Relationship between syringomyelia and myxomatous mitral valve disease in Cavalier King Charles spaniels

BACKGROUND

Syringomyelia (SM) and myxomatous mitral valve disease (MMVD) are highly prevalent in Cavalier King Charles spaniels (CKCS). Cardiac status in CKCS with and without SM is currently unknown.

OBJECTIVES

To investigate the association between SM and MMVD severity in CKCS and CKCS with SM with and without clinical signs of SM.

ANIMALS

Fifty-five CKCS: 40 with SM (22 symptomatic and 18 asymptomatic) and 15 without SM.

METHODS

A combined retrospective and prospective study. MRI and echocardiography were used to diagnose SM and MMVD, respectively. The association between SM and MMVD severity (left ventricle internal diameter in diastole normalized to bodyweight [LVIDDN] and left atrium to aortic ratio [LA/Ao]) were tested using multivariable linear regression analysis adjusting for sex and age.

RESULTS

Overall, no significant difference in LVIDDN and LA/Ao was found between CKCS with or without SM. However, CKCS with symptomatic SM had significantly smaller LVIDDN (1.45 [1.30-1.50]) (median [IQR]) and LA/Ao (1.20 [1.10-1.28]) compared to CKCS with asymptomatic SM (1.60 [1.50-1.90] and 1.40 [1.20-1.75]) as well as CKCS without SM (0.24 [0.03-0.45] and 0.30 [0.05-0.56]) (all P values <.03).

CONCLUSIONS AND CLINICAL IMPORTANCE

An association between MMVD and SM was not confirmed in this cohort of CKCS, indicating that MMVD and SM do not co-segregate. However, CKCS with symptomatic SM had smaller left ventricle and atrial size compared to CKCS with asymptomatic SM and CKCS without SM.

Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

Algorithm for predicting valvular heart disease from heart sounds in an unselected cohort

Objective

This study aims to assess the ability of state-of-the-art machine learning algorithms to detect valvular heart disease (VHD) from digital heart sound recordings in a general population that includes asymptomatic cases and intermediate stages of disease progression.

Methods

We trained a recurrent neural network to predict murmurs from heart sound audio using annotated recordings collected with digital stethoscopes from four auscultation positions in 2,124 participants from the Tromsø7 study. The predicted murmurs were used to predict VHD as determined by echocardiography.

Results

The presence of aortic stenosis (AS) was detected with a sensitivity of 90.9%, a specificity of 94.5%, and an area under the curve (AUC) of 0.979 (CI: 0.963-0.995). At least moderate AS was detected with an AUC of 0.993 (CI: 0.989-0.997). Moderate or greater aortic and mitral regurgitation (AR and MR) were predicted with AUC values of 0.634 (CI: 0.565-703) and 0.549 (CI: 0.506-0.593), respectively, which increased to 0.766 and 0.677 when clinical variables were added as predictors. The AUC for predicting symptomatic cases was higher for AR and MR, 0.756 and 0.711, respectively. Screening jointly for symptomatic regurgitation or presence of stenosis resulted in an AUC of 0.86, with 97.7% of AS cases (n = 44) and all 12 MS cases detected.

Conclusions

The algorithm demonstrated excellent performance in detecting AS in a general cohort, surpassing observations from similar studies on selected cohorts. The detection of AR and MR based on HS audio was poor, but accuracy was considerably higher for symptomatic cases, and the inclusion of clinical variables improved the performance of the model significantly.

Major congenital heart defects are rarely diagnosed after newborns' hospital discharge with modern screening

AIM

Our aim was to assess undiagnosed congenital heart defects (CHD) after newborns' hospital discharge in patients with a murmur or CHD suspicion, to find out the signs that predict CHDs and to estimate the costs of the examinations.

METHODS

We reviewed retrospective medical records of patients (n = 490) referred for the evaluation of CHD suspicion during 2017-2018.

RESULTS

The median age of the patients was 2.5 (IQR 0.5-7.4) years. Sixty-three (13%) patients had an abnormal echocardiography. Neither ductal-dependent nor cyanotic CHDs were found. Cardiac interventions were performed for 14 out of 63 (22%) patients. Clinical signs indicating CHDs were murmur grade ≥3 (10/11 [91%] vs. 53/479 [11%], p < 0.001) and harsh murmur (15/44 [34%] vs. 48/446 [11%], p < 0.001). Abnormal electrocardiography did not indicate CHD (8/40 [20%] vs. 55/447 [12%], p = 0.165). The total cost of the examinations was 259 700€. The share of the cost of studies assessed as benign was 59%.

CONCLUSION

Only a few CHDs were found after newborn hospital discharge among patients who received foetal and newborn screening and were examined due to CHD suspicion. The high number of benign murmurs in children leads to many referrals, resulting in unnecessary healthcare costs.

A Novel Earbud Detects Aortic Stenosis Murmur Before and After Transcatheter Aortic Valve Replacement

Noninvasive infrasonic hemodynography using the MindMics earbuds captures low-frequency acoustic vibrations throughout the cardiac cycle. In an n-of-1 analysis, we propose a new method of assessing severe aortic stenosis by using infrasonic hemodynography to detect its characteristic systolic ejection murmur before and after transcatheter aortic valve replacement.

Self-Reported Utilization of International Guidelines for Staging Dogs with Myxomatous Mitral Valve Degeneration: A Survey among Veterinary Practitioners

BACKGROUND

ACVIM developed and published guidelines for staging myxomatous mitral valve degeneration in dogs in 2009. An updated version was published in 2019. The present study aimed to investigate whether these guidelines are actually used by the intended public more than a decade after their first publication.

METHODS

An online survey was distributed among Dutch and Belgian veterinarians through online channels and mailing lists.

RESULTS

Of the 524 responses, only 363 complete surveys were analyzed. The ACVIM guidelines are used by 60% of the respondents. Veterinarians find it more difficult to differentiate stage B1 from B2 in asymptomatic dogs compared to diagnosing stage C. Three-quarters of the respondents would recommend echocardiography for an incidentally detected new murmur with an intensity of 3 out of 6 in an adult dog. Two-thirds of the respondents find coughing a convincing finding for stage C disease. Close to half of the respondents associate a horizontal, dull percussion line with pulmonary edema. For confirming cardiogenic pulmonary edema, 98% of the respondents used thoracic radiographs.

CONCLUSIONS

Veterinary practitioners might not have the expected training and equipment to be able to apply the guidelines in their practices, especially in the differentiation of stage B1 from stage B2.

Beyond Heart Murmur Detection: Automatic Murmur Grading From Phonocardiogram

OBJECTIVE

Murmurs are abnormal heart sounds, identified by experts through cardiac auscultation. The murmur grade, a quantitative measure of the murmur intensity, is strongly correlated with the patient's clinical condition. This work aims to estimate each patient's murmur grade (i.e., absent, soft, loud) from multiple auscultation location phonocardiograms (PCGs) of a large population of pediatric patients from a low-resource rural area.

METHODS

The Mel spectrogram representation of each PCG recording is given to an ensemble of 15 convolutional residual neural networks with channel-wise attention mechanisms to classify each PCG recording. The final murmur grade for each patient is derived based on the proposed decision rule and considering all estimated labels for available recordings. The proposed method is cross-validated on a dataset consisting of 3456 PCG recordings from 1007 patients using a stratified ten-fold cross-validation. Additionally, the method was tested on a hidden test set comprised of 1538 PCG recordings from 442 patients.

RESULTS

The overall cross-validation performances for patient-level murmur gradings are 86.3% and 81.6% in terms of the unweighted average of sensitivities and F1-scores, respectively. The sensitivities (and F1-scores) for absent, soft, and loud murmurs are 90.7% (93.6%), 75.8% (66.8%), and 92.3% (84.2%), respectively. On the test set, the algorithm achieves an unweighted average of sensitivities of 80.4% and an F1-score of 75.8%.

CONCLUSIONS

This study provides a potential approach for algorithmic pre-screening in low-resource settings with relatively high expert screening costs.

SIGNIFICANCE

The proposed method represents a significant step beyond detection of murmurs, providing characterization of intensity, which may provide an enhanced classification of clinical outcomes.

Unveiling the Silent Ductus: A Classical Presentation of Patent Ductus Arteriosus in an Asymptomatic 23-Year-Old Male

The patent ductus arteriosus (PDA) refers to the persistence of a connection between the descending aorta distal to the left subclavian artery and the pulmonary trunk beyond fetal life. Adult congenital heart disease is a rare condition, with asymptomatic cases being particularly uncommon. The following report presents the case of a young adult male, aged 23, who was discovered to possess a patent ductus arteriosus in an incidental manner. The patient presented with an acute chest complaint and was found to be asymptomatic upon examination at the hospital. Based on the preliminary medical information provided, a tentative diagnosis of a ventricular septal defect was established. However, a comprehensive echocardiographic examination revealed the presence of a patent ductus arteriosus (PDA).

Prevalence and Prognosis of Atenolol-Responsive Systolic Anterior Motion of the Septal Mitral Valve Leaflet in Young Cats with Severe Dynamic Left Ventricular Outflow Tract Obstruction

BACKGROUND

Severe dynamic left ventricular outflow tract obstruction (DLVOTO) secondary to the systolic anterior motion of the septal mitral valve leaflet (SAM) can result either from congenital mitral valve disorders or left ventricular concentric hypertrophy of any cause, in cats commonly hypertrophic cardiomyopathy (HCM). Though HCM cannot be reversed, the question remains whether atenolol can cure cats with severe DLVOTO resulting from a presumed mitral valve dysplasia.

METHODS

In this retrospective case series, client-owned asymptomatic cats younger than 1.5 years with echocardiographic evidence of SAM and severe DLVOTO were included. Oral atenolol therapy and recheck echocardiography after 2-3 months were recommended. The owners and referring veterinarians were called for long-term follow-up information.

RESULTS

Of the 28 included cats, 23 were treated with atenolol. Recheck echocardiography performed in 17 cats showed a resolution of SAM in 47%. In the long term, SAM remained absent in only 9% of the treated cats. Cardiac-related death occurred in 26% of the atenolol-treated cats.

CONCLUSIONS

The long term benefit of twice-daily atenolol therapy was documented in 9% of cats. Whether the cats where atenolol failed to resolve DLVOTO on long-term had HCM, or a therapy-resistant congenital primary mitral valve disorder remains unclear.

A Continuous Murmur as the Only Clinical Sign for Complex Coronary Artery Fistulas Diagnosis

An asymptomatic patient presented at our hospital exhibiting a Brugada electrocardiography pattern with coronary artery fistulas. Coronary artery fistula is a congenital or acquired rare abnormal condition with increased symptoms and complications over time. In the absence of the therapeutic consensus, we discuss the association and management for this condition. (Level of Difficulty: Advanced.).

An Adult Patient With a Tetralogy of Fallot Case

Tetralogy of Fallot (ToF) is considered the most frequent cyanotic congenital heart abnormality with a low adulthood survival rate if kept untreated. The majority of cases are symptomatic during infancy and mandate early treatment. Few instances of survival to asymptomatic middle-age patients have been reported, and they are decreasing due to early detection. We reported a case of a middle-aged man who was asymptomatic during his life and recently diagnosed with ToF. The patient underwent surgical repair with excellent outcomes. The case represents the possibility of diagnosing such cases in a relatively old patient despite medical development and advances.

Parachute Mitral Valve: A Case of Isolated Accessory Mitral Valve Tissue

A 69-year-old male presented to the emergency room with dyspnea on exertion lasting more than 2 weeks. Echocardiography showed an ill-defined subaortic structure. Subsequent transesophageal echocardiography revealed a parachute-like structure prolapsing into the left ventricular outflow tract causing subvalvular aortic obstruction. Surgical excision confirmed this structure as an accessory anterior mitral leaflet. (Level of Difficulty: Intermediate.).

Echocardiographic Evaluation in Neonates with Heart Murmurs

Auscultation of the heart is one of the most important tools of physical examination in neonates, which is very helpful in the diagnosis or rejection of congenital heart diseases (CHDs). The aim of this study is to investigate the causes of heart murmur in neonates hospitalized in neonatal unit in Imam Reza Hospital, Kermanshah, Iran. This cross-sectional study was conducted within the period of 18 months on neonates hospitalized in neonatal unit whose heart murmur, diagnosed through examination, and echocardiography was conducted to investigate the existence of CHD. In 62.1% of the cases, murmuring was auscultated within the first week after birth. Among 172 neonates with heart murmur, 25 subjects (14.5%) had normal echocardiogram, and others had abnormal echocardiogram in which ventricular septal defect (31.4%) was the most common CHD. Patent ductus arteriosus (23.3%) was the second common CHD found. Other defects were atrial septal defect, persistent foramen ovale, pulmonary stenosis, and tricuspid regurgitation. Among the neonates with CHD, 55 subjects were females and 92 cases were males. There was CHD history in previous siblings in 10 cases. In 73 neonates with CHD, the mother had not taken folic acid in the first trimester of pregnancy. A total of 14.5% of the hospitalized neonates suffered from innocent murmur, and the rest with heart murmur had abnormal echocardiography and suffered from CHD (85.5%). Heart murmur in neonates could be a symptom of CHD, and timely echocardiography is very important in diagnosing the type of disease.

Innocent Heart Murmur

Heart murmur is the most common reason for a referral to a pediatric cardiologist. Virtually all children have a heart murmur during their childhood. Less than 1% of murmurs are pathological in children. Innocent/functional heart murmur is the most common type of heart murmur. There are multiple theories proposed to identify etiology of innocent heart murmur with varying consensus, but everybody agrees that innocent heart murmur does not carry any morbidity or mortality risk. Even today, heart murmur is associated with high physician uncertainty and parental anxiety. Extensive cardiac evaluation for such a benign finding is also associated with high health care utilization and cost. This article attempts to review this long-known finding which continues to remain a diagnostic challenge.

Traumatic Ventricular Septal Defect Resulting from a Motor Vehicle Collision

This case report describes a rare case of ventricular septal defect due to non-penetrating trauma in a 43 year old male involved in a motor vehicle collision. The diagnosis was made by echocardiogram and the patient was taken immediately to the operating room for emergent surgical repair of the ventricular septal defect and survived.

Murmur clinic: validation of a new model for detecting heart valve disease

OBJECTIVES

We aimed to determine if auscultation or a point-of-care scan could reduce the need for standard echocardiography (transthoracic echocardiogram (TTE)) in community patients with asymptomatic murmurs.

METHODS

Requests from general practitioners were directed to a new murmur clinic. Auscultation and a point-of-care scan were performed by a cardiologist between 1 October 2013 and 31 December 2014 and by a scientist between 21 July 2015 and 9 May 2017.

RESULTS

In the first phase (cardiologist), there were 75 patients, mean age 54 (56 women), and in the second phase there were 100 patients, mean age 60 (76 women). In the total population of 175, abnormalities were shown on TTE in 52 (30%), on point-of-care scan in 52 (30%) and predicted on auscultation in 45 (26%) (p=0.125; 95% CI -0.02 to 0.29). The sensitivity of auscultation was not significantly different for the cardiologist (91%) as for the scientist (83%) (p=0.18; 95% CI -0.22 to 0.175) and the specificity was 100% for both. Accuracy was 97% for the cardiologist and 95% for the scientist. For the point-of-care scan, the sensitivity, specificity, positive and negative predictive values and accuracy were 100% for both cardiologist and scientist.

CONCLUSION

Most patients in a specialist murmur clinic had normal auscultation and point-of-care scans and no additional valve disease was detected by standard echocardiography. This suggests that a murmur clinic is a valid model for reducing demand on hospital echocardiography services.

Managing a "New" Murmur in Healthy Children and Teens

An asymptomatic child with a murmur can be challenging practice management conundrum. Some providers refer all patients with a "new" murmur to a cardiologist, likely resulting in excessive resource utilization and parental anxiety. This study examines whether the prevalence of significant cardiac pathology differs in asymptomatic patients aged 2 to 18 years who were referred for a murmur that was "new" versus those referred for a murmur that was known to exist and followed conservatively during the previous 2 years. Of 473 patients meeting inclusion criteria, 33/473 (7.0%) were diagnosed with cardiac pathology, with 21/357 (5.9%) occurring among "new" murmur referrals and 12/116 (10.3%) occurring among "known" murmur referrals. Notably, 34/357 (9.5%) patients referred for a "new" murmur had no murmur present when assessed by the cardiologist. This study suggests that asymptomatic children with a "new" murmur may be conservatively managed. This may lessen health care resource utilization rates and overall parental anxiety.

Prenatal identification of CHD murmur using four segment phonocardiographic signal analysis

Congenital heart defects (CHD) are one of the utmost birth defects present in the neonatal after birth and a big challenge for the researchers to identify the structural abnormality during the antepartum period. An algorithm is presented here to identify the presence of CHD through foetal phonocardiographic (fPCG) signals. The recorded fPCG is decomposed using Daubechies4 wavelet with sub-level threshold to remove the noise in the signal. The Shannon energy is used to identify the different peaks of signals and then S1 and S2 according to the intervals between adjacent peaks. The signal is segmented into four important parts: S1, S1S2, S2 and S2S1. The FFT is used to identify the frequency component present in four segments which in turn indicates the presence of pathological murmur that may turn into CHD. The algorithm is tested on 25 samples with accuracy rate 88% in identifying the presence of a murmur.

Incomplete Kawasaki disease in a 12-month-old girl presenting with cardiac murmur and iron deficiency anemia

Kawasaki disease (KD) is an acute necrotizing vasculitis that occurs in children <5 years of age. The cause of KD remains unknown, but various complications, including dilatation of the coronary arteries, can occur. Coronary artery aneurysm or ectasia are the most important complications of KD. Children with suspected KD who do not fulfill the diagnostic criteria may have incomplete KD. Given that incomplete KD is associated with delayed diagnosis and treatment, children with incomplete KD have a high risk of cardiovascular complications. Meanwhile, iron deficiency anemia (IDA) is one of the most prevalent micronutrient deficiencies in the world. Children with IDA are prone to infection and inflammation. We report the case of a 12-month-old girl with incomplete KD who presented with cardiac murmur and severe IDA.

Occurrence of mitral valve insufficiency in clinically healthy Beagle dogs

Chronic degenerative valve disease (CDVD) is the most common cardiac disease in dogs, usually resulting in mitral valve insufficiency (MVI). The goal of this study was to investigate the occurrence of MVI in clinically healthy Beagle populations. A total of 79 adult healthy Beagles (41 females and 38 males; age: 5.6 ± 2.7 years, range 1.4 to 11.7 years) were examined. The diagnosis of MVI was based on the detection of a systolic murmur heard above the mitral valve, and was confirmed by colour flow Doppler (CFD) echocardiography. Systolic mitral valve murmurs were detected in 20/79 dogs (25.3%), of them 11 males and 9 females with no statistically significant gender difference (P = 0.6059). The strength of the murmur on the semi-quantitative 0/6 scale yielded intensity grade 1/6 in 10 dogs, grade 2/6 in 4 dogs, and grade 3/6 in 6 dogs. Mild to moderate MVI was detected by CFD in all these 20 dogs with systolic murmurs. Of them, 17 dogs had mild and 3 demonstrated moderate MVI, showing 10-30% and 30-50% regurgitant jets compared to the size of the left atrium, respectively. The age of dogs with MVI was 7.1 ± 2.3 years, which was significantly different from that of dogs without MVI (5.1 ± 2.7 years, P = 0.0029). No significant differences in body weight (P = 0.1724) were found between dogs with MVI (13.8 ± 2.8 kg) and those without MVI (12.8 ± 3.0 kg). Mitral valve disease causing MVI is relatively common in Beagle dogs, just like in other small breed dogs reported in the literature.

Acute Aortic Valve Rupture From Infective Endocarditis After Transrectal Prostate Biopsy: A Call to Revise the AHA Guidelines for Prevention of Infective Endocarditis

We describe the case of a 63-year-old man with a known murmur who presented with a 4-month history of intermittent fever and a progressive reduction in energy level after a transrectal prostate biopsy (TRPB). He subsequently presented with acute heart failure secondary to aortic valve cusp rupture caused by endocarditis and underwent urgent aortic valve surgery. The 2008 American College of Cardiology/American Heart Association Guideline update on infective endocarditis has narrowed the use of antibiotic prophylaxis before most accepted dental procedures and continues to recommend against prophylaxis before genitourinary or gastrointestinal procedures. In contrast, the American Urological Association recommends the use of fluoroquinolones for the prevention of transrectal ultrasound–derived infectious complications. Notably, TRPB is associated with a high frequency of bacteremia and bacteriuria. In our case, an antibiotic course before the procedure and a more meticulous medical work-up after febrile illness might have mitigated the patient’s catastrophic medical presentation.

Nasal consonant production in Broca's and Wernicke's aphasics: speech deficits and neuroanatomical correlates

The present study investigated the articulatory implementation deficits of Broca's and Wernicke's aphasics and their potential neuroanatomical correlates. Five Broca's aphasics, two Wernicke's aphasics, and four age-matched normal speakers produced consonant-vowel-(consonant) real word tokens consisting of [m, n] followed by [i, e, a, o, u]. Three acoustic measures were analyzed corresponding to different properties of articulatory implementation: murmur duration (a measure of timing), amplitude of the first harmonic at consonantal release (a measure of articulatory coordination), and murmur amplitude over time (a measure of laryngeal control). Results showed that Broca's aphasics displayed impairments in all of these parameters, whereas Wernicke's aphasics only exhibited greater variability in the production of two of the parameters. The lesion extent data showed that damage in either Broca's area or the insula cortex was not predictive of the severity of the speech output impairment. Instead, lesions in the upper and lower motor face areas and the supplementary motor area resulted in the most severe implementation impairments. For the Wernicke's aphasics, the posterior areas (superior marginal gyrus, parietal, and sensory) appear to be involved in the retrieval and encoding of lexical forms for speech production, resulting in increased variability in speech production.