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Open access

Ramasamy Manivarmane, Rebecca Taylor, and Rajdeep Khattar

Our case highlights the finding of an abnormal pulmonary valve on 2D echocardiography, confirmed to be of bicuspid morphology with 3D imaging. The use of biplane imaging both in transthoracic and transoesophageal echocardiography and routine use of three-dimensional views particularly in transoesophageal echocardiography are of incremental value in better delineating pulmonary valve anatomy.

Learning points:

  • Bicuspid pulmonary valve as an isolated clinical entity is a rare finding in clinical practice with an incidence of about 0.1%.

  • The true prevalence of the condition may be underestimated because of difficulty in visualising the pulmonary valve en-face on standard two-dimensional echocardiography.

  • Trans-oesophageal echocardiography may provide better visualization of the pulmonary valve when transthoracic images are affected by interference from the left lung.

  • Routine use of 3D echocardiography with biplane and zoomed views should be advocated for a full morphological assessment of the pulmonary valve, whether imaging via the transthoracic or transoesophageal approach.

Open access

Peter H Waddingham, Sanjeev Bhattacharyya, Jet Van Zalen, and Guy Lloyd

Objective

Patients with non-ischaemic systolic heart failure (HF) and idiopathic dilated cardiomyopathy (DCM) are a heterogenous group with varied morbidity and mortality. Prognostication in this group is challenging. We performed a systematic review and meta-analysis to examine the significance of the presence of contractile reserve as assessed via stress imaging on mortality and hospitalisation.

Methods

A search for studies that non-invasively assessed contractile reserve in patients with DCM or non-ischaemic HF with reduced ejection fraction, stress imaging with follow-up data comparing outcomes. A range of imaging modalities and stressors were included. We examined primary endpoints of mortality and secondary endpoints of combined cardiovascular events including HF progression or hospitalisation. Our analysis compared endpoints in patients with contractile reserve and those without it.

Results

Nine prospective cohort studies were identified describing a total of 787 patients. These studies are methodologically but not statistically heterogenous (I 2 = 31%). Using a random effect model, the presence of contractile reserve was associated with a significantly lower risk of mortality and cardiovascular events odds ratios of 0.20 (CI 0.11, 0.39) (P < 0.00001) and 0.13 (CI 0.04, 0.40) (P = 0.0004), respectively.

Conclusion

Regardless of stressor and imaging modality and despite the significant methodological heterogeneity within the current data (imaging techniques and parameters), patients with non-ischaemic cardiomyopathy and reduced EF who demonstrate contractile reserve have a lower mortality, and lower events/hospitalisations. The presence of contractile reserve therefore offers a potential positive prognostic indicator when managing these patients.

Open access

Jennifer Winter, Aparna Kulkarni, Mary Craft, Ling Li, Lisa K Hornberger, David A Danford, and Shelby Kutty

Introduction

We compared right and left ventricular cardiac output (RVCO and LVCO) in fetuses of diabetic mothers (FDM) with a large normal cohort.

Methods

We prospectively enrolled 264 normal fetuses and 30 FDM. Fetal CO parameters such as semilunar valve velocity time integrals (AVVTI, PVVTI), ventricular outflow diameters (LVOTD, RVOTD) and stroke volumes (AVSV, PVSV) were measured, and LVCO and RVCO were calculated. These were normalized using non-linear regression to estimated fetal weight (EFW) to provide means and standard deviations. Among FDMs, mean Z scores and 95% confidence limits (CL) were calculated and compared to zero.

Results

LVCO, RVCO and parameters they were calculated from, increased predictably and non-linearly with increasing EFW. In FDM, LVCO was depressed (mean Z −1.679, 95% CL −2.404, −0.955, P < 0.001), and AVVTI, LVOTD and AVSV were significantly lower than normal. Similarly, RVCO (mean Z = −1.119, CL −1.839, −0.400, P = 0.003), RVOTD (mean −2.085, CL −3.077, −1.093, P < 0.001) and PVSV (mean −1.184, CL −1.921, −0.446, P = 0.003) were lower than normal, however, PVVTI was not different (mean Z 0.078, CL −0.552, +0.707, P = 0.803).

Conclusion

Normal biventricular stroke volumes and outputs follow a non-linear regression with EFW. FDM have significantly lower right and left heart stroke volumes and outputs for weight than do normal fetuses.

Open access

Antigoni Deri and Kate English

This review article will guide the reader through the basics of echocardiographic assessment of congenital left to right shunts in both paediatric and adult age groups. After reading this article, the reader will understand the pathology and clinical presentation of atrial septal defects (ASDs), ventricular septal defects (VSDs), atrioventricular septal defects (AVSDs) and patent arterial duct. Echocardiography is the mainstay in diagnosis and follow-up assessment of patients with congenital heart disease. This article will therefore describe the echocardiographic appearances of each lesion, and point the reader towards specific features to look for echocardiographically.

Open access

David Oxborough, Daniel Augustine, Sabiha Gati, Keith George, Allan Harkness, Thomas Mathew, Michael Papadakis, Liam Ring, Shaun Robinson, Julie Sandoval, Rizwan Sarwar, Sanjay Sharma, Vishal Sharma, Nabeel Sheikh, John Somauroo, Martin Stout, James Willis, and Abbas Zaidi

Sudden cardiac death (SCD) in an athlete is a rare but tragic event. In view of this, pre-participation cardiac screening is mandatory across many sporting disciplines to identify those athletes at risk. Echocardiography is a primary investigation utilized in the pre-participation setting and in 2013 the British Society of Echocardiography and Cardiac Risk in the Young produced a joint policy document providing guidance on the role of echocardiography in this setting. Recent developments in our understanding of the athlete’s heart and the application of echocardiography have prompted this 2018 update.

Open access

Yasufumi Nagata, Yuichiro Kado, Takeshi Onoue, Kyoko Otani, Akemi Nakazono, Yutaka Otsuji, and Masaaki Takeuchi

Background

Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) play important roles in diagnosis and management of cardiac diseases. However, the issue of the accuracy and reliability of LVEF and GLS remains to be solved. Image quality is one of the most important factors affecting measurement variability. The aim of this study was to investigate whether improved image quality could reduce observer variability.

Methods

Two sets of three apical images were acquired using relatively old- and new-generation ultrasound imaging systems (Vivid 7 and Vivid E95) in 308 subjects. Image quality was assessed by endocardial border delineation index (EBDI) using a 3-point scoring system. Three observers measured the LVEF and GLS, and these values and inter-observer variability were investigated.

Results

Image quality was significantly better with Vivid E95 (EBDI: 26.8 ± 5.9) than that with Vivid 7 (22.8 ± 6.3, P < 0.0001). Regarding the inter-observer variability of LVEF, the r-value, bias, 95% limit of agreement and intra-class correlation coefficient for Vivid 7 were comparable to those for Vivid E95. The % variabilities were significantly lower for Vivid E95 (5.3–6.5%) than those for Vivid 7 (6.5–7.5%). Regarding GLS, all observer variability parameters were better for Vivid E95 than for Vivid 7. Improvements in image quality yielded benefits to both LVEF and GLS measurement reliability. Multivariate analysis showed that image quality was indeed an important factor of observer variability in the measurement of LVEF and GLS.

Conclusions

The new-generation ultrasound imaging system offers improved image quality and reduces inter-observer variability in the measurement of LVEF and GLS.

Open access

Caroline Schneider, Lynsey Forsythe, John Somauroo, Keith George, and David Oxborough

Background

Left ventricular (LV) function is dependent on load, intrinsic contractility and relaxation with a variable impact on specific mechanics. Strain (ε) imaging allows the assessment of cardiac function; however, the direct relationship between volume and strain is currently unknown. The aim of this study was to establish the impact of preload reduction through head-up tilt (HUT) testing on simultaneous left ventricular (LV) longitudinal and transverse function and their respective contribution to volume change.

Methods

A focused transthoracic echocardiogram was performed on 10 healthy male participants (23 ± 3 years) in the supine position and following 1 min and 5 min of HUT testing. Raw temporal longitudinal ε (Ls) and transverse ε (Ts) values were exported and divided into 5% increments across the cardiac cycle and corresponding LV volumes were traced at each 5% increment. This provided simultaneous LV longitudinal and transverse ε and volume loops (deformation volume analysis – DVA).

Results

There was a leftward shift of the ε-volume loop from supine to 1 min and 5 min of HUT (P < 0.001). Moreover, longitudinal shortening was reduced (P < 0.001) with a concomitant increase in transverse thickening from supine to 1 min, which was further augmented at 5 min (P = 0.018).

Conclusions

Preload reduction occurs within 1 min of HUT but does not further reduce at 5 min. This decline is associated with a decrease in longitudinal ε and concomitant increase in transverse ε. Consequently, augmented transverse relaxation appears to be an important factor in the maintenance of LV filling in the setting of reduced preload. DVA provides information on the relative contribution of mechanics to a change in LV volume and may have a role in the assessment of clinical populations.

Open access

Hisham Sharif, Stephen Ting, Lynsey Forsythe, Gordon McGregor, Prithwish Banerjee, Deborah O’Leary, David Ditor, Keith George, Daniel Zehnder, and David Oxborough

This study sought to examine layer-specific longitudinal and circumferential systolic and diastolic strain, strain rate (SR) and diastolic time intervals in hypertensive patients with and without diastolic dysfunction. Fifty-eight treated hypertensive patients were assigned to normal diastolic function (NDF, N = 39) or mild diastolic dysfunction (DD, N = 19) group. Layer-specific systolic and diastolic longitudinal and circumferential strains and SR were assessed. Results showed no between-group difference in left ventricular mass index (DD: 92.1 ± 18.1 vs NDF: 88.4 ± 16.3; P = 0.44). Patients with DD had a proportional reduction in longitudinal strain across the myocardium (endocardial for DD −13 ± 4%; vs NDF −17 ± 3, P < 0.01; epicardial for DD −10 ± 3% vs NDF −13 ± 3%, P < 0.01; global for DD: −12 ± 3% vs NDF: −15 ± 3, P = 0.01), and longitudinal mechanical diastolic impairments as evidenced by reduced longitudinal strain rate of early diastole (DD 0.7 ± 0.2 L/s vs NDF 1.0 ± 0.3 L/s, P < 0.01) and absence of a transmural gradient in the duration of diastolic strain (DD endocardial: 547 ± 105 ms vs epicardial: 542 ± 113 ms, P = 0.24; NDF endocardial: 566 ± 86 ms vs epicardial: 553 ± 77 ms, P = 0.03). Patients with DD also demonstrate a longer duration of early circumferential diastolic strain (231 ± 71 ms vs 189 ± 58 ms, P = 0.02). In conclusion, hypertensive patients with mild DD demonstrate a proportional reduction in longitudinal strain across the myocardium, as well as longitudinal mechanical diastolic impairment, and prolonging duration of circumferential mechanical relaxation.

Open access

Jalal Asadi, Sanjay S Bhandari, and Nauman Ahmed

A 25-year-old male with a background of ulcerative colitis presented with a two-week history of central chest pain. His ECG on presentation showed global T wave inversion with a peak troponin I of 165 ng/mL. Clinical diagnosis of myopericarditis/myocarditis was made. Echocardiography and cardiac magnetic resonance (MR) confirmed the diagnosis. On detailed assessment of his medication history, mesalazine was suspected as an etiological factor, with discontinuation resulting in an improvement in symptoms, inflammatory markers and cardiac enzymes. This is a unique case of mesalazine-induced myopericarditis on a background of inflammatory bowel disease.

Learning points:

  • Myopericarditis can be due to infectious and non-infectious causes.

  • Myopericarditis may be related to systemic diseases such as inflammatory bowel disease (IBD) or as a consequence of its treatment.

  • Cardiac magnetic resonance has proven to be a valuable technique for assessing myocardial injury and inflammation in myocarditis.

  • Importance of taking a thorough medical history to distinguish the type of chest pain in order to make a correct diagnosis.

Open access

Islam Fathi Hussein Ali Elsisi and Ananth Kidambi

Summary

This is a case report of intracardiac foreign bodies that gained access to the heart by migration from a peripheral vein. The case report describes the diagnostic findings on cardiac imaging and summarizes different approaches to management.

Learning points:

  • Appearance of embolized cardiac missiles with reverberation and acoustic shadowing.

  • Role of different imaging modalities in the diagnosis of intracardiac foreign bodies.

  • Indications for surgical or transcatheter retrieval.