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Open access

Ewa A Konik, Merri Bremer, Peter T Lin and Sorin V Pislaru

Summary

A 67-year-old man with myelodysplastic syndrome, disseminated histoplasmosis, and mitral valve replacement presented with dyspnea and peripheral edema. Transthoracic echocardiography demonstrated abnormal pulmonic valve with possible vegetation. Color flow imaging showed laminar flow from main pulmonary artery into right ventricular outflow tract (RVOT) in diastole. The continuous wave Doppler signal showed dense diastolic envelope with steep deceleration slope. These findings were consistent with severe pulmonic valve regurgitation, possibly due to endocarditis. Transesophageal echocardiography demonstrated an echodense mass attached to the pulmonic valve. The mitral valve bioprosthesis appeared intact. Bacterial and fungal blood cultures were negative; however, serum histoplasma antigen was positive. At surgery, the valve appeared destroyed by vegetations. Gomori methenamine silver-stains showed invasive fungal hyphae and yeast consistent with a dimorphic fungus. Valve cultures grew one colony of filamentous fungus. Itraconazole was continued based on expert infectious diseases diagnosis. After surgery, dyspnea and ankle edema resolved. To the best of our knowledge, histoplasma endocarditis of pulmonic valve has not been previously reported. Isolated pulmonic valve endocarditis is rare, accounting for about 2% of infectious endocarditis (IE) cases. Fungi account for about 3% of cases of native valve endocarditis. Characterization of pulmonary valve requires thorough interrogation with 2D and Doppler echocardiography techniques. Parasternal RVOT view allowed visualization of the pulmonary valve and assessment of regurgitation severity. As an anterior structure, it may be difficult to image with transesophageal echocardiography. Mid-esophageal right ventricular inflow–outflow view clearly showed the pulmonary valve and vegetation.

Learning points

  • Identification and characterization of pulmonary valve abnormalities require thorough interrogation with 2D and Doppler echocardiography techniques.

  • Isolated pulmonary valve IE is rare and requires high index of suspicion.

  • Histoplasma capsulatum IE is rare and requires high index of suspicion.

Open access

Z H Teoh, J Roy, J Reiken, M Papitsas, J Byrne and M J Monaghan

Moderate-to-severe tricuspid regurgitation is associated with higher mortality and morbidity yet remains significantly undertreated. The reasons for this are complex but include a higher operative mortality for patients undergoing isolated tricuspid valve surgery. This study sought to determine the prevalence of patients with moderate-to-severe tricuspid regurgitation and identify those who could be potentially suitable for percutaneous tricuspid valve intervention by screening patients referred for transthoracic echocardiography (ECHO) at a tertiary center. Our results showed that the prevalence of moderate-to-severe tricuspid regurgitation in our total ECHO patient population was 2.8%. Of these, approximately one in eight patients with moderate-to-severe tricuspid regurgitation would be potentially suitable for percutaneous intervention and suggests a large, unmet clinical need in this population.

Open access

Isaac Adembesa, Adriaan Myburgh and Justiaan Swanevelder

Summary

We present a patient with rheumatic heart disease involving all the heart valves. An intraoperative transoesophageal echocardiography confirmed severe mitral stenosis, severe aortic regurgitation, severe tricuspid regurgitation and stenosis, and severe pulmonary stenosis. The patient underwent successful quadruple valve replacement during a single operation at the Groote Schuur Hospital, Cape Town, South Africa.

Learning points:

  • Rheumatic heart disease can affect all the heart valves including the pulmonary valve.

  • Intraoperative transoesophageal echocardiography is key for diagnosis, monitoring and confirmation of successful surgical result during heart valve surgery.

  • Combined surgical procedure of all four valves is possible though associated with long procedural time.

Open access

Francesca Tedoldi, Maximilian Krisper, Clemens Köhncke and Burkert Pieske

Summary

We present a very rare example of chronic right heart failure caused by torrent tricuspid regurgitation. Massive right heart dilatation and severe tricuspid regurgitation due to avulsion of the tricuspid valve apparatus occurred as a result of a blunt chest trauma following the explosion of a gas bottle 20 years before admission, when the patient was a young man in Vietnam. After this incident, the patient went through a phase of severe illness, which can retrospectively be identified as an acute right heart decompensation with malaise, ankle edema, and dyspnea. Blunt chest trauma caused by explosives leading to valvular dysfunction has not been reported in the literature so far. It is remarkable that the patient not only survived this trauma, but had been managing his chronic heart failure well without medication for over 20 years.

Learning points

  • Thorough clinical and physical examination remains the key to identifying patients with relevant valvulopathies.

  • With good acoustic windows, TTE is superior to TEE in visualizing the right heart.

  • Traumatic avulsion of valve apparatus is a rare but potentially life-threatening complication of blunt chest trauma and must be actively sought for. Transthoracic echocardiography remains the method of choice in these patients.

Open access

Daniel Hammersley, Aamir Shamsi, Mohammad Murtaza Zaman, Philip Berry and Lydia Sturridge

A 63-year-old female presented to hospital with progressive exertional dyspnoea over a 6-month period. In the year preceding her admission, she reported an intercurrent history of abdominal pain, diarrhoea and weight loss. She was found to be hypoxic, the cause for which was initially unclear. A ventilation–perfusion scan identified a right-to-left shunt. Transoesophageal echocardiography (TOE) demonstrated a significant right-to-left intracardiac shunt through a patent foramen ovale (PFO); additionally severe tricuspid regurgitation was noted through a highly abnormal tricuspid valve. The findings were consistent with carcinoid heart disease with a haemodynamically significant shunt, resulting in profound systemic hypoxia. 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) and imaging were consistent with a terminal ileal primary carcinoid cancer with hepatic metastasis. Liver biopsy confirmed a tissue diagnosis. The patient was commenced on medical therapy for carcinoid syndrome. She subsequently passed away while undergoing anaesthetic induction for valvular surgery to treat her carcinoid heart disease and PFO.

Learning points:

  • Carcinoid syndrome is a rare condition, which presents a significant diagnostic challenge due to its insidious presentation and symptoms. This frequently results in a marked delay in diagnosis.

  • Carcinoid heart disease is characterised by distortion and fixation of right-sided heart valves, which cause valvular regurgitation, stenosis or both. Valvular abnormalities are often found in association with right ventricular failure.

  • In the case described, carcinoid heart disease was found in association with a significant right-to-left intracardiac shunt, created through a PFO due to right atrial volume overload. This prevented right ventricular failure at the expense of creating a state of severe induced systemic hypoxia.

  • This physiological adaptation resulted in an unusual presentation of this condition, due to symptoms resulting from hypoxia, rather than the classical symptoms of carcinoid syndrome or right ventricular failure.

Open access

Emily Worley, Bushra Rana, Lynne Williams and Shaun Robinson

Objective

The left atrium (LA) is exposed to left ventricular pressure during diastole. Applying the 2016 American Society of Echocardiography left ventricular diastolic function (LVDF) guidelines, this study aims to investigate whether left atrial ejection fraction (LAEF) and left atrial active emptying fraction (LAAEF) are markers of diastolic dysfunction (LVDD).

Methods

Retrospective cohort of consecutive patients (n = 124) who underwent transthoracic echocardiography were studied. Doppler peak velocities of passive (MV E) and active filling (MV A) were measured and ratio E/A calculated. Tissue Doppler imaging parameters of peak early (e′) of the septal and lateral mitral annulus were measured, and average E/e′ ratio (E/e′) was calculated. Tricuspid regurgitation velocity, left atrial maximum volume, left atrial minimum volume and LA volume pre-contraction were measured, allowing calculation of LAEF and LAAEF. Subjects were assigned LVDF categories.

Results

Binomial logistic regression model (X 2(2) = 48.924, P < 0.01) determined that LAEF and LAAEF predicted diastolic dysfunction with sensitivity 85.5% and specificity 78%. ROC curves determined good diagnostic accuracy for LAEF and LAAEF to predict LVDD, AUC 0.826 and 0.861 respectively. Logistic regression model (X 2(2) = 39.525, P < 0.01) predicted those patients with E/e′ ≥14 using LAEF and LAAEF with sensitivity 51.6% and specificity 92.4%. Moderate correlations were found between E/e′ and log derivatives of LAEF and LAAEF.

Conclusions

A decline in LAAEF and LAEF is associated with worsening LVDD.

Open access

Mohammed Andaleeb Chowdhury, Jered M Cook, George V Moukarbel, Sana Ashtiani, Thomas A Schwann, Mark R Bonnell, Christopher J Cooper and Samer J Khouri

Background

This analysis aims to assess the prognostic value of pre-operative right ventricular echocardiographic parameters in predicting short-term adverse outcomes and long-term mortality after coronary artery bypass graft (CABG).

Methods

Study design: Observational retrospective cohort. Pre-operative echocardiographic data, perioperative adverse outcomes (POAO) and long-term mortality were retrospectively analyzed in 491 patients who underwent isolated CABG at a single academic center between 2006 and 2014.

Results

Average age of enrolled subjects was 66 ± 11.5 years with majority being male (69%). 227/491 patients had 30 days POAO (46%); most common being post-operative atrial fibrillation (27.3%) followed by prolonged ventilation duration (12.7%). On multivariate analysis, left atrial volume index ≥42 mL/m2 (LAVI) (OR (95% CI): 1.98 (1.03–3.82), P = 0.04), mitral E/A >2 (1.97 (1.02–3.78), P = 0.04), right atrial size >18 cm2 (1.86 (1.14–3.05), P = 0.01), tricuspid annular plane systolic excursion (TAPSE) <16 mm (1.8 (1.03–3.17), P = 0.04), right ventricular systolic pressure (RVSP) ≥36 mmHg (pulmonary hypertension) (1.6 (1.03–2.38), P = 0.04) and right ventricle myocardial performance index (RVMPI) >0.55 (1.58 (1.01–2.46), P = 0.04) were found to be associated with increased 30-day POAO. On 3.5-year follow-up, cumulative survival was decreased in patients with myocardial performance index (MPI) ≥0.55 (log rank: 4.5, P = 0.034) and in patients with mitral valve E/e′ ≥14 (log rank: 4.9, P = 0.026).

Conclusion

Pre-operative right ventricle dysfunction (RVD) is associated with increased perioperative complications. Furthermore, pre-operative RVD and increased left atrial pressures are associated with long-term mortality post CABG.

Open access

Girish Dwivedi, Ganadevan Mahadevan, Donie Jimenez, Michael Frenneaux and Richard P Steeds

Only limited data are available from which normal ranges of mitral annular (MA) and tricuspid annular (TA) dimensions have been established. Normative data are important to assist the echocardiographer in defining the mechanism of atrioventricular valve regurgitation and to inform surgical planning. This study was conceived to establish normal MA and TA dimensions. Consecutive healthy subjects over the age of 60 were randomly recruited from the community as part of a screening project within South Birmingham. MA and TA dimensions in end-systole and end-diastole were evaluated in the parasternal and apical acoustic windows views using transthoracic echocardiography. Gender (males (M) and females (F))-specific dimensions were then assessed. A total of 554 subjects were screened and 74 with pathology considered to have an effect on annular dimensions were excluded from analysis. The mean age of the remaining 480 subjects was 70±7 years and the majority were female (56%). Dimensions were larger in men than in women and greater at end-diastole than end-systole (both P<0.05). Mean MA diameters at end-systole in the parasternal long axis view (cm) were 3.44 cm (M) and 3.11 cm (F) and at end-diastole 3.15 cm (M) and 2.83 cm (F) respectively. Mean TA diameters (cm) at end-systole in the apical 4 chamber view were 2.84 (M) and 2.80 (F) and at end-diastole 3.15 (M) and 3.01 (F) respectively. The reference ranges derived from this study differ from current published standards and should help to improve distinction of normal from pathological findings, in identifying aetiology and defining the mechanism of regurgitation.

Open access

A E Velcea, S Mihaila Baldea, D Muraru, L P Badano and D Vinereanu

Summary

Neck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.

Learning points:

  • Internal jugular venous malformations, such as aneurisms or hypoplasia, could be associated with an increased risk of thrombosis and major embolic events.

  • Systemic thrombolysis can be an efficient solution in cases of pulmonary embolism with right heart thrombosis.

  • Multimodality imaging is greatly valuable in clarifying the diagnosis of atypical cases.

Open access

Philip McCall, Alvin Soosay, John Kinsella, Piotr Sonecki and Ben Shelley

Right ventricular (RV) dysfunction occurs following lung resection and is associated with post-operative complications and long-term functional morbidity. Accurate peri-operative assessment of RV function would have utility in this population. The difficulties of trans thoracic echocardiographic (TTE) assessment of RV function may be compounded following lung resection surgery and no parameters have been validated in this patient group. This study compares conventional TTE methods for assessing RV systolic function to a reference method in a lung resection population. Right ventricular index of myocardial performance (RIMP), fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE) and S' Wave velocity at the tricuspid annulus (S'), along with speckle tracked global and free wall longitudinal strain (RV-GPLS and RV-FWPLS respectively) are compared with RV ejection fraction obtained by cardiovascular magnetic resonance (RVEFCMR). Twenty-seven patients undergoing lung resection underwent contemporaneous CMR and TTE imaging; pre-operatively, on post-operative day two and at two months. Ability of each of the parameters to predict RV dysfunction (RVEFCMR <45%) was assessed using the area under the receiver operating characteristic curve (AUROCC). RIMP, FAC and S' demonstrated no predictive value for poor RV function (AUROCC <0.61, p>0.05). TAPSE performed marginally better with an AUROCC of 0.65 (p=0.04). RV-GPLS and RV-FWPLS demonstrated good predictive ability with AUROCC's of 0.74 and 0.76 respectively (p<0.01 for both). This study demonstrates that the conventional TTE parameters of RV systolic function are inadequate following lung resection. Longitudinal strain performs better and offers some ability to determine poor RV function in this challenging population.