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Background

The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge echocardiograms. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre.

Methods

After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year, we reviewed the feasibility, results and relationship between the TPS and mortality, extubation time and length of stay.

Results

From 01 September 2015 to 04 July 2016, there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, three had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, ten had more than one period of cardiopulmonary bypass. All four deaths <30 days after surgery (1.9%) had optimal TPS. There was a statistically significant difference in extubation times in the RACHS category 4 patients (3 days vs 5 days, P < 0.05) and in PICU and total length of stay in the RACHS category three patients (2 and 8 days vs 12.5 and 21.5 days respectively) if leaving theatre with an inadequate result.

Conclusions

Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. An ‘inadequate’ TPS did not predict mortality but correlated with a longer ventilation time and longer length of stay compared to those with optimal or adequate scores.

Summary

Tuberculous pericarditis is a rare diagnosis seen among as few as 1% of tuberculosis (TB) patients in developed countries. We present a case of a 60-year-old male suffering from a transient constrictive pericarditis and subclinical involvement of the myocardium in a clinical case of tuberculous pericarditis with corresponding improvement after the initiation of anti-tuberculous treatment. We suggest monitoring of myocardial function using global longitudinal strain by myocardial speckle tracking strain analysis as supplement to routine left ventricular ejection fraction to assess clinical improvement in patients at risk of developing constrictive pericarditis.

Learning points:

• Fibroelastomas are most commonly found on left-sided heart valves (aortic > mitral) and have the potential to cause systemic emboli associated with significant morbidity and mortality.

• A left atrial appendage (LAA) mass in a patient presenting with cerebrovascular events does not always represent thrombus. Uncommon aetiologies such as a cardiac tumour should be considered in the differential diagnosis.

• Transthoracic echocardiography (TTE) does not provide an accurate assessment of the LAA and should not be used to detect pathology within this structure. Transoesophageal echocardiography (TOE) is superior to TTE in imaging the LAA and provides a complete delineation of its anatomy. In addition, TOE can detect very small highly mobile lesions (as described in this case), which may be missed on other imaging modalities.

Background

Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.

Methods

Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.

Results

Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO₂peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO₂peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S′) and age were the strongest independent predictors for VO₂peak (R ² = 0.76; P < 0.0001). Exercise S′ was the strongest independent predictor for NT-ProBNP (R ² = 0.48; P = 0.001).

Conclusion

A large proportion of patients had a lower than predicted VO₂peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S′ on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.

Background

Data about the epidemiology of valvular heart disease (VHD) in the elderly is scarce. Hand-held ultrasound devices (HUDs) enable point-of-care ultrasound scanning (POCUS) but their use in an elderly population has not been reported for VHD screening in primary practice.

Methods

One hundred consecutive subjects aged >70 years without a VHD diagnosis had 2D and colour Doppler POCUS by an accredited sonographer, using a contemporary HUD (Vscan), in a primary practice setting. Patients with left-sided valve pathology identified by Vscan were referred for formal echo in the local tertiary cardiac centre.

Results

Mean age (s.d.) was 79.08 (3.74) years (72–92 years); 61 female. By Vscan, we found five patients with ≥moderate aortic stenosis (AS), eight with ≥moderate mitral regurgitation (MR) and none with ≥moderate aortic regurgitation. In the AS and MR groups each, one patient had valve intervention following from the initial diagnosis by Vscan, two and one respectively are under follow-up in the valve clinic, while two and four respectively refused TTE or follow-up. Two patients with moderate MR by Vscan had mild and mild/moderate MR respectively by TTE and were discharged. Total cost for scanning 100 patients was $18,201 – i.e. $182/patient.

Conclusions

Screening with a hand-held scanner (Vscan), we identified 5/100 elderly subjects who needed valve replacement or follow-up in valve clinic, at a cost of $182/patient. These findings have potential significance for the allocation of resources in the context of an ageing population.