPSE correlated with ARDS severity (PaO₂ /FiO₂ ratios), P=.004, and was lower among 30-day nonsurvivors compared with survivors, P=.002.

CONCLUSIONS

Mild RV dysfunction is common after ARDS onset. RV morphologic changes coupled with dysfunction can be detected noninvasively through TTE changes with TAPSE, MPI, and FAC. Mild RV dysfunction by TAPSE is associated with ARDS severity and mortality.

Giant left atrial appendage aneurysm compressing the left anterior descending coronary artery

Left atrial appendage aneurysm (LAAA) is a rare congenital structural heart disease. It is often diagnosed by echocardiography; however, other imaging modalities can add to its diagnosis and its potential effects on the surrounding structures. A 16-year-old boy presented with dyspnea and palpitation. Transthoracic echocardiography showed a large LAAA communicating with the LA through a narrow neck with impaired left ventricular (LV) systolic function. Multidetector cardiac tomography showed that the LAAA is compressing the left anterior descending artery. The LAAA was surgically resected followed by improvement of the LV systolic function.

Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery

Transthoracic and transoesophageal echocardiography are increasingly used as tools to improve clinical assessment following cardiac surgery. However, most physicians are not trained in echocardiography, and there is no widespread agreement on the feasibility, indications or effect on outcome of transthoracic or transoesophageal echocardiography for patients after cardiac surgery. We performed a systematic review of electronic databases for focused transthoracic and transoesophageal echocardiography after cardiac surgery which revealed 15 full-text articles. They consistently reported that echocardiography is feasible, whether performed by a novice or expert, and frequently resulted in important changes in diagnosis of cardiac abnormalities and their management. However, most were observational studies and there were no well-designed trials investigating the impact of echocardiography on outcome. We conclude that both transthoracic and transoesophageal echocardiography are useful following cardiac surgery.

Transthoracic Echocardiography Provides Important Long-Term Prognostic Information in Selected Patients Undergoing Endovascular Abdominal Aortic Repair

BACKGROUND

The value of performing transthoracic echocardiography (TTE) as part of the clinical assessment of patients awaiting endovascular repair of the abdominal aorta is little evaluated. We aimed to estimate the prognostic importance of information derived from TTE on long-term all-cause mortality in a selected group of patients undergoing endovascular aneurysm repair.

METHODS AND RESULTS

This was a retrospective cohort study of 273 consecutive patients selected for endovascular aneurysm repair. All patients included in the analysis underwent TTE before their procedure. Multivariable Cox regression analysis was used to estimate the effect of TTE measures on all-cause mortality. Over a mean follow-up of 3.2±1.5 years, there were 78 deaths with a mean time to death of 1.28±1.16 years. A greater tubular ascending aorta (hazard ratio [HR] 5.6, 95% confidence interval [CI] 2.77-11.33), presence of mitral regurgitation (HR 8.13, 95% CI 4.09-12.16), lower left ventricular ejection fraction (HR 0.96, 95% CI 0.93-0.98), younger age (HR 0.97, 95% CI 0.95-0.99), and presence of diabetes mellitus (HR 1.46, 95% CI 1.24-1.89) were predictors of all-cause mortality.

CONCLUSIONS

Echocardiography provides important long-term prognostic information in patients undergoing endovascular aneurysm repair. These TTE indices were more important at predicting outcome than standard conventional risk factors in this patient group. A greater tubular ascending aorta, presence of mitral regurgitation, reduced left ventricular ejection fraction, younger age, and diabetes mellitus were independently associated with long-term mortality.

Echocardiographic parameters of right ventricular function predict mortality in acute respiratory distress syndrome: a pilot study

Right ventricular (RV) dysfunction in acute respiratory distress syndrome (ARDS) contributes to increased mortality. Our aim is to identify reproducible transthoracic echocardiography (TTE) parameters of RV dysfunction that can be used to predict outcomes in ARDS. We performed a retrospective single-center cohort pilot study measuring tricuspid annular plane systolic excursion (TAPSE), Tei index, RV-fractional area change (RV-FAC), pulmonary artery systolic pressure (PASP), and septal shift, reevaluated by an independent blinded cardiologist (JK). Thirty-eight patients were included. Patients were divided on the basis of 30-day survival. Thirty-day mortality was 47%. Survivors were younger than nonsurvivors. Survivors had a higher pH, PaO2∶FiO2 ratio, and TAPSE. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were lower in survivors. TAPSE has the strongest association with increased 30-day mortality from date of TTE. Accordingly, TAPSE has a strong positive correlation with PaO2∶FiO2 ratios, and Tei index has a strong negative correlation with PaO2∶FiO2 ratios. Septal shift was associated with lower PaO2∶FiO2 ratios. Decrease in TAPSE, increase in Tei index, and septal shift were seen in the severe ARDS group. In multivariate logistic regression models, TAPSE maintained a significant association with mortality independent of age, pH, PaO2∶FiO2 ratios, positive end expiratory pressure, PCO2, serum bicarbonate, plateau pressures, driving pressures, APACHE II, SAPS II, and SOFA scores. In conclusion, TAPSE and other TTE parameters should be used as novel predictive indicators for RV dysfunction in ARDS. These parameters can be used as surrogate noninvasive RV hemodynamic measurements to be manipulated to improve mortality in patients with ARDS and contributory RV dysfunction.

The role of TTE in assessment of the patient before and following TAVI for AS

Transcatheter aortic valve implantation is now accepted as a standard mode of treatment for an increasingly large population of patients with severe aortic stenosis. With the availability of this technique, echocardiographers need to be familiar with the imaging characteristics that can help to identify which patients are best suited to conventional surgery or transcatheter aortic valve implantation, and what parameters need to be measured. This review highlights the major features that should be assessed during transthoracic echocardiography before presentation of the patient to the 'Heart Team'. In addition, this review summarises the aspects to be considered on echocardiography during follow-up assessment after successful implantation of a transcatheter aortic valve.

Sonographic Characterization of Arterial Dissections in Takayasu Arteritis

OBJECTIVES

Takayasu arteritis is a relatively rare chronic nonspecific form of large-vessel vasculitis in which the involved vessels develop stenoses, occlusions, dilatations or aneurysms, and dissections. Dissections of the arteries in patients with Takayasu arteritis are not well understood. In this study, we explored the sonographic characterization of these rare complications secondary to Takayasu arteritis.

METHODS

We evaluated arterial dissections in 72 patients with a clinical diagnosis of Takayasu arteritis by vascular sonography and transthoracic echocardiography. We analyzed the dissection distribution and morphologic characteristics of the dissected intima/layer and lumen of the involved vessels.

RESULTS

Twelve of 72 patients had arterial dissections, in whom 16 dissected segments were identified. The involved arteries included the carotid, subclavian, vertebral, brachial, celiac, and femoral arteries, aortic arch, and abdominal aorta. The dissection lesions occurred at any age and coexisted with the aforementioned injuries. Evaluation of the dissected intima/layer and the involved lumen by sonography was technically complicated. The morphologic characteristics of the dissected intimae and involved lumens were complex, with most of the dissected intimae/layers having the characteristic "macaroni" sign in the arterial wall. High-frequency and high-resolution sonography, color Doppler flow imaging, and other techniques were useful in elucidating greater lesion details.

CONCLUSIONS

Arterial dissections in Takayasu arteritis can involve any anatomic vessel location and have complex morphologic characteristics. Sonography is the optimal technique for diagnosis and follow-up of patients with Takayasu arteritis and dissections.

ACR Appropriateness Criteria Clinically Suspected Pulmonary Arteriovenous Malformation

Pulmonary arteriovenous malformations are often included in the differential diagnosis of common clinical presentations, including hypoxemia, hemoptysis, brain abscesses, and paradoxical stroke, as well as affecting 30% to 50% of patients with hereditary hemorrhagic telangiectasia (HHT). Various imaging studies are used in the diagnostic and screening settings, which have been reviewed by the ACR Appropriateness Criteria Vascular Imaging Panel. Pulmonary arteriovenous malformation screening in patients with HHT is commonly performed with transthoracic echocardiographic bubble study, followed by CT for positive cases. Although transthoracic echocardiographic bubble studies and radionuclide perfusion detect right-to-left shunts, they do not provide all of the information needed for treatment planning and may remain positive after embolization. Pulmonary angiography is appropriate for preintervention planning but not as an initial test. MR angiography has a potential role in younger patients with HHT who may require lifelong surveillance, despite lower spatial resolution compared with CT. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Transthoracic Echocardiography-Guided Percutaneous Patent Ductus Arteriosus Occlusion: A New Strategy for Interventional Treatment

INTRODUCTION

Percutaneous patent ductus arteriosus (PDA) occlusion has become the preferred therapeutic option, which uses fluoroscopy as the guidance. To reduce the x-ray exposure, PDA occlusion using the Amplatzer Duct Occluder II (ADO II) under guidance of transthoracic echocardiography only was conducted. This single center study aims to access the safety and efficiency of this new strategy.

METHODS AND RESULTS

From June 2013 to May 2015, 63 consecutive PDA patients underwent transthoracic echocardiography-guided PDA occlusion through the femoral artery. Outpatient follow-up was conducted at 1, 3, and 6 months, and yearly. Sixty-two patients successfully underwent echocardiography-guided percutaneous PDA occlusion. One patient was converted to minimally invasive transthoracic occlusion due to failure of delivery sheath passage through tortuous PDA. Mean procedure duration was 24.3 ± 7.0 minutes; ADO II diameter averaged 4.6 ± 0.9 mm; 8 cases showed traces of residual shunt immediately after operation which resolved after 24 hours; and mean hospital stay was 3.4 ± 0.5 days. There was no occluder migration, hemolysis, pericardial effusion, pulmonary branch or aortic stenosis at mean 13.5 ± 4.8 months follow-up.

CONCLUSIONS

This study demonstrated that percutaneous PDA occlusion can be successfully performed under guidance of transthoracic echocardiography only and appears safe and effective while avoiding radiation and contrast agent use.

Epiaortic fat pad area: A novel index for the dimensions of the ascending aorta

We sought to investigate the possible association between the area of the epiaortic fat pad (EAFP) and dimensions of the ascending aorta. A total of 193 individuals underwent transthoracic echocardiography (TTE) prospectively. The area of the EAFP was traced anterior to the aortic root and correlated with the diameter of the aorta. The mean area of the EAFP was 5.16 ± 2.28 cm(2) Absolute and indexed dimensions of the ascending aorta had a significant correlation with the area of the EAFP (p <0.001 for all). In a multivariate linear regression model, age >65 (p <0.001), body mass index >30 kg/m(2) (p = 0.02) and a history of hyperlipidemia (p = 0.003) were identified as independent predictors of the area for EAFP. In conclusion, both the absolute and indexed diameters of the ascending aorta at the different segments that directly come into contact with the EAFP linearly correlate with the area of the EAFP measured by TTE.

Relationship between mitral annulus function and mitral regurgitation severity and left atrial remodelling in patients with primary mitral regurgitation

AIMS

To explore the relationship between the mitral annular (MA) remodelling and dysfunction, mitral regurgitation (MR) severity, left ventricular (LV) and atrial (LA) size and function in patients with organic MR (OMR).

METHODS AND RESULTS

A total of 52 patients (57 ± 15 years, 31 men) with mild to severe OMR and 52 controls underwent 3D transthoracic echocardiography acquisitions of the mitral valve (MV), LA, and LV. MA geometry and dynamics, LV and LA volumes, LV ejection fraction (LVEF) and emptying fractions (LAEF) were assessed using dedicated software packages. LA and LV myocardial deformations were assessed using 2D speckle-tracking echocardiography. OMR patients presented larger and more spherical MA than controls during the entire systole (P < 0.001). Although the MA non-planarity at early-systole was similar between OMR and controls (157 ± 13° vs. 153 ± 12°, P = NS), the MA became flatter from mid- to end-systole (153 ± 12 vs. 146 ± 10° and 157 ± 12 vs. 147 ± 8°, P < 0.01) in OMR. MA area fractional change was lower in patients with OMR (22 ± 5% vs. 28 ± 5%, P < 0.001), and correlated with the MR orifice and volume (r = -0.52 and r = -0.55). MA fractional area change correlated with LA minimum and maximum volumes (r = 0.77 and r = 0.70), total and active LAEF (r = 0.72 and r = 0.76), and LA negative strain and strain rate (r = 0.52 and r = 0.57), but not with the LVEF or LV global longitudinal strain. In a multivariate regression model using LAEF and LVEF, solely active LAEF correlated with the MA fractional area change (β = 0.51, P = 0.005).

CONCLUSION

In patients with OMR, MA reduced function correlates with the MR severity and the LA size and function, but not with the LV function.

Right Ventricular Function Is Associated with Left Ventricular Stroke Volume in Patients with Severe Aortic Stenosis and Preserved Ejection Fraction

BACKGROUND

A subset of patients with severe aortic stenosis (AS) have lower stroke volumes and valve gradients despite a normal left ventricular ejection fraction (LVEF), referred to as paradoxical low-flow AS (PLF AS). However, the role of right ventricular (RV) function in patients with severe AS and preserved LVEF is not known. We hypothesized that right ventricular function is associated with left ventricular stroke volume in patients with severe AS and preserved LVEF.

METHODS

From an echocardiographic database, we retrospectively identified 102 patients with an indexed aortic valve area ≤0.6 cm(2) /m(2) and LVEF ≥ 50%. We used univariate and multivariate linear regression analysis to assess the association between aortic valve stroke volume index (SVi) and right ventricular systolic function as measured by tricuspid annular plane systolic excursion (TAPSE) and by right ventricular fractional area change (FAC).

RESULTS

Our population was 98% male with mean age 77.4 ± 9.3 years and mean SVi of 36.1 ± 7.9 mL/m(2) . Forty-four patients (43%) met criteria for PLF AS. TAPSE and FAC were positively associated with SVi in both univariate and multivariate regression analysis after correcting for left ventricular variables (β coefficient - TAPSE (cm): 4.59 ± 1.3, P = 0.001; FAC (%): 0.19 ± 0.08, P = 0.014). Additionally, PLF AS patients had significantly lower mean TAPSE and lower mean FAC when compared dichotomously to normal flow AS patients (P < 0.05).

CONCLUSIONS

Right ventricular systolic function assessed by TAPSE and FAC is significantly related to aortic valve flow in patients with severe AS and preserved LVEF.

Efficacy and Safety of Transthoracic Echocardiography Alone in Transcatheter Closure of Secundum-Type Atrial Septal Defects in Adults

BACKGROUND

On-site transthoracic echocardiography (TTE) to guide the transcutaneous closure of secundum-type atrial septal defects (ASDs) in the catheterization laboratory remains unclear, especially in adults.

METHODS

Between 2005 and 2012, a total of 82 adults underwent transcutaneous closure of ASDs. The initial 15 cases underwent the procedure with both on-site transesophageal echocardiography (TEE) and TTE monitoring. Since January 2008, a total of 67 patients underwent on-site TTE alone to guide the procedure.

RESULTS

Among the 82 adult patients who underwent a transcutaneous closure of the secundum-type ASD procedure, all had successful closure of the defects, and no periprocedural adverse complications occurred. No statistical significance was observed in the successful complete shunt closure rate between the TEE plus TTE and TTE groups during sequential follow-up (postprocedure 24 hour [87% vs. 92%],1 month [93% vs. 95%], 3 month [93% vs. 97%], and 12 month [93% vs. 97%], P > 0.05, respectively) nor was a significant difference observed between the two groups, including decreased right ventricular dimension (29.5 ± 3.3 vs. 32.0 ± 4.9 mm, 26.5 ± 3.0 vs. 28.7 ± 4.6 mm, 26.2 ± 3.1 vs. 28.2 ± 4.8 mm, and 25.6 ± 2.8 vs. 27.7 ± 4.7 mm, P > 0.05, respectively) or increased left ventricular end-diastolic dimension (41.1 ± 2.0 vs. 42.6 ± 3.0 mm, 44.3 ± 2.7 vs. 45.5 ± 3.1 mm, 44.2 ± 2.8 vs. 45.4 ± 3.1 mm, 44.9 ± 2.7 vs. 45.8 ± 2.6 mm, P > 0.05, respectively) before the procedure, and at the 3-, 6-, and 12-month follow-up evaluations.

CONCLUSION

This study showed that TTE guidance alone may be considered efficacious and safe as TEE during a transcutaneous ASD occlusion procedure in select adults.

Preventive echocardiographic examination in athletes and workers - Quadricuspid aortic valve and atrial septal aneurysm in a young basketball player

Ensuring safety of young athletes and employees who perform hard physical work within the scope of their professional duties, with a special focus on prevention of a sudden cardiac death at sports fields or during hard physical work is one of the most important tasks, which demands joint effort of cardiologists and sport physicians or occupational physicians, who qualify patients for a job or a sport discipline. Apart from hypertrophic and arhythmogenic right ventricular cardiomyopathy, coronary anomalies and aortic dissection belong to the most frequent causes of dramatic complications during competitive exercise or work with an increased energy expenditure. Although a detailed medical history and a physical examination combined with 12-lead ECG assessment may significantly improve the safety in competitive sports, adding echocardiography examination gives a detailed and noninvasive insight into the heart morphology and function. Therefore, in our opinion, it should constitute a standard part of the evaluation of candidates for competitive sports. The practice indicates that beyond subjects with severe heart diseases and those classified as normal, there is a group of individuals with abnormalities which should be more closely monitored, but are not contraindications against professional sports or work with an increased energy expenditure. We describe the case of a young female with a diagnosis of rare congenital aortic valve disease, quadricuspid valve, with mild regurgitation and atrial septal aneurysm which was established during transthoracic echocardiography and confirmed and expanded during TEE examination.

Feasibility of proximal right coronary artery imaging by 2D and 3D echocardiography in comparison to coronary angiography

The present study was carried out to test the feasibility of proximal right coronary artery (RCA) imaging and to detect proximal RCA narrowing and occlusion by 2D and 3D transthoracic echocardiography in comparison to coronary angiography (CA). Standardised 2D and 3D echocardiography were performed prior to CA in 97 patients with sinus rhythm. The following parameters were determined: the longest longitudinal detectable RCA segment, the minimum and maximum width of the RCA, the area and number of detectable narrowing >50% of the proximal RCA and the correlation between the echocardiographic and angiographic findings. The visualisation of the proximal RCA and the detection of coronary artery narrowing in the proximal RCA are generally possible. Differences in width and area were not statistically significant between 2D and 3D echocardiography, but showed significant differences between echocardiography and CA. For the detection of proximal RCA narrowing, higher sensitivity and specificity values were obtained by 2D than by 3D echocardiography. However, in patients with sufficient image quality 3D echocardiography permits a more detailed visualisation of the anatomical proportions and an en-face view into the RCA ostium. The visualisation of the proximal RCA is feasible and narrowing can be detected by 2D and 3D echocardiography if image quality is sufficient. CA is the gold standard for the detection of coronary artery stenoses. However, the potential of this new approach is clinically important because crucial findings of the proximal RCA can be presumably detected non-invasively prior to CA.

Pulmonary arterial hypertension in systemic lupus erythematosus may benefit by addition of immunosuppression to vasodilator therapy: an observational study

OBJECTIVE

To document changes in pulmonary arterial systolic pressure (PASP) in patients with SLE who have received CYC for any indication.

METHODS

Twenty-four patients with SLE pulmonary arterial hypertension (PAH) with a PASP of >30 mmHg by transthoracic echocardiography received i.v. CYC (n = 24) or steroids (n = 24) with or without vasodilators (n = 20). Baseline clinical characteristics and PASP were evaluated before and after therapy at 6 months. Responders were defined as those who had a decrease in PASP of >15 mmHg from baseline along with improvement in their New York Heart Association functional class.

RESULTS

There were 11 responders (45.83%), with a decrease in mean PASP from 59.33 mmHg at baseline to 43.29 mmHg at the end of 6 months (P < 0.0001). The decrease in mean PASP from 39.75 mmHg at baseline to 34.4 mmHg at the end of 6 months was significant in four patients who received immunosuppression alone (P = 0.04). There was no difference in baseline PASP and disease activity between responders and non-responders. Two deaths were noted.

CONCLUSION

Immunosuppression and vasodilators produced significant improvement in SLE PAH over 6 months.

Rare Mycotic Aneurysm of the Mitral Valve without Aortic Valve Involvement

Mycotic aneurysms can be a rare, but serious complication of infectious endocarditis. We report the case of a 20-year-old woman who presented with fever and malaise from streptococcal bacteremia and found to have vegetation on the anterior leaflet of the mitral valve. On follow-up visit, the patient was noted to have a mycotic aneurysm of the anterior mitral valve without aortic involvement. Her clinical course was complicated by mitral valve chordal rupture, severe mitral regurgitation, and dyspnea from severe mitral regurgitation for which she underwent successful surgical repair of the mitral valve.

Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic dissection

STUDY OBJECTIVE

The purpose of the present study was to establish the accuracy of transthoracic echocardiography (TTE) in diagnosis of acute type A aortic dissection in comparison to computed tomography (CT), with reference to the intraoperative image.

METHODS

The retrospective analysis included 178 patients referred to the cardiac surgery unit in our center due to acute type A dissection between 01-01-2008 and 31-12-2013, who underwent both TTE and CT. Intraoperative image was considered as a reference.

RESULTS

Statistical analysis did not show any significant differences between computed tomography and echocardiography in the detection of the proximal aortic dissection. In patients with aortic valve abnormalities, procedure of choice was replacement by a composite graft (77,59%), whereas patients with a normal image of aortic valve were more likely to have the valve sparing procedure (50,88%). The R-Spearman statistics shows a strong positive correlation between maximum diameter of ascending aorta measured by TTE and CT (cc 0.869) and TTE and intraoperative measurement (cc 0.844).

CONCLUSION

Our data confirm that transthoracic echocardiography is a reliable method for diagnosis of proximal aortic dissection. TTE provides a reliable value of maximum diameter of the ascending aorta in comparison to both CT and direct intraoperative measurement. Moreover, transthoracic echocardiography gives the additional information that influences the operative technique of choice and identifies the high-risk patients (cardiac tamponade, severe aortic dilatation, severe aortic regurgitation). Our retrospective analysis confirms the pivotal role of TTE in the evaluation of the patients with suspected proximal aortic dissection in emergency room setting.

A propensity score-matching analysis of transthoracic echocardiography and abdominal ultrasonography for the detection of abdominal aortic aneurysms

INTRODUCTION

We previously reported that the prevalence of abdominal aortic aneurysms (AAAs) was higher in patients undergoing scheduled transthoracic echocardiography (TTE) than in patients undergoing abdominal ultrasonography (AUS); however, intergroup patient backgrounds differed significantly in that report.

PURPOSE

We tested the hypothesis that TTE could detect AAA as effectively as AUS.

DESIGN

A propensity score-matching analysis of a cross-sectional study was adopted as the design for this study.

METHODS

We enrolled 7,619 and 15,433 patients scheduled to undergo TTE with additional evaluation of abdominal aorta at the end of the routine study and AUS, respectively, from 2009 to 2010 in our hospital, as reported. A propensity score for profiles of patients who underwent TTE or AUS was developed to adjust for potential confounding bias. Consequently, 4,388 patients in each group were matched for analyses.

RESULTS

In propensity-matched patients, AAA was detected in 59 patients of the TTE group and in 48 patients of the AUS group; the prevalence of AAA detection did not differ significantly between TTE and AUS groups (P = 0.331). Positive associations were observed between AAA detection and male sex (adjusted odds ratio [OR]: 3.25; 95% confidence interval [CI], 2.05–5.15; P < 0.001), older age (adjusted OR: 1.029; 95% CI: 1.01–1.04; P < 0.001), and the presence of ischemic heart disease (adjusted OR: 1.78; 95% CI: 1.04–3.03; P = 0.033) and hypertension (adjusted OR: 2.16; 95% CI: 1.38–3.37; P = 001).

CONCLUSION

TTE detected AAA with comparable efficacy as AUS in propensity-matched groups who underwent scheduled TTE and AUS.

A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography

There have been significant advances in the field of echocardiography with the introduction of a number of new techniques into standard clinical practice. Consequently, a 'standard' echocardiographic examination has evolved to become a more detailed and time-consuming examination that requires a high level of expertise. This Guideline produced by the British Society of Echocardiography (BSE) Education Committee aims to provide a minimum dataset that should be obtained in a comprehensive standard echocardiogram. In addition, the layout proposes a recommended sequence in which to acquire the images. If abnormal pathology is detected, additional views and measurements should be obtained with reference to other BSE protocols when appropriate. Adherence to these recommendations will promote an increased quality of echocardiography and facilitate accurate comparison of studies performed either by different operators or at different departments.