The therapeutic implications of bicuspid aortic valve associations have come under scrutiny in the transcatheter aortic valve implantation era. We evaluate the spectrum of mitral valve disease in patients with bicuspid aortic valves to determine the need for closer echocardiographic scrutiny/follow-up of the mitral valve. A retrospective analysis of echocardiograms done at a referral hospital over five years was conducted in patients with bicuspid aortic valves with special attention to congenital abnormalities of the mitral valve. One hundred and forty patients with a bicuspid aortic valve were included. A congenital mitral valve abnormality was present in eight (5.7%, P = 0.01) with a parachute mitral valve in four (2.8%), an accessory mitral valve leaflet in one (0.7%), mitral valve prolapse in one, a cleft in one and the novel finding of a trileaflet mitral valve in one. Minor abnormalities included an elongated anterior mitral valve leaflet (P < 0.001), the increased incidence of physiological mitral regurgitation (P < 0.001), abnormal papillary muscles (P = 0.002) and an additional chord or tendon in the left ventricle cavity (P = 0.007). Mitral valve abnormalities occur more commonly in patients with bicuspid aortic valves than matched healthy individuals. The study confirms that abnormalities in these patients extend beyond the aorta. These abnormalities did not have a significant functional effect.
Annari van Rensburg, Philip Herbst, and Anton Doubell
Riëtte Du Toit, Phillip G Herbst, Annari van Rensburg, Hendrik W Snyman, Helmuth Reuter, and Anton F Doubell
Lupus myocarditis occurs in 5–10% of patients with systemic lupus erythematosus (SLE). No single feature is diagnostic of lupus myocarditis. Speckle tracking echocardiography (STE) can detect subclinical left ventricular dysfunction in SLE patients, with limited research on its utility in clinical lupus myocarditis. We report on STE in comparison to conventional echocardiography in patients with clinical lupus myocarditis.
Methods and results
A retrospective study was done at a tertiary referral hospital in South Africa. SLE patients with lupus myocarditis were included and compared to healthy controls. Echocardiographic images were reanalyzed, including global longitudinal strain through STE. A poor echocardiographic outcome was defined as final left ventricular ejection fraction (LVEF) <40%. 28 SLE patients fulfilled the criteria. Global longitudinal strain correlated with global (LVEF: r = −0.808; P = 0.001) and regional (wall motion score: r = 0.715; P < 0.001) function. In patients presenting with a LVEF ≥50%, global longitudinal strain (P = 0.023), wall motion score (P = 0.005) and diastolic function (P = 0.004) were significantly impaired vs controls. Following treatment, LVEF (35–47% (P = 0.023)) and wall motion score (1.88–1.5 (P = 0.017)) improved but not global longitudinal strain. Initial LVEF (34%; P = 0.046) and global longitudinal strain (−9.5%; P = 0.095) were lower in patients with a final LVEF <40%.
This is the first known report on STE in a series of patients with clinical lupus myocarditis. Global longitudinal strain correlated with regional and global left ventricular function. Global longitudinal strain, wall motion score and diastolic parameters may be more sensitive markers of lupus myocarditis in patients presenting with a preserved LVEF ≥50%. A poor initial LVEF and global longitudinal strain were associated with a persistent LVEF <40%. Echocardiography is a non-invasive tool with diagnostic and prognostic value in lupus myocarditis.
Sarah R Blake, Jamal N Khan, and Adrian Chenzbraun
Preetham R Muskula, Taiyeb M Khumri, and Michael L Main
Caroline Bleakley, Mehdi Eskandari, and Mark Monaghan
Transcatheter aortic valve implantation (TAVI) was initially proven as an alternative to valve replacement therapy in those beyond established risk thresholds for conventional surgery. With time the technique has been methodically refined and offered to a progressively lower risk cohort, and with this evolution has come that of the significant imaging requirements of valve implantation. This review discusses the role of transoesophageal echocardiography (TOE) in the current TAVI arena, aligning it with that of cardiac computed tomography, and outlining how TOE can be used most effectively both prior to and during TAVI in order to optimise outcomes.
Carolyn M Larsen and Sharon L Mulvagh
Cardio-oncology is a rapidly growing field aimed at minimizing the effects of cardiovascular morbidity and mortality in cancer survivors. To meet this aim, patients are assessed at baseline to define their risk of cardiotoxicity and then followed closely during and after chemotherapy to assess for early signs or symptoms of cardiovascular disease. Cardiac imaging, and in particular, transthoracic echocardiography, plays an essential role in the baseline assessment and serial follow-up of cardio-oncology patients. The objectives of this paper are to review the mechanisms of cardiotoxicity of several common chemotherapeutic agents associated with an increased risk for left ventricular systolic dysfunction and to outline recommendations regarding the baseline assessment and serial follow-up of cardio-oncology patients with a focus on the role of echocardiography.
Martin R Cowie
Heart failure is appropriately described as an epidemic, with 1–2% of health care expenditure being directed at its management. In England, the National Institute for Health and Care Excellence (NICE) has issued guidance on the best practice for the diagnosis and treatment of acute and chronic heart failure. Echocardiography is key to the diagnosis of the underlying cardiac abnormalities, and access to this (with our without biochemical testing using natriuretic peptides) is key to high-quality and speedy diagnosis. New models of care aim to speed up access to echocardiography, but a shortage of technically trained staff remains a limiting factor in improving standards of care. The NHS audits the quality of care and outcome for patients admitted to hospital with heart failure, and this continues to show wide variation in practice, particularly, where patients are not reviewed by the local heart failure multidisciplinary team. Recently, the All Party Parliamentary Group on Cardiac Disease issued 10 suggestions for improvement in care for patients with heart failure – access to echocardiography being one of the key suggestions. Time will tell as to whether this support from law makers will assist in the implementation of NICE-recommended standards of care consistently across the country.
Dimitris Klettas, Emma Alcock, Rafal Dworakowski, Philip MacCarthy, and Mark Monaghan
The role of transoesophageal echocardiography in cardiac interventional structural procedures is well established and appreciated. However, the need for general anaesthesia (GA) throughout the procedure remains a controversial issue. The aim of the present study is to assess the feasibility and imaging quality of using a transnasal microrobe that allows the usage of conscious sedation in patients who undergo cardiac structural interventional procedures without missing the benefits, guidance and navigation of conventional trans-procedural TEE.
We analysed the trans-procedural images of 24 consecutive patients who underwent TAVI, TMVI or ASD/PFO closure, using a transnasal 2D microprobe (PHILIPS) and then we compared them with images taken by using a conventional 3D TEE probe (PHILIPS). In particular, we compared the imaging quality of the two probes regarding: (1) The anatomy, visualisation of valvular calcification and transvalvular colour Doppler of the aortic and mitral valve; (2) the imaging quality of PFO, ASD and interatrial communication colour flow; (3) the imaging of left ventricle systolic function and pericardial space and (4) transgastric imaging.
All images were graded with a scale from 5 to 1. The average grade of imaging quality in the mitral valve was: anatomy, 4.3; calcification, 3.8; colour Doppler, 4.2. The average grade of imaging quality in the aortic valve was: anatomy, 4.3; calcification, 3.7; colour Doppler, 4.3. The average grade of imaging quality in PFO/ASD was 4.3. The average grade of imaging quality in LV/pericardial space was 4.2. The average grade of imaging quality in transgastric imaging was 4.1.
These results suggest that transnasal TEE can provide good anatomical image quality of relevant cardiac structures during cardiac structural interventions and this may facilitate these procedures being performed during conscious sedation without having to lose TEE guidance.
Preetham R Muskula, Rigoberto Ramirez, A Michael Borkon, and Michael L Main
Malgorzata Wamil, Sacha Bull, and James Newton
Despite significant advancements in the field of cardiovascular imaging, transoesophageal echocardiography remains the key imaging modality in the management of valvular pathologies. This paper provides echocardiographers with an overview of the modern role of TOE in the diagnosis and management of valvular disease. We describe how the introduction of 3D techniques has changed the detection and grading of valvular pathologies and concentrate on its role as a monitoring tool in interventional cardiology. In addition, we focus on the echocardiographic and Doppler techniques used in the assessment of prosthetic valves and provide guidance for the evaluation of prosthetic valves. Finally, we summarise quantitative methods used for the assessment of valvular stenosis and regurgitation and highlight the key areas where echocardiography remains superior over other novel imaging modalities.