Jenna Smith, Sarah Waters, Brian Campbell, and John Chambers
Ying X Gue, Sanjay S Bhandari, and Damian J Kelly
A 73-year-old male was brought into hospital with chest pain and inferior ST elevation on ECG. The patient immediately proceeded to the catheter lab for primary percutaneous coronary intervention. Angiography did not identify any culprit lesions to account for the patient’s electrocardiographic changes and ongoing symptoms of chest pain. Bedside echocardiography revealed critical aortic stenosis. Intra-aortic balloon pump (IABP) was inserted, resulting in resolution of chest pain and ST-segment changes. The patient underwent successful aortic valve (AV) replacement without the need for coronary intervention. This is a rare presentation of critical aortic stenosis (AS) presenting as ST-segment elevation myocardial infarction (STEMI).
Aortic stenosis (AS) affects 2–9% of population above 65 years old and increases with age.
AS induces ischaemia via abnormal cardiac coronary coupling.
Focused clinical examination in patients with ST-segment elevation myocardial infarction (STEMI) is vital prior to cardiac catheterisation.
Detection of murmurs should be followed on by an echocardiography examination.
Other differentials of STEMI include acute aortopathy, endocarditis with embolus, myopericarditis and intracranial haemorrhage.
Nuno Pires, Wei Li, Roxy Senior, and Rajdeep S Khattar
A rare isolated double orifice mitral valve (DOMV) was diagnosed in a 77-year-old male patient, being assessed for surgical repair of the ascending aorta. This is a rare congenital abnormality, usually discovered as an incidental finding during investigation of other congenital heart defects. This case shows that a detailed assessment of all cardiac structures is necessary, not only in young patients, but also in the elderly population, to minimise the under-diagnosis of such rare anomalies. The use of 3D transthoracic echocardiography (TTE) has an increasingly significant role in establishing the diagnosis and extending the morphological and functional understanding of the anomaly.
Thoroughly assessing all cardiac structures, in accordance with the minimum dataset guidelines for transthoracic echocardiography, ensures not only a comprehensive assessment of the primary indication for the scan, but also improves the detection of concomitant and otherwise unknown lesions.
Despite falling under the category of congenital heart defects, several rare anomalies such as DOMV can be present in elderly patients, and the adult echocardiographer should have appropriate knowledge and awareness for detecting these conditions.
3D TTE provides a comprehensive assessment of the morphology of DOMV, over and above the information obtained by 2D imaging.
Apostolos Vrettos, Paula Mota, James Nash, Iain Thorp, Max Baghai, and Adam Marzetti
Pulmonary valve endocarditis is a rare type of infective endocarditis (IE). Streptococcus pneumoniae is a pathogen that is uncommonly associated with IE. A 50 year-old male was referred to us after an incidental echocardiographic finding of a pulmonary valve vegetation. The patient had a recent admission for drainage of a scrotal abscess from which S. pneumoniae was isolated, complicated by hospital acquired pneumonia and pulmonary embolism. Analysis using polymerase chain reaction of the surgically resected mass revealed signs of 16S ribosomal DNA consistent with S. pneumoniae infection. This was an extremely rare case of pneumococcal pulmonary valve IE presenting entirely asymptomatically in the absence of any known risk factors.
Streptococcus pneumoniae endocarditis can present with very few symptoms or even entirely asymptomatically, as in this case.
Pulmonary valve endocarditis can affect healthy patients, even in the absence of any known predisposing risk factors or pre-existing heart conditions.
An echocardiogram may be considered following severe infection with sepsis by pneumococci, to screen for vegetations that could evolve silently over the following weeks.
Sergio Barros-Gomes, Niyada Naksuk, Dragan Jevremovic, and Hector R Villarraga
Cardiac amyloidosis (CA) is relatively rare and frequently misdiagnosed. Other disorders presenting with increased left ventricular (LV) mass can mimic its diagnosis. This case illustrates unique findings of primary light chain (AL) amyloidosis in a patient with remarkable signs of CA. Here, we report a 49-year-old male with prior diagnosis of hypertrophic cardiomyopathy (HCM) based on an echocardiogram performed 1 year earlier, which presented with 8 weeks of periorbital rash. The patient had numbness in the past 3 years. More recently, the patient presented with shortness of breath. Physical examination was remarkable for periorbital purpura, macroglossia and orthostatic hypotension. Cardiac auscultation showed S3 and S4. Electrocardiography showed diffuse low-voltage QRS complexes. Echocardiography revealed severe diastolic impairment; granular ‘sparkling’ pattern of the myocardium with thickened walls, interatrial septum and valves; and pericardial effusion. Diastolic dysfunction and thick walls with low ECG voltage are compelling diagnostic findings. Laboratory workup showed increased free light chain-differential (FLC-diff), N-terminal fragment of brain natriuretic peptide (NT-BNP) and cardiac Troponin T (cTnT). Bone marrow biopsy confirmed AL amyloidosis. A diagnosis of AL amyloidosis with cardiac involvement mimicking HCM was made. The patient died during hospitalization due to sudden cardiac death. This case illustrates the importance of the combination of clinical, serological, and electro- and echocardiographic findings to establish the diagnosis of CA.
Several disorders presenting with increased LV mass can mimic CA.
Echocardiography is one of the most important methods to diagnose CA and HCM.
Signs of CA include LV wall thickness; thickening of interatrial septum, valves and right ventricular free wall; and pericardial effusion. Diastolic dysfunction and thick walls on echocardiography with low ECG voltage are the hallmark of disease.
CA is a major prognostic factor in AL amyloidosis.
Signs of HCM on echocardiography include several patterns of LV hypertrophy, such as sigmoidal, reverse curve, neutral and apical morphologies; LV outflow tract or mid-cavity obstruction; systolic anterior motion of mitral leaflets; mitral regurgitation and diastolic dysfunction.
The combination of clinical and serological features, along morphological and functional structures, has an important role for establishing diagnosis and predicting prognosis.
Richard P Steeds, Martin R Cowie, Bushra S Rana, John B Chambers, Simon Ray, Janaki Srinivasan, Konstantin Schwarz, Christopher J Neil, Caroline Scally, John D Horowitz, Michael P Frenneaux, Cristina Pislaru, Dana K Dawson, Oliver J Rothwell, Keith George, John D Somauroo, Rachel Lord, Mike Stembridge, Rob Shave, Martin Hoffman, Euan A Ashley, Francois Haddad, Thijs M H Eijsvogels, David Oxborough, Reinette Hampson, Chris D Kinsey, Sothinathan Gurunathan, Anastasia Vamvakidou, Nikolaos Karogiannis, Roxy Senior, Shahram Ahmadvazir, Benoy N Shah, Konstantinos Zacharias, Dan Bowen, Shaun Robinson, Ugochukwu Ihekwaba, Karen Parker, James Boyd, Cameron G Densem, Charlotte Atkinson, Jonathan Hinton, Edmund B Gaisie, Dhrubo J Rakhit, Arthur M Yue, Paul R Roberts, Dean Thomas, Pat Phen, Jonathan Sibley, Sarah Fergey, and Paul Russhard
Daniel A Jeffery, Guy Lloyd, and Arjun K Ghosh
Baskar Sekar, Joe Martins, and Sanjiv Petkar
Thomas Mathew, Lynne Williams, Govardhan Navaratnam, Bushra Rana, Richard Wheeler, Katherine Collins, Allan Harkness, Richard Jones, Dan Knight, Kevin O'Gallagher, David Oxborough, Liam Ring, Julie Sandoval, Martin Stout, Vishal Sharma, Richard P Steeds, and on behalf of the British Society of Echocardiography Education Committee
Heart failure (HF) is a debilitating and life-threatening condition, with 5-year survival rate lower than breast or prostate cancer. It is the leading cause of hospital admission in over 65s, and these admissions are projected to rise by more than 50% over the next 25 years. Transthoracic echocardiography (TTE) is the first-line step in diagnosis in acute and chronic HF and provides immediate information on chamber volumes, ventricular systolic and diastolic function, wall thickness, valve function and the presence of pericardial effusion, while contributing to information on aetiology. Dilated cardiomyopathy (DCM) is the third most common cause of HF and is the most common cardiomyopathy. It is defined by the presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions (hypertension and valve disease) or coronary artery disease sufficient to cause global systolic impairment. This document provides a practical approach to diagnosis and assessment of dilated cardiomyopathy that is aimed at the practising sonographer.
Jamal N Khan, Timothy Griffiths, Tamseel Fatima, Leah Michael, Andreea Mihai, Zeeshan Mustafa, Kully Sandhu, Robert Butler, Simon Duckett, and Grant Heatlie
Physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There are however no published data on the feasibility of PLSE. We sought to assess the feasibility, safety and robustness of PLSE and cardiologist-led stress echocardiography (CLSE) for coronary artery disease (CAD) assessment.
Retrospective analysis of 898 patients undergoing PLSE or CLSE for CAD assessment using exercise or dobutamine stress over 24 months. PLSE involved 2 cardiac physiologists (exercise) or 1 physiologist plus 1 cardiac nurse (dobutamine). A cardiology registrar was present in the echocardiography department during PLSE in case of medical complications. CLSE involved 1 physiologist and 1 trainee cardiologist who analysed the study and reviewed findings with an imaging cardiologist. Sixteen-segment wall motion scoring (WMS, WMSI) analysis was performed. Feasibility (stressor, image quality, proportion of completed studies, agreement with imaging cardiologist analysis) and safety (complication rate) were compared for PLSE and CLSE.
The majority of studies were CLSE (56.2%) and used dobutamine (68.7%). PLSE more commonly used exercise (69.2%). Overall, 96% of studies were successfully completed (>14 diagnostic segments in 98%, P = 0.899 PLSE vs CLSE). Commencement of PLSE was associated with an increase in annual SE’s performed for CAD assessment. Complication rates were comparably very low for PLSE and CLSE (0.8% vs 1.8%, P = 0.187). There was excellent agreement between PLSE and CLSE WMS interpretation of 480 myocardial segments at rest (κ = 0.87) and stress (κ = 0.70) and WMSI (ICCs and Pearson’s r >0.90, zero Bland–Altman mean bias).
This to our knowledge is the first study of the feasibility of PLSE. PLSE performed by well-trained physiologists is feasible and safe in contemporary practice. PLSE and CLSE interpretation of stress echocardiography for CAD agree very closely.