We evaluated a 26yr old male with dyspnoea and clinical evidence of MS. To our surprise, echocardiographic evaluation revealed a primum ASD with normal function of the left and right atrioventricular (AV) valve. A left sided supra-valvular ridge or divided left atrium was identified with peak and mean gradients of 43/21mmHg respectively. The primum ASD was repaired with a pericardial patch and the supraventricular ridge causing left ventricular inflow obstruction was resected. The patient was discharged five days after surgery and has remained asymptomatic during routine follow up. Post-operative echocardiography revealed successful surgery with normal diastolic gradients of the left AV valve.
Jacob Daniel Cilliers, Alfonso Pecoraro, and Jacques Janson
Trisha Singh, Jonathan Hinton, Rosie Swallow, James Kersey, and Charles Hillier
Young stroke patients should be investigated thoroughly to look for cardiac and extra-cardiac sources of emboli. We present a patient who was investigated for a cardiac source of emboli following an ischemic stroke. She was found to have a small patent foramen ovale (PFO), but due to the late appearances of bubbles on the bubble study it was thought that this was an incidental finding. Further investigation confirmed a PAVM was the source of emboli causing her stroke.
- Paradoxical embolus is a rare complication of a pulmonary arterio-venous malformation (PAVM).
- Young stroke patients should be investigated for intra and extra-cardiac shunts, in particular, patent foramen ovale (PFO), ideally with a bubble study.
- Consider an extra-cardiac source of embolism when bubbles are seen in arriving late into the left heart.
Na Hyun Park, Hazem Lashin, and Rosalba Spiritoso
Fulminant myocarditis can present with life-threatening arrhythmias and cardiogenic shock due to ventricular failure. The diagnosis of myocarditis usually requires histological and immunological information, as its aetiology may be infectious (viral or non-viral), autoimmune or drug related. The treatment of fulminant myocarditis depends on the underlying cause but usually includes high dose systemic steroids as well as physiological support. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) can be used to support patients as a bridge to recovery by supporting biventricular function and decompressing the heart. V-A ECMO carries risks and complications of its own such as thrombus formation or bleeding. Different diagnostic modalities, such as transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE), are central to the monitoring of progression of disease and recovery of heart function. This case highlights the importance of early recognition and early support with V-A ECMO in fulminant myocarditis, as well as the role of repeated echocardiography when weaning from physiological support.
- Myocarditis is a life-threatening condition and early recognition of cardiac failure can be assisted with a bedside echocardiogram.
- Extracorporeal membrane oxygenation is used as a bridging method of treatment for patients with cardiogenic failure in myocarditis but has its own risks related to anticoagulation and the procedure itself.
- There are currently no standardised guidelines of when to wean a patient off extracorporeal membrane oxygenation, but echocardiography acts as an important guide to detect complications as well as cardiac recovery.
Diana DeCampos, Rogério Teixeira, Carolina Saleiro, Ana Botelho, and Lino Gonçalves
Chronic aortic regurgitation (AR) patients typically remain asymptomatic for a long time. Left ventricular mechanics, namely global longitudinal strain (GLS), has been associated with outcomes in AR patients. The authors conducted a systematic review to summarize and appraise GLS impact on mortality, the need for aortic valve replacement (AVR) and disease progression in AR patients. A literature search was performed using these key terms 'aortic regurgitation' and 'longitudinal strain' looking at all randomized and nonrandomized studies conducted on chronic aortic regurgitation. The search yielded six observational studies published from 2011 and 2018 with a total of 1571 patients with moderate to severe chronic AR. Only two studies included all-cause mortality as their endpoint. The other studies looked at the association between GLS with AVR and disease progression. The mean follow-up period was 4.2 years. We noted a great variability of clinical, methodological and/or statistical origin. Thus, meta-analytic portion of our study was limited. Despite a relevant heterogeneity, an impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value in risk stratification and decision-making.
Sathish Kumar Parasuraman PhD MRCP, Janaki Srinivasan, and Paul Broadhurst
Current guidelines do not advise follow-up echocardiograms after ST-segment elevation myocardial infarction (STEMI), unless the left ventricular ejection fraction is ≤40%. We present an interesting case of left ventricular pseudo-aneurysm – diagnosed 6 months after index STEMI presentation. Follow-up echocardiogram was performed in her case, due to jaw pain during routine haemodialysis. The patient was successfully treated with percutaneous closure device. This case raises the question of whether echo follow-up should be routinely advised after STEMI – even in those with minimal cardiac symptoms.
- Patients with left ventricular pseudo-aneurysm can be haemodynamically stable and may not always be in extremis.
- Left ventricular pseudo-aneurysm can develop months after ST elevation myocardial infarction.
- In patients re-presenting with cardiac symptoms after ST elevation myocardial infarction, a repeat echocardiogram should be considered.
- In patients suffering ST elevation myocardial infarction, it is reasonable to consider repeat echocardiography even with mild LV dysfunction, especially with late presentation or disproportionately high biomarkers.
Vasiliki Tsampasian, Vasileios Panoulas, Richard J Jabbour, Neil Ruparelia, Iqbal S Malik, Nearchos Hadjiloizou, Angela Frame MSc, Sayan Sen, Nilesh Sutaria, Ghada W Mikhail, and Petros Nihoyannopoulos
To assess left ventricular (LV) function before and after transcatheter aortic valve implantation (TAVI) using conventional echocardiographic parameters and global longitudinal LV strain (GLS) and compare outcomes between Edwards S3 and Evolut R valves.
Methods and results:
Data were collected for consecutive patients undergoing TAVI at Hammersmith hospital between 2015 and 2018. Of the 303 patients, those with coronary artery disease and atrial fibrillation were excluded leading to a total of 85 patients, which constituted our study group. The mean follow-up was 49 ± 39 days. In total, 60% of patients were treated with Edwards S3 and 40% Evolut R. TAVI resulted in an early improvement of GLS (−13.96 to −15.25%, P = 0.01) but not ejection fraction (EF) (47.6 to 50.1%, P = 0.09). LV mass also improved, especially in patients with marked baseline LV hypertrophy (P < 0.001). There were no appreciable differences of LV function improvement and overall LV remodelling after TAVI between the two types of valves used (P = 0.14).
TAVI results in reverse remodelling and improvement of GLS, especially in patients with impaired baseline LV function. There were no differences in the extent of LV function improvement between Edwards S3 and Evolut R valves but there was a greater incidence of aortic regurgitation with Evolut R.
Lijun Qian, Feng Xie, Di Xu, and Thomas R Porter
Resting myocardial perfusion (MP) and wall motion (WM) imaging during real-time myocardial contrast echocardiography (MCE) improves the detection of coronary artery disease (CAD). However, its prognostic role in different clinical settings (emergency department and outpatient setting) remains unclear.
A systematic search in PubMed and Embase databases, and the Cochrane library, was conducted to evaluate the role of resting MP and WM in predicting major adverse cardiac events (MACE), including death, nonfatal myocardial infarction (NFMI) and urgent revascularization in patients presenting to either outpatient clinics or emergency departments with suspected symptomatic CAD. Summary receiver operating characteristic (SROC) curves, sensitivity and specificity plots were applied to assess diagnostic performance using RevMan 5.3.
Seven studies met criteria, including 3668 patients (six with follow up ranging from 2 days to 2.6 years). The Relative Risk (RR) for predicting MACE in patients with both abnormal resting MP and WM was 6.1 (95% CI, 5.1–7.2) and 14.3 (95% CI, 10.3–19.8) for death/NFMI, when compared to normal resting MP and WM patients. Having both abnormal resting MP and WM was also more predictive of MACE (RR, 1.7; 95% CI 1.5–1.9) and death/NFMI (RR, 2.2; 95% CI, 1.8–2.7) when compared to abnormal WM with normal resting MP.
In this meta-analysis of both ED and outpatient clinic presentations for suspected CAD, having both a resting regional MP and WM abnormality identifies the highest risk patient for adverse events.