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Open access

Ruchika Meel, Ferande Peters, Bijoy K Khandheria, Elena Libhaber and Mohammed Essop

Background

Chronic mitral regurgitation (MR) historically has been shown to primarily affect left ventricular (LV) function. The impact of increased left atrial (LA) volume in MR on morbidity and mortality has been highlighted recently, yet the LA does not feature as prominently in the current guidelines as the LV. Thus, we aimed to study LA and LV function in chronic rheumatic MR using traditional volumetric parameters and strain imaging.

Methods

Seventy-seven patients with isolated moderate or severe chronic rheumatic MR and 40 controls underwent echocardiographic examination. LV and LA function were assessed with conventional echocardiography and 2D strain imaging.

Results

LA stiffness index was greater in chronic rheumatic MR than controls (0.95 ± 1.89 vs 0.16 ± 0.13, P = 0.009). LA dysfunction was noted in the reservoir, conduit, and contractile phases compared with controls (P < 0.05). LA peak reservoir strain (ƐR), LA peak contractile strain, and LV peak systolic strain were decreased in chronic rheumatic MR compared with controls (P < 0.05). Eighty-six percent of patients had decreased LA ƐR and 58% had depressed LV peak systolic strain. Decreased ƐR and normal LV peak systolic strain were noted in 42%. Thirteen percent had normal ƐR and LV peak systolic strain. One patient had normal ƐR with decreased LV peak systolic strain.

Conclusions

In chronic rheumatic MR, there is LA dysfunction in the reservoir, conduit, and contractile phases. In this study, LA dysfunction with or without LV dysfunction was the predominant finding, and thus, LA dysfunction may be an earlier marker of decompensation in chronic rheumatic MR.

Open access

Muhammad Khan, Ruben DeSousa, Kam Rai and Jamal Nasir Khan

A 31-year old male was admitted with suspected infective endocarditis given intravenous drug use, lung and cerebral abscesses and Staphyloccus aureus bacteraemia. TTE imaging was limited given supine positioning and mechanical ventilation but suggested a posterior mitral valve leaflet (PMVL) mass. Three-dimensional TOE provided uniquely detailed assessment of two complex infective masses. The attachment of the presumed P2 mass on TTE was indeterminant even on 2D-TOE, appearing attached to the PMVL or AMVL depending on rotational view. 3D-TOE imaging and subsequent multiplanar and volumerendered reconstruction revealed this to be a complex, large vegetation attached to the anterior aspect of the anterolateral commissure with mobile heads prolapsing into the left atrium and causing mild mitral regurgitation through a small basal perforation. The second mass was a filamentous vegetation attached to the LVOT, prolapsing towards but not contacting the aortic valve.Comprehensive assessment of complex vegetations is crucial for optimal surgical planning. 3D-TOE allows rapid, accurate, unique assessment of such masses through unlimited multiplanar reconstructions, volume rendered real-time imaging and colour full-volume regurgitation assessment which may not always possible on 2D-TTE or 2D-TOE. 3D imaging should be routinely used in TOE and in particular in suspected endocarditis.

Open access

Justin Jose, Kirsty Randall, Julia Baron and Jeffrey Khoo

Transthoracic echocardiography (TTE) is widely used as a pre-operative screening tool. It can provide extensive information about cardiac function and underlying pathology, which could influence decisions regarding surgery. This patient was referred for TTE as part of the pre-op screening, as he had a biological prosthetic aortic valve. This was a rare case where misleading TTE measurements inadvertently led to the patient being referred for transcatheter aortic valve replacement (TAVR), which delayed non-cardiac surgery.

Routine pre-op TTE in a district hospital showed severely increased gradients compared to the previous year, so the patient was referred to a tertiary centre for TAVR. However peri-operative trans-oesophageal echocardiography (TOE) showed lower gradients and satisfactory valve area. The cause of high gradients at the time of pre-op screening was retrospectively attributed to profound anaemia present at the time. When the anaemia was corrected, the prosthetic valve gradients reduced to levels similar to the previous year. This case reiterates the fact that Echocardiographers should be familiar with haemodynamic factors that could affect the validity of Doppler measurements that use Bernoulli’s equation and the continuity principle. This report also looks at how echocardiographers can mitigate the effects of non-valvar factors.

Open access

Stella Kyung, Alan Goldberg, Steven Feinstein, Stephanie Wilson, Sharon Mulvagh and Petros Nihoyannopoulos

The 34th annual Advances in Contrast Ultrasound (ACU) International Bubble Conference convened in Chicago, IL, USA, on September 5–6, 2019 to feature new directions of research, preclinical and first-in-man clinical trials, and novel clinical applications highlighting the diversity and utility of contrast enhanced ultrasound (CEUS). An expert group comprising clinicians, engineers, basic scientists, government officials, attorneys, and industry partners convened to collaborate on cutting-edge ultrasound enhancement technology. Utilizing this information, the International Contrast Ultrasound Society (ICUS) continues to have cause to advocate for the safe and appropriate use of CEUS with expanding indications and applications.

Open access

Sarah Ritzmann, Stephanie Baker, Marcus Peck, Tom E Ingram, Jane Allen, Laura Duffy, Richard P Steeds, Andrew Houghton, Andrew Elkington, Nina Bual, Robert Huggett, Keith Pearce, Stavros Apostolakis, Khalatabari Afshin and the British Society of Echocardiography Departmental Accreditation and Clinical Standards Committees with input from the Intensive Care Society

This article sets out a summary of standards for departmental accreditation set by the British Society of Echocardiography (BSE) Departmental Accreditation Committee. Full accreditation standards are available at www.bsecho.org. The BSE were the first national organisation to establish a quality standards framework for departments that support the practice of individual echocardiographers. This is an updated version which recognises that, not only should all echocardiographers be individually accredited as competent to practice, but that departments also need to be well organised and have the facilities, equipment and processes to ensure the services they deliver are of an appropriate clinical standard. In combination with individual accreditation, departmental accreditation lays down standards to help ensure safe and effective patient care. These standards supersede the 2012 BSE Departmental Accreditation Standards. Standards are set to cover all potential areas of practice, including transthoracic (level 2) echocardiography, transoesophageal echocardiography, stress echocardiography, training, and emergency (level 1) echocardiography. The emergency echocardiography standard is a new addition to departmental accreditation and has been developed with input from the Intensive Care Society.

Open access

Patrick Savage and Michael Connolly

Summary

Mitral valve repair is the gold standard treatment for degenerative mitral valve disease with superior perioperative and long-term morbidity and mortality outcomes vs mitral valve replacement. The 10 year survival freedom from redo valve repair varies from 72 to 90%. Often, failure of valve repair necessitating redo surgery is directly related to disease progression; however, rarely it can be attributed to technical complications such as annuloplasty dehiscence, leaflet suture rupture, incorrect artificial chord length or incorrect annuloplasty position. We report one such case of severe mitral regurgitation secondary to a degenerative annuloplasty ring suture occurring 1 year post valve repair.

Learning points:

  • Differentiation of causative pathology involved in recurrent mitral regurgitation following repair has important implications for patient outcomes.
  • In the hands of an experienced practitioner echocardiography – in particular, integrated 2D- and 3D echocardiography – is a powerful tool for differentiating between progressive disease and procedural failure.
Open access

Abbas Zaidi, Daniel S Knight, Daniel X Augustine, Allan Harkness, David Oxborough, Keith Pearce, Liam Ring, Shaun Robinson, Martin Stout, James Willis, Vishal Sharma and the Education Committee of the British Society of Echocardiography

The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.

Open access

Nam Tran, Chun Shing Kwok, Sadie Bennett, Karim Ratib, Grant Heatlie and Thanh Phan

Summary

A 62-year-old female was admitted with severe left-sided chest pain, nausea and pre-syncope. She had widespread T wave inversion on ECG and elevated troponins and was suspected to have an acute coronary syndrome event. Invasive coronary angiogram revealed normal coronary anatomy with no flow-limiting lesions. Echocardiography and cardiac MRI revealed impaired left ventricular (LV) systolic impairment, a mobile LV apical thrombus and a moderate global pericardial effusion with no significant compromise. Full blood count analysis indicated the patient to have significant eosinophilia, and the patient was diagnosed with idiopathic eosinophilic myocarditis. She was commenced on Prednisolone and Apixaban, and eosinophil levels returned to normal after 10 days of steroids. Over the course of 3 months, the patient had a complete recovery of her LV function and resolution of the LV thrombus. This case highlights a rare, reversible case of idiopathic eosinophilic myocarditis which may present similar to acute coronary syndrome.

Learning points:

  • Eosinophilic myocarditis (EM) is a rare disease that can exhibit symptoms similar to acute coronary syndrome events.
  • The diagnosis of EM should be considered in patients with chest pain, normal coronary angiogram and pronounced eosinophilia levels.
  • Endomyocardial biopsy is the gold standard diagnostic tool; however, it has a low sensitivity detection rate and its use is not indicated in some patients.
  • Echocardiography is useful in the initial detection of cardiac involvement and complications. However, echocardiography lacks diagnostic specificity for all forms of myocarditis including EM.
  • Cardiac magnetic resonance is a useful method and may add in diagnosing all forms of myocarditis including EM.
  • Patients with EM should be identified promptly and treated with high doses of oral glucocorticoid to reduce the risk of permanent cardiac dysfunction.
Open access

Handi Salim, Martin Been, David Hildick-Smith and Jamal Nasir Khan