P46 THREE–DIMENSIONAL ECHOCARDIOGRAPHY EVALUATION OF MITRAL VALVE ANATOMY AFTER PERCUTANEOUS EDGE TO EDGE REPAIR

Background

Transcatheter edge–to–edge repair (TEER) is a safe strategy for high–risk patients with significant mitral regurgitation (MR). We aimed to characterize by three–dimensional echocardiography (3D–E) acute reshaping of mitral valve apparatus, with specific reference to the underlying MR mechanism (functional (FMR)and degenerative (DMR))

Methods

We prospectively enrolled 15 patients(November 2020 to September 2021),(median age 81 y.o, range 79–84, 50% male, 1 urgent procedure) with severe mitral valve regurgitation who underwent intra–procedural 3D–E before and after device deployment. Using a dedicated semiautomatic software, we obtain parametric quantification of mitral valve anatomy to describe acute changes in FMR and DMR.

Results

Eight patients (53%) were affected by FMR of whom one case was performed as bridge to heart transplantation candidacy. In the remaining 7 DMR cases, P2 prolapse was present in 5 (71%), commissural flail and A2 flail in 2 cases. Procedural success (MR < 2) was achieved in 14 cases (93%). 30–day survival was 100% in elective cases. A second clip was necessary in 8 patients (53%). After TEER, the FMR group experienced an immediate annular reshaping, with reduction of antero–posterior diameter (p 0.05), next to a recovery of physiological saddle–shape, defined by lower non–planar angle (p = 0.001) and higher annulus height (p ≤ 0.001). The DMR group showed a trend of decrease of maximum annular velocity, addressing a stabilizing effect of the device.The deployment of a second clip has no significant effect of the annular reshaping in both groups.

Conclusions

TEER causes multiple effects on mitral valve geometry which variesaccording to MR mechanism. Three–D parametric quantification of MV anatomy identifiedspecific parameters of acute annular remodeling. FMR exhibited pronounced modification. This “annuloplasty–like” effect may play a role in the late freedom from MR.

Real-Time 3D echocardiography in a young adult with idiopathic dilatation of the pulmonary artery: a case report

Idiopathic dilatation of the pulmonary artery (IDPA) is an uncommon anomaly occurring in 0.6% of patients with congenital heart disease. IDPA is characterized by the enlargement of the main pulmonary artery with or without dilatation of the right and left pulmonary arteries. We describe 2D and Real-Time 3D Echocardiography findings in a young adult with IDPA. To the best of our knowledge this is the first case reporting all echocardiographic findings diagnostic for IDPA.

An isolated anterior mitral leaflet cleft: a case report

Introduction

The anterior mitral leaflet cleft is an unusual congenital lesion most often encountered in association with other congenital heart defects. The isolated anterior leaflet cleft is quite a rare anomaly and is usually cause of mitral valve regurgitation. The importance of the lesion is that it is often correctable. When feasible, cleft suture and, eventually, annuloplasty are preferable to valve replacement. Echocardiography is the first choice technique in the evaluation of mitral valve disease, providing useful information about valve anatomy and hemodynamic parameters.

Case presentation

We present a case of an isolated anterior mitral leaflet cleft producing moderate-severe mitral regurgitation correctly identified by echocardiography and successfully surgically corrected.

Conclusion

Isolated cleft is a rare aberration, that has to be known in order to be diagnosed. Transthoracic and transesophageal echocardiography is the most useful non invasive technique for cleft diagnosis and to indicate the right surgical correction.

Infective endocarditis on mitral annular calcification: a case report

Introduction

Mitral annular calcification is a common finding in elderly patients; it is considered a benign cardiac abnormality but it can be a predisposing factor for infective endocarditis. Although described in numerous necropsy studies, endocarditis on mitral annular calcification has rarely been reported during life, and the frequency of sepsis can be underestimated because of difficult diagnosis.

Case presentation

We present a case of infective endocarditis on mitral annulus calcification in a patient with acute coronary syndrome, diagnosed with transthoracic echocardiography.

Conclusion

Transthoracic echocardiography may contribute to a correct diagnosis, showing typical findings of infective endocarditis on mitral annular calcification in order to administrate an adequate antibiotic prophylaxis in patients undergoing endoscopic or invasive procedures.

Caseous calcification of the mitral annulus with mitral regurgitation and impairment of functional capacity: a case report

Introduction

Mitral annular calcification is a common echocardiographic finding, especially in the elderly. Caseous calcification of the mitral annulus, however, is a relatively rare variant, having an echocardiographic prevalence of 0.6% in patients with mitral annular calcification. Caseous calcification needs to be differentiated from infected mitral annular calcification, mitral annular abscess and tumours. It is not malignant, and medical therapy with clinical follow-up is the therapeutic option. Surgery should be reserved for co-existent mitral valve dysfunction.

Case presentation

We report the case of a 69-year-old woman, in whom caseous calcification of the mitral annulus was found at transthoracic echocardiography. Cardiac surgery was performed because of significant mitral regurgitation and impairment of functional capacity.

Conclusion

Caseous calcification of the mitral annulus needs to be considered and confirmed by transthoracic echocardiography since there is potential for diagnostic confusion or misdiagnosis. This lesion appears to have a benign prognosis but, when associated with mitral valve dysfunction, cardiac surgery appears to be the best therapeutic option.

Feasibility, safety and tolerability of accelerated dobutamine stress echocardiography

A continuous infusion of a single high dose of dobutamine has been, recently, suggested as a simple and effective protocol of stress echocardiography. The present study assesses the feasibility, safety, and tolerability of an accelerated dobutamine stress protocol performed in patients with suspected or known coronary artery disease. Two hundred sixty five consecutive patients underwent accelerated dobutamine stress echocardiography: the dobutamine was administered at a constant dose of 50 μg/kg/min for up to 10 minutes. The mean weight-adjusted cumulative dose of dobutamine used was 330 ± 105.24 μg/kg. Total duration of dobutamine infusion was 6.6 ± 2.1 min. Heart rate rose from 69.9 ± 12.1 to 123.1 ± 22.1 beats/min at peak with a concomitant change in systolic blood pressure (127.6 ± 18.1 vs. 167.6 ± 45.0 mmHg). Dobutamine administration produced a rapid increase in heart rate (9.4 ± 5.9 beats/min²). The side effects were similar to those described with the standard protocol; the most common were frequent premature ventricular complexes (21.5%), frequent premature atrial complexes (1.5%) and non sustained ventricular tachycardia (1.5%); among non cardiac symptoms the most frequent were nausea (3.4%), headache (1.1%) and symptomatic hypotension (1.1%). No major side effects were observed during the test. Our data demonstrate that a continous infusion of a single high dose of dobutamine is a safe and well tolerated method of performing stress echocardiography in patients with suspected or known coronary artery disease. This new protocol requires the administration of lower cumulative dobutamine dose than standard protocol and results in a significant reduction in test time.

Rest and Dobutamine stress echocardiography in the evaluation of mid-term results of mitral valve repair in Barlow's disease

Background

Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up.

Methods and Results

Twenty patients selected for the study (12 men and 8 women, mean age 60 ± 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 ± 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed.

Conclusion

Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.

Evaluation of 17-mm St. Jude Medical Regent prosthetic aortic heart valves by rest and dobutamine stress echocardiography

BACKGROUND

The prosthesis used for aortic valve replacement in patients with small aortic root can be too small in relation to body size, thus showing high transvalvular gradients at rest and/or under stress conditions. This study was carried out to evaluate rest and Dobutamine stress echocardiography (DSE) hemodynamic response of 17-mm St. Jude Medical Regent (SJMR-17 mm) in relatively aged patients at mean 24 months follow-up.

METHODS AND RESULTS

The study population consisted of 19 patients (2 men, 17 women, mean age 69.2 +/- 7.3 years). All patients underwent rest Doppler echocardiography before and after surgery and basal and DSE at follow up (infused at rate of 5 microg/Kg/min and increased by 5 microg/Kg/min at 5 min intervals up to 40 microg/Kg/min). The following parameters were evaluated at rest and/or under DSE: heart rate (HR), ejection fraction (EF), cardiac output (CO), peak and mean velocity and pressure gradients (MxV, MnV, MxPG, MnPG), effective orifice area (EOA), indexed EOA (EOAi), left ventricular mass (LVM), indexed LVM (LVMi), Velocity Time Integral at left ventricular outflow tract (VTI LVOT) and transvalvular (Aortic VTI), Doppler velocity index (DVI). At rest MxPG and MnPG were 29.2 +/- 7.1 and 16.6 +/- 5.8 mmHg, respectively; EOA and EOAi resulted 1.14 +/- 0.3 cm(2) and 0.76 +/- 0.2 cm(2)/m(2); DVI was normal (0.50 +/- 0.1). At follow-up LVM and LVMi decreased significantly from pre-operative value of 258 +/- 43 g and 157.4 +/- 27.7 g/m(2) to 191 +/- 23.8 g and 114.5 +/- 10.6 g/m(2), respectively. DSE increased significantly HR, CO, EF, MxGP (up to 83.4 +/- 2 1.9 mmHg), MnPG (up to 43.2 +/- 12.7 mmHg). EOA, EOAi, DVI increased insignificantly (from baseline up to 1.2 +/- 0.4 cm(2), 0.75 +/- 0.3 cm(2)/m(2) and 0.48 +/- 0.1 respectively). Two patients developed significant intraventricular gradients.

CONCLUSION

These data show that SJMR 17-mm prostheses can be safely implanted in aortic position in relatively aged patients, offering a satisfactory hemodynamic performance at rest and under DSE, with full utilization of its available orifice, suggesting that a possible mild prosthesis-patient mismatch is not an issue of clinical relevance when this small prosthesis is used. Rest and Dobutamine stress echocardiography is a useful and effective means for evaluating prosthesis hemodynamics and for monitoring the expected LVH regression.

Biphasic transoesophageal vs. transthoracic electrical cardioversion of persistent atrial fibrillation

OBJECTIVE

To compare the efficacy and safety of transoesophageal (TOC) vs. transthoracic (TTC) electrical cardioversion, both with biphasic shocks, for sinus rhythm (SR) restoration in patients with persistent atrial fibrillation (AF).

METHODS

We randomised 210 patients (151 male, 59 female, mean age 66 +/- 9 years) with persistent AF into two groups: group 1 (n = 104) undergoing TOC with a step-up protocol of 30, 50, 70 and 100 J, and group 2 (n = 106) undergoing TTC with a step-up protocol of 70, 100, 120 and 150 J.

RESULTS

The two groups were homogeneous as for clinical and instrumental characteristics, except for left ventricular ejection fraction (50.5 +/- 10% in group 1 vs. 53 +/- 8% in group 2, P < 0.05) and thoracic impedance (63 +/- 8 Omega in group 1 vs. 66 +/- 6 Omega in group 2, P < 0.005). SR was restored in 98 (94%) group 1 patients vs. 99 (93%) group 2 patients (P = NS). First shock was effective in 48 (46%) group 1 patients vs. 54 (51%) group 2 patients (P = NS). Mean delivered energy was 50.4 +/- 23.6 and 95.1 +/- 29.6 J; mean effective energy was 47.3 +/- 20.7 and 91.2 +/- 26.6 J in group 1 and group 2, respectively. Cross-over to the highest energy level was never effective. TOC tolerability was optimal (mean discomfort score 1.2 on a 1-4 grading scale). Markers of myocardial necrosis did not increase and no procedure-related complications occurred. On logistic regression analysis, the most predictive variables of unsuccessful cardioversion were AF duration (P = 0.0001) and low left atrial appendage emptying velocity (P = 0.02).

CONCLUSIONS

Both TOC and TTC with biphasic shocks are effective and safe for SR restoration in patients with persistent AF; however, the considerably lower levels of delivered and effective energies for SR restoration allow TOC to be performed during mild sedation with optimal tolerability, thus avoiding general anaesthesia.

Usefulness of the dipyridamole-Doppler test for diagnosis of coronary artery disease

Two-dimensional and Doppler echocardiographic studies and a hemodynamic investigation were performed during dipyridamole testing in 42 subjects (13 control subjects and 29 patients with coronary artery disease [CAD]), to evaluate the ability of dipyridamole Doppler echocardiography in identifying patients with ischemic left ventricular dysfunction. In the control group, after dipyridamole infusion, Doppler-derived parameters increased significantly from baseline (p less than 0.001). In patients with CAD, peak flow velocity, flow velocity integral and stroke volume failed to increase after dipyridamole infusion (0.89 +/- 0.21 to 0.85 +/- 0.18 m/s, difference not significant; 14 +/- 3 to 12 +/- 4 cm, difference not significant, and 56 +/- 13 to 50 +/- 14 ml/beat, p less than 0.05, respectively). Heart rate, rate pressure product, systemic vascular resistance and mean right atrial pressure had similar variations in the 2 groups. Changes in the 3 Doppler-derived parameters are closely related to the variations of peak positive dP/dt, stroke volume (thermodilution) and left ventricular end-diastolic pressure and are closely related to the coronary angiography jeopardy score and to the appearance of wall motion abnormalities. Thus, by combining Doppler and 2-dimensional echocardiography, dipyridamole-induced myocardial ischemia may be detected in a high percentage of CAD patients, providing a sensitive tool for identifying patients with high-risk coronary artery anatomy.