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 (TTE) and transoesophageal (TOE) echocardiography, 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 VA-ECMO in fulminant myocarditis, as well as the role of repeated echocardiography when weaning from physiological support.
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Na Hyun Park, Hazem Lashin and Rosalba Spiritoso
Sathish Kumar Parasuraman, Janaki Srinivasan and Paul A Broadhurst
The 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 six 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 if echo follow-up should be routinely advised after STEMI – even in those with minimal cardiac symptoms.
Vasiliki Tsampasian, Vasileios F. Panoulas, Richard Jabbour, Neil Ruparelia, Iqbal S Malik, Nearchos Hadjiloizou, Angela Frame, Sayan Sen, Nilesh Sutaria, Ghada W Mikhail and Petros Nihoyannopoulos
Aims: 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 compared 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. 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).
Conclusions: 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 greater incidence of aortic regurgitation with Evolut R.
Prathap Kanagala and Iain B Squire
Lijun Qian, Feng Xie, Di Xu and Thomas R Porter
Background: 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.
Methods: 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.
Results: Seven studies met criteria, including 3668 patients (six with follow up ranging from two 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.
Conclusion: 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.
Patrick Savage and Michael Connolly
Prosthetic valve thrombosis is a rare but serious complication of mechanical valve replacement requiring prompt diagnosis and treatment. Unfortunately, it is often difficult to evaluate this based on single modality imaging alone. We demonstrate a case where the use of both 3D-TOE and valve fluoroscopy allowed for the differentiation between prosthetic valve thrombosis versus prosthetic mitral valve dyssychrony. In the images outlined below, it can be seen clearly on fluoroscopy that although there is dyssychrony of valve leaflet closure, their overall mobility is good. Additionally, using 3D-TOE it can be clearly noted that there is no evidence of pannus or thrombus. Using these two imaging modalities in concert facilitated the clear diagnosis of valve dyssynchrony versus valve thrombosis.
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.
Ruchika Meel, Ferande Peters, Bijoy K Khandheria, Elena Libhaber and Mohammed Essop
Chronic mitral regurgitation (MR) historically has been shown to primarily affect left ventricular (LV) function. The impact of increased left atrial (LA) volume in MR on morbidity and mortality has been highlighted recently, yet the LA does not feature as prominently in the current guidelines as the LV. Thus, we aimed to study LA and LV function in chronic rheumatic MR using traditional volumetric parameters and strain imaging.
Seventy-seven patients with isolated moderate or severe chronic rheumatic MR and 40 controls underwent echocardiographic examination. LV and LA function were assessed with conventional echocardiography and 2D strain imaging.
LA stiffness index was greater in chronic rheumatic MR than controls (0.95 ± 1.89 vs 0.16 ± 0.13, P = 0.009). LA dysfunction was noted in the reservoir, conduit, and contractile phases compared with controls (P < 0.05). LA peak reservoir strain (ƐR), LA peak contractile strain, and LV peak systolic strain were decreased in chronic rheumatic MR compared with controls (P < 0.05). Eighty-six percent of patients had decreased LA ƐR and 58% had depressed LV peak systolic strain. Decreased ƐR and normal LV peak systolic strain were noted in 42%. Thirteen percent had normal ƐR and LV peak systolic strain. One patient had normal ƐR with decreased LV peak systolic strain.
In chronic rheumatic MR, there is LA dysfunction in the reservoir, conduit, and contractile phases. In this study, LA dysfunction with or without LV dysfunction was the predominant finding, and thus, LA dysfunction may be an earlier marker of decompensation in chronic rheumatic MR.
Rakhee Hindocha, David Garry, Nadia Short, Tom E Ingram, Richard P Steeds, Claire L Colebourn, Keith Pearce, Vishal Sharma and the Accreditation and Education Committees of the British Society of Echocardiography
The British Society of Echocardiography has previously outlined a minimum dataset for a standard transthoracic echocardiogram, and this remains the basis on which an echocardiographic study should be performed. The importance of ultrasound in excluding critical conditions that may require urgent treatment is well known. Several point-of-care echo protocols have been developed for use by non-echocardiography specialists. However, these protocols are often only used in specific circumstances and are usually limited to 2D echocardiography. Furthermore, although the uptake in training for these protocols has been reasonable, there is little in the way of structured support available from accredited sonographers in the ongoing training and re-accreditation of those undertaking these point-of-care scans. In addition, it is well recognised that the provision of echocardiography on a 24/7 basis is extremely challenging, particularly outside of tertiary cardiac centres. Consequently, following discussions with NHS England, the British Society of Echocardiography has developed the Level 1 echocardiogram in order to support the rapid identification of critical cardiac pathology that may require emergency treatment. It is intended that these scans will be performed by non-specialists in echocardiography and crucially are not designed to replace a full standard transthoracic echocardiogram. Indeed, it is expected that a significant number of patients, in whom a Level 1 echocardiogram is required, will need to have a full echocardiogram performed as soon as is practically possible. This document outlines the minimum dataset for a Level 1 echocardiogram. The accreditation process for Level 1 echo is described separately.