Left ventricular function evaluation of the fetal heart: reference intervals and inter-observer variability of 2D speckle-tracking echocardiography measurements

AIMS

Measurement of myocardial strain using 2D speckle-tracking echocardiography can successfully quantify ventricular function, being considered superior to conventional echocardiography. This study aimed to establish reference intervals, interobserver agreements and reliability of two fetal echocardiographic parameters which reflect left ventricular myocardial function, left ventricular apical 4 chamber endo peak strain (AP4pLS) and ejection fraction (EF).

MATERIAL AND METHODS

We conducted a prospective study on 103 healthy fetuses. In each case, cardiac ultrasound images obtained were stored and afterwards were subject to offline 2D speckle-tracking echocardiographic analyses. In 15 randomly chosen subjects a second examiner also carried out an offline analysis of the 4-chamber view and the archived images, in order to assess inter-observer reproducibility and agreement level. Our study group was sub-divided into four different gestational age groups.

RESULTS

Reference ranges were established for the two measured parameters, AP4pLS and EF, which did not differ significantly between four different gestational age groups (p=0.98 and p=0.64) and neither correlated with gestational age progression (p=0.37 and p=0.08). An excellent level of agreement between the two examiners was found for the echocardiographic measurements, expressed through an intra-class correlation coefficient (ICC) value of 0.85 (0.62-0.94 for 95%CI) for AP4pLS and 0.78 (0.47- 0.92 for 95% CI) for EF.

CONCLUSIONS

Speckle tracking AP4pLS and EF parameters are useful for assessment of ventricular myocardial function in healthy fetuses and can be reliably reproduced by two different skilled examiners. Further studies conducted on larger populations are required to standardize reference values of fetal speckle-tracking measurements.

Impaired Speckle-Tracking-Derived Left Ventricular Longitudinal Strain Is Associated with Transposition of Great Arteries in Neonates: A Single-Center Study

The transposition of great arteries (TGA) is one of the most frequent and severe congenital heart diseases. After newborn stabilization and while pending surgical correction, echocardiographic monitoring with a careful evaluation of left ventricle (LV) performance is warranted. In this study, our objectives were (i) to compare myocardial function, assessed via speckle-tracking echocardiography, between neonates with TGA and neonates without TGA and (ii) to identify a strain parameter with a good discriminatory ability for TGA. We conducted a retrospective, single-center study. A total of 90 neonates were examined, of whom 66 were included (16 comprised the TGA group and 50 comprised the control group). The results of a bivariate analysis showed that classic echocardiography parameters displayed no significant differences between the two studied groups (p = 0.785 for EF, p = 0.286 for MAPSE and p = 0.315 for TAPSE). We found a statistically significant difference between the two groups for the mean values of the LVpGLS parameter (adjusted p = 0.0047), with impaired LV myocardium function being observed in the TGA group after adjusting for other covariates. Regarding segmental strain, the mean medial and apical inter-ventricular septum strain values were found to be significantly lower in the neonates with TGA than in the controls (95% CI for difference in means: [-6.45, -0.65], [-8.56, -1.97]). The results of an ROC analysis showed that LVpGLS had a significant ability to differentiate between neonates with TGA and controls (AUC = 0.712, 95% CI: [0.52, 0.903], p = 0.011). In conclusion, LVpGLS is a parameter with a significant discriminatory ability for LV dysfunction, and it is useful in the evaluation of ventricular myocardial function in newborns with TGA.

Interobserver Agreement and Reference Intervals for Biventricular Myocardial Deformation in Full-Term, Healthy Newborns: A 2D Speckle-Tracking Echocardiography-Based Strain Analysis

Data regarding reference intervals for strain parameters derived from 2D speckle-tracking echocardiography in full-term newborns are limited and still under development. Our objectives were to establish the level of reproducibility and reference intervals in assessing myocardial function using 2D speckle-tracking echocardiography for longitudinal and regional strain measurements. A total of 127 full-term newborns were examined to be included in the study, of which 103 were analyzed. We used two-dimensional acquisitions from apical four-chamber view of both ventricles and analyzed the autostrain function offline. We obtained interobserver agreement between the two observers ranging from good to excellent for all speckle-tracking parameters except for the strain of the medial portion of the left ventricle (LV) lateral wall and the strain measured on the basal portion of the inter-ventricular septum, which reflected a fair interobserver reproducibility (ICC = 0.52, 95% IC: 0.22–0.72 and ICC = 0.43, 95% IC: 0.12–0.67, respectively). The reference values obtained for the LV peak longitudinal strain were between −24.65 and −14.62, those for the right ventricle (RV) free wall were from −28.69 to −10.68, and those for the RV global four-chamber were from −22.30 to −11.37. In conclusion, two-dimensional peak longitudinal LV and RV strains are reproducible with good to excellent agreement and may represent a possible alternative for the cardiac assessment of healthy newborns in the clinical practice.

Fetal Tachyarrhythmia Management from Digoxin to Amiodarone-A Review

Sustained fetal tachycardias are rare but represent a high risk of mortality and morbidity. Consensus has yet to be found regarding their optimal management. The aim of this narrative review is to summarize the data available in the current literature regarding the efficacy and safety of medications used in the management of intrauterine tachyarrhythmias and to provide possible treatment protocols. In this review, we would like to emphasize the importance of a thorough evaluation of both the fetus and the mother, prior to transplacental antiarrhythmic drug initiation. Factors such as the hemodynamic status of the fetus, possible mechanisms of fetal arrhythmia, and concomitant maternal conditions are of primordial importance. As a possible treatment protocol, we would like to recommend the following: due to the risk of sustained supraventricular tachycardia (SVT), fetuses with frequent premature atrial beats should be evaluated more frequently by echocardiography. A careful hemodynamic evaluation of a fetus with tachycardia is primordial in forestalling the appearance of hydrops. In the case of atrial flutter (AFL), sotalol therapy could represent a first choice, whereas when dealing with SVT patients, flecainide should be considered, especially for hydropic patients. These data require consolidation through larger scale, non-randomized studies and should be handled with caution.

Hemispheric infiltrative grade II gliomas in adults: association of residual tumour volume and extent of tumour resection with malignant transformation

OBJECTIVES

Evaluation of the impact of surgical treatment on malignant transformation (MT) of adult supratentorial infiltrative grade II gliomas (G2G) in a series of chemotherapy and radiotherapy-naïve patients.

BACKGROUND

Despite G2G are slow-growing tumours, they typically undergo MT with a subsequent fatal disease course. An extensive resection alone likely changes their biological behaviour and defers MT; however, this impact is not unequivocally confirmed.

METHODS

Thirty-eight chemotherapy and radiotherapy-naïve adult patients operated from 2005 till 2014 for a G2G were investigated. Based on postoperative magnetic resonance imaging (MRI) and/or positron emission tomography follow-up (FU) scans, the patients were classified as "transformers" (15 patients in whom MT occurred during the FU-period) and "non-transformers" (23 patients).

RESULTS

The follow-up period of "non-transformers" was longer (p <0.0001). After adjustment for known risk factors - age, male sex, astrocytoma histology, preoperative tumour volume, preoperative contrast enhancement and positive isocitrate dehydrogenase 1 gene mutation status - a larger log postoperative tumour volume (p=0.031) and a smaller extent of resection (p=0.0086) were associated with a shorter MT-free survival.

CONCLUSION

In our series, less extensive resections were associated with a shorter time to MT. Our data support an adoption of techniques enabling extensive G2G resections, such as intraoperative imaging and awake resections, into everyday routine (Tab. 1, Fig. 2, Ref. 40).

Successful percutaneous stenting of coarctation of the aorta in Turner syndrome – a case report and literature review

Turner syndrome (TS) is the most common chromosomal abnormality affecting females and cardiac abnormalities have been described in up to 50% of patients. Although coarctation represents one of the most frequent cardiac malformation, treatment options in these patients represent an area of debate, due to associated aortopathy and risk for aortic dissection. In addition to the contradictory data found in the literature, regarding the safety profile and utility of stenting of coarctation of the aorta in TS patients, we present the case of a patient of pediatric age, who successfully underwent the procedure, being free from periprocedural and short-term complications. Beside the presentation itself, we aimed to review and summarize the data available in the literature regarding this topic. As a conclusion, we emphasize the role of minimally invasive interventional therapy and wish to underline the need of further, larger scale studies and guidelines in this patient group. Given the related aortopathy, all preventive measures should be undertaken to avoid aortic dissection during stent implantation in this vulnerable population. Although the evolution of our patient was favorable, data found in the literature is somewhat contradictory and a close follow-up is indicated to help evaluate the risk of long-term complications.

Detection of SARS-CoV-2 pneumonia: two case reports

Background

Developing therapeutic strategies for a SARS-CoV-2 infection is challenging, but first the correct diagnosis has to be made. Unspecific upper and lower respiratory tract symptoms can be misleading; hence, a nasopharyngeal swab test with a real-time reverse-transcription-polymerase chain reaction is of great importance. However, early viral clearing jeopardizes a sound diagnosis of COVID-19.

Case presentation

We report on two Caucasian patients who had negative pharyngeal swab tests at the onset of SARS-CoV-2 pneumonia. In one patient, the virus was not even detectable in bronchoalveolar lavage despite typical radiomorphologic changes.

Conclusions

Negative PCR findings in both the pharynx and bronchoalveolar lavage do not exclude COVID-19 pneumonia. Computed tomography is a crucial diagnostic prerequisite in this context.

Predictors of Inadequate Mixing in Transposition of the Great Arteries — a Critical Neonatal Condition

Background: Simple transposition of the great arteries (TGA) is a cyanotic critical congenital heart defect representing a neonatal cardiovascular emergency, which requires surgery early after birth. In case of inadequate mixing between systemic and pulmonary circulations, creating an unrestrictive interatrial communication is mandatory. The aim of the present study was to identify the most important echocardiographic parameters that can predict the need for balloon atrial septostomy (BSA) in TGA neonates.

Material and methods: We retrospectively reviewed the echocardiographic recordings of newborns with TGA referred to our emergency room during a 6-year period. We measured the following echocardiographic parameters: atrial septal defect (ASD) size, interatrial septum (IAS) length, peak/mean inter-atrial pressure gradient, transverse diameter of the left atrium (LA), and transverse diameter of the right atrium (RA). Also, the ratio between ASD/IAS, the ratio between LA/RA, the ratio between mitral/tricuspid annulus, the ASD peak gradient/ASD diameter and the ASD diameter/(LA:RA ratio) were calculated.

Results: There were 37 neonates with simple TGA presented to the emergency room, split into two groups: those with BAS (n = 21) and those without BAS (n = 16). Besides significant differences between the two groups in ASD size, peak/mean interatrial pressure gradient, and LA:RA ratio, we found that ASD peak gradient/ASD diameter was significantly higher, but ASD diameter/(LA:RA ratio) was significantly lower in the group that required BAS compared with the group without BAS. Multivariate analysis showed that ASD diameter/(LA:RA ratio) was an independent predictor of septostomy requirement, with a cut-off value of 2.58.

Conclusion: ASD diameter/(LA/RA ratio) is a useful echocardiographic parameter that can provide supplementary information regarding inadequate mixing and the need for BAS in neonates with TGA.

Original Research. Diagnosis of the Aortic Coarctation in the Neonatal Period — a Critical Condition in the Emergency Room

Background: Critical coarctation of the aorta is the most common congenital heart disease with ductal-dependent systemic circulation. In severe forms, this disease represents a critical condition, which can become life-threatening. The aim of this study was to evaluate the usefulness of different echocardiographic parameters in the prediction of aortic coarctation in newborns. Material and method: This is a retrospective study performed by reviewing echocardiographic images of both pre-term and full-term newborns presented with aortic coarctation to the emergency room of a clinic of pediatric cardiology. Based on echocardiographic measurements, both the common carotid artery-subclavian artery index (CSAi) and the aortic isthmus-descending aorta index (I/D) were calculated. Results: Fifty-two newborns presented in acute settings with aortic coarctation and were included in the study, divided into: subgroup 1 (n = 26) - ductal-dependent aortic coarctation; subgroup 2 (n = 2) - non-ductaldependent aortic coarctation; and subgroup 3 (n = 24) - unconfirmed aortic coarctation. ROC analysis identified a cutoff value of 1.37 for the CSAi index and a cutoff value of 0.46 for the I/D index as being associated with the highest predictive power for the diagnosis of aortic coarctation. Conclusions: The CSAi and I/D indices are simple and accessible echocardiographic parameters that can provide supplemental information for the pediatric cardiologist in acute cases of newborns with suspicion of aortic coarctation. These new indices can contribute to the decision-making process in case of pre-term and full-term newborns with suspicion of coarctation of the aorta, independent of the presence of persistent ductus arteriosus.

Comparative Measurements of Aortic Diameters Using Transthoracic Echocardiography and Thoracic Computed Tomography Angiography in Neonatal Aortic Coarctation

Background: Critical aortic coarctation is defined as the severe narrowing of the isthmic aortic lumen, representing a neonatal cardiac emergency, part of the congenital heart diseases with duct-dependent systemic circulation.

Aim of the study: To assess the correlation between transthoracic echocardiography and computed tomography angiography (CTA) in the measurement of aortic diameters in a group of newborns diagnosed with duct-dependent aortic coarctation and/or associated hypoplastic aortic arch.

Material and method: We performed a retrospective study on neonates diagnosed with duct-dependent aortic coarctation and/or associated hypoplastic aortic arch between January 1, 2015 and March 1, 2017. The studied parameters were diameters of the aorta at the level of the aortic annulus, coronary sinuses, sinotubular junction, ascending aorta, proximal and distal aortic arch, and the aortic isthmus. Measurements were obtained by transthoracic echocardiography and thoracic CTA.

Results: Fifteen newborns diagnosed with duct-dependent aortic coarctation and/or associated hypoplastic aortic arch were included in this study. There was no statistically significant difference between the two imaging methods, the T test highlighting differences only between the measurements of the aortic annulus (p <0.016) and coronary sinuses (p <0.008). The patients included in the study associated other cardiovascular abnormalities: persistent ductus arteriosus (100%), atrial septal defect (100%), aortic arch hypoplasia (80%), bicuspid aortic valve (73.3%).

Conclusions: These methods reveal important information on the anatomy of the cardiovascular malformation and its impact on the clinical and paraclinical status of the patient, being fundamental for establishing an optimal therapeutic approach.

Repression of intestinal drug metabolizing enzymes by the SV40 large T antigen

Toxic compounds such as carcinogens are removed from the body by the action of a series of detoxifying enzymes and transporters expressed in the liver and the small intestine. We have found that intestinal epithelial cells expressing the SV40 large T antigen (TAg) contain significantly lower levels of mRNAs, encoding several drug metabolizing/detoxifying enzymes and transporters compared to their non-transgenic littermates. In addition, TAg blocks the induction of these mRNAs by xenobiotics. The repression depends on an intact LXCXE motif in TAg, suggesting that inactivation of the retinoblastoma (Rb) family of tumor suppressors plays a role in the process. These results imply that a functional Rb pathway in the intestine is necessary for the expression of the detoxification system used to clear carcinogens, and suggest that loss of this tumor suppressor might alter susceptibility to chemical injury. In addition, the effect of TAg on the detoxification pathway appears to be tissue-specific, as its ectopic expression in the liver failed to suppress the P450 enzymes. The TAg-mediated suppression of drug metabolizing/detoxifying enzymes may have broad implications in the metabolism and mechanism of action of both carcinogens and prescription drugs.

Analytical investigation of plasma-treated carbon fibres

As-grown and heat-treated vapour grown carbon fibres (VGCF) in the as-prepared state, washed in HCl/H(2)O, and treated in O(2) plasma for different periods have been investigated by means of XPS and scanning electron microscopy (SEM). The surface energy of the carbon fibres before and after plasma treatment was determined from the wetting contact angle. Washing introduced hydroxyl, carbonyl and carboxyl groups onto the fibre surfaces and oxygen plasma treatment increases the total atomic concentration of oxygen up to 17%. This is in good agreement with the value of the polar component of the surface energy. Plasma treatment also enhanced the fibre surface porosity (by etching).

[Electrocardiographic and arterial pressure changes in the acute phase of subarachnoid hemorrhage]

A prospective study was made of 30 patients, admitted to the neurology ward with subarachnoidal hemorrhage (SAH), at its onset. The diagnosis was established on the basis of anamnesis, clinical examination, spinal puncture, anatomopathological examination. The patients with other cerebrovascular affections or with antecedents of ischaemic cardiac affections were excluded. ECG tracings, serum ionogram, AT and VA at the onset and in evolution, and their modifications were followed and assessed in all the patients. The conclusion is reached that SAH in acute phase is associated with transitory ECG and pressure anomalies which become elements of unfavourable prognosis when persistent and deeply altered. They are valuable, at hand, elements in the differential diagnosis, and in the opportune therapeutical intervention.