Handheld echocardiography in patients with cardiovascular disease: to use or not to use, that is the question.

The physical examination is one of the most important diagnostic tools for physicians. Traditionally, a physical examination consists of inspection (looking), palpation (feeling), percussion (reflection of sound) and auscultation (listening). Handheld echography devices could become the new fifth element of a physical examination. The use of handheld echocardiography has recently increased because the devices have become smaller, easier to handle and more affordable. Handheld echocardiography is used by many specialists involved in acute cardiovascular care. In this narrative review we give a summary of the diagnostic accuracy and limitations of cardiovascular physical examination combined with handheld echocardiography. In patients with cardiovascular disease, adding handheld echocardiography to physical examination increases the sensitivity for detecting valvular heart disease (71% vs 46%) and left ventricular dysfunction with an ejection fraction < 50% (84% vs 43%). Handheld echocardiography might be better for ruling out diseases with a low pre-test probability than in confirming diseases with a high pre-test probability.

Baseline MDCT findings after prosthetic heart valve implantation provide important complementary information to echocardiography for follow-up purposes.

OBJECTIVES: Recent studies have proposed additional multidetector-row CT (MDCT) for prosthetic heart valve (PHV) dysfunction. References to discriminate physiological from pathological conditions early after implantation are lacking. We present baseline MDCT findings of PHVs 6 weeks post implantation. METHODS: Patients were prospectively enrolled and TTE was performed according to clinical guidelines. 256-MDCT images were systematically assessed for leaflet excursions, image quality, valve-related artefacts, and pathological and additional findings. RESULTS: Forty-six patients were included comprising 33 mechanical and 16 biological PHVs. Overall, MDCT image quality was good and relevant regions remained reliably assessable despite mild-moderate PHV-artefacts. MDCT detected three unexpected valve-related pathology cases: (1) prominent subprosthetic tissue, (2) pseudoaneurysm and (3) extensive pseudoaneurysms and valve dehiscence. The latter patient required valve surgery to be redone. TTE only showed trace periprosthetic regurgitation, and no abnormalities in the other cases. Additional findings were: tilted aortic PHV position (n = 3), pericardial haematoma (n = 3) and pericardial effusion (n = 3). Periaortic induration was present in 33/40 (83 %) aortic valve patients. CONCLUSIONS: MDCT allowed evaluation of relevant PHV regions in all valves, revealed baseline postsurgical findings and, despite normal TTE findings, detected three cases of unexpected, clinically relevant pathology. KEY POINTS: • Postoperative MDCT presents baseline morphology relevant for prosthetic valve follow-up. • 83 % of patients show periaortic induration 6 weeks after aortic valve replacement. • MDCT detected three cases of clinically relevant pathology not found with TTE. • Valve dehiscence detection by MDCT required redo valve surgery in one patient. • MDCT is a suitable and complementary imaging tool for follow-up purposes.

Are novel non-invasive imaging techniques needed in patients with suspected prosthetic heart valve endocarditis? A systematic review and meta-analysis.

OBJECTIVES: Multimodal non-invasive imaging plays a key role in establishing a diagnosis of PHV endocarditis. The objective of this study was to provide a systematic review of the literature and meta-analysis of the diagnostic accuracy of TTE, TEE, and MDCT in patients with (suspected) PHV endocarditis. METHODS: Studies published between 1985 and 2013 were identified via search and cross-reference of PubMed/Embase databases. Studies were included if (1) they reported on the non-invasive index tests TTE, TEE, or MDCT; (2) data was provided on PHV endocarditis as the condition of interest; and (3) imaging results were verified against either surgical inspection/autopsy or clinical follow-up reference standards, thereby enabling the extraction of 2-by-2 tables. RESULTS: Twenty articles (including 496 patients) met the inclusion criteria for PHV endocarditis. TTE, TEE, and MDCT + TEE had a pooled sensitivity/specificity for vegetations of 29/100%; 82/95%, and 88/94%, respectively. The pooled sensitivity/specificity of TTE, TEE, and MDCT + TEE for periannular complications was 36/93%, 86/98%, and 100/94%, respectively. CONCLUSIONS: TEE showed good sensitivity and specificity for establishing a diagnosis of PHV endocarditis. Although MDCT data are limited, this review showed that MDCT in addition to TEE may improve sensitivity in detecting life-threatening periannular complications. KEY POINTS: • Multimodal imaging is an important ingredient of diagnostic workup for PHV endocarditis. • Transthoracic and transesophageal echography may miss life-threatening periannular complications. • MDCT can improve sensitivity for the detection of life-threatening periannular complications.

Coronary artery assessment by multidetector computed tomography in patients with prosthetic heart valves.

OBJECTIVES: Patients with prosthetic heart valves may require assessment for coronary artery disease. We assessed whether valve artefacts hamper coronary artery assessment by multidetector CT. METHODS: ECG-gated or -triggered CT angiograms were selected from our PACS archive based on the presence of prosthetic heart valves. The best systolic and diastolic axial reconstructions were selected for coronary assessment. Each present coronary segment was scored for the presence of valve-related artefacts prohibiting coronary artery assessment. Scoring was performed in consensus by two observers. RESULTS: Eighty-two CT angiograms were performed on a 64-slice (n = 27) or 256-slice (n = 55) multidetector CT. Eighty-nine valves and five annuloplasty rings were present. Forty-three out of 1160 (3.7%) present coronary artery segments were non-diagnostic due to valve artefacts (14/82 patients). Valve artefacts were located in right coronary artery (15/43; 35%), left anterior descending artery (2/43; 5%), circumflex artery (14/43; 32%) and marginal obtuse (12/43; 28%) segments. All cobalt-chrome containing valves caused artefacts prohibiting coronary assessment. Biological and titanium-containing valves did not cause artefacts except for three specific valve types. CONCLUSIONS: Most commonly implanted prosthetic heart valves do not hamper coronary assessment on multidetector CT. Cobalt-chrome containing prosthetic heart valves preclude complete coronary artery assessment because of severe valve artefacts. KEY POINTS: • Most commonly implanted prosthetic heart valves do not hamper coronary artery assessment • Prosthetic heart valve composition determines the occurrence of prosthetic heart valve-related artefacts • Björk-Shiley and Sorin tilting disc valves preclude diagnostic coronary artery segment assessment.

[The treatment of stable coronary artery disease: always optimal medical therapy, coronary revascularization only on indication]. / De behandeling van stabiel kransvatlijden.

No trial or meta-analysis in patients with stable coronary artery disease, normal left ventricular function and without left main stenosis, has shown that adding revascularization to optimal medical therapy (OMT) decreases hard endpoints: myocardial infarction (MI) and overall mortality. However, Navarese concludes that OMT with elective revascularization reduces "cardiac" mortality, and is associated with a reduction in spontaneous MI. His meta-analysis is biased by a less hard primary endpoint "cardiac mortality" (often poorly defined and/or not independently assessed), exclusion of revascularisation-related MI and inclusion of vintage trials without platelet aggregation inhibitors, statins or PCIs. Overall the description of OMT is incomplete; even after 2000 the LDL cholesterol values are missing in half of the trials. Trials and meta-analyses without a clear focus on OMT and without clear and hard primary endpoints do not provide clear information for the doctor in the consulting room who wants to make the best treatment choice.

[Dyspnoea]. / Dyspneu.

Dyspnoea is an important and common symptom in patients with pulmonary or cardiovascular disease. It is a vital signal that we all can experience, for instance during heavy exercise, but it can also be an expression of a variety of diseases. In this updated educational article, we provide an answer to 10 questions on the causes of dyspnoea and the effectiveness of various diagnostic and therapeutic strategies. We propose a strategy to assess dyspnoea in clinical practice. Key points are determining the severity of the problem, forming a differential diagnosis, thinking about the mechanism of dyspnoea and intervening in a timely manner. We conclude that the assessment and treatment of dyspnoea often requires a multidisciplinary approach.

[Stable angina pectoris deserves better treatment]. / Behandeling van stabiele angina pectoris moet beter.

In the Netherlands, the burden of coronary artery disease is higher than that of any other disease. The healthcare costs amount to approximately 2.3 billion per year. Cardiovascular risk management (CVRM) reduces mortality and prevents myocardial infarction in patients with stable angina pectoris (AP). In patients with stable AP without a left main coronary artery stenosis or heart failure, percutaneous coronary intervention (PCI) does not reduce mortality, nor does it prevent myocardial infarction. The effect on AP is questionable. Improvement of treatment of stable AP can be achieved using intensive CVRM and targeted anti-anginal medication and only if optimal medical therapy (OMT) is not sufficient, a PCI. Clear communication and sharing of tasks between general practitioners and cardiologists in the form of network medicine is necessary, making use of multidisciplinary guidelines and unambiguous, jointly applied quality indicators. Financing of the treatment trajectory for stable AP should promote this integral approach.

Two cases of cardiac arteriovenous malformation complicated by a local angioproliferative process.

Vascular malformations of the heart are extremely rare with only a few cases of the arteriovenous type of vascular malformation (AVM) reported. We investigated the pathology of two additional cases, which were complicated by the occurrence of a local vasoproliferative response of immature but benign vessels. We suppose that the mass forming effect of this vasoproliferative response, which has also been reported recently as a complication of congenital AVM elsewhere in the body, has significantly contributed to the onset of symptoms and ultimate death of both patients.

[Treatment of mitral regurgitation with the MitraClip]. / Behandeling van mitralisklepinsufficiëntie met een mitralisclip.

The consideration for treatment of mitral regurgitation is dependent on its underlying cause: degenerative or functional. The percutaneous MitraClip treatment is mostly suitable for patients with severe, symptomatic mitral regurgitation and additional risk factors, who therefore do not qualify for surgical treatment but still have a life expectancy of more than one year. The MitraClip treatment has undergone technical improvements in the past ten years and has a low rate of periprocedural and postprocedural complications. Patients with severe functional mitral regurgitation, a relatively preserved left ventricular function, and a limited left ventricular volume benefit most from a MitraClip treatment. The number of MitraClip procedures in the Netherlands is strongly increasing and has shown good results. Besides the development of the MitraClip and introduction of new devices, careful patient selection is the most important instrument to achieve better results.

[Dyspnoea]. / Dyspneu.

Dyspnoea is an important and common symptom in patients with pulmonary or cardiovascular disease. It is a vital signal that we all can experience, for instance during heavy exercise, but it can also be an expression of a variety of diseases. In this educational article, we provide an answer to 10 questions on the causes of dyspnoea and the effectiveness of various diagnostic and therapeutic strategies. We propose a strategy to assess dyspnoea in clinical practice. Key points are determining the severity of the problem, forming a differential diagnosis, thinking about the mechanism of dyspnoea and intervening in a timely manner. We conclude that the assessment and treatment of dyspnoea often requires a multidisciplinary approach.

Health-related quality of life and posttraumatic stress disorder among survivors of left-sided native valve endocarditis.

BACKGROUND: The long-term prognosis of endocarditis is described primarily in relation to clinical outcome measures-for example, such complications as cerebrovascular accident, cardiac failure, need for cardiac surgery, relapse rate, and mortality. To our knowledge, to date, no studies have examined the health-related quality of life and the prevalence of long-term persistence of physical symptoms for survivors of left-sided native valve endocarditis. METHODS: We conducted a prospective follow-up study of patients treated for left-sided native valve endocarditis from 1 November 2000 through 31 October 2003 in 23 hospitals in the Netherlands. Of 86 patients eligible to participate, 55 completed questionnaires administered 3 m and 12 m after discharge; an additional 12 patients completed questionnaires 12 m after discharge only, making a total of 67 patients in our study. Persistence of symptoms and employment status were recorded. The health-related quality of life was measured by using the Dutch version of the Medical Outcomes Study Short Form 36-item health survey and the Posttraumatic Stress Disorder questionnaire. RESULTS: Three months after the end of antimicrobial treatment, 41 (75%) of 55 patients still had physical symptoms. Twelve months after the end of antimicrobial treatment, 36 (54%) of 67 patients still had physical symptoms. Before the episode of endocarditis, 30 (81%) of 37 patients aged < or =60 years were employed and working. At 3 m follow-up, 16 (52%) of 31 patients returned to work, and at 12 m follow-up, 24 (65%) of 37 patients were working. One year after discharge, the health-related quality of life was impaired in 5 of 8 dimensions, compared with age-adjusted standard values, and 7 (11%) of 64 patients suffered from posttraumatic stress disorder. CONCLUSIONS: A year after discharge, most survivors of left-sided native valve endocarditis still had persisting symptoms and a seriously diminished quality of life, and 11% of patients suffered from posttraumatic stress disorder.

Prognostic value of serial C-reactive protein measurements in left-sided native valve endocarditis.

BACKGROUND: The clinical course of left-sided native valve infective endocarditis varies from uncomplicated disease to fulminant infection. Although several factors are known to affect clinical outcome, it is difficult to predict morbidity and mortality in individual patients. The objective of this study was to determine the value of serial C-reactive protein (CRP) measurements as a predictor of clinical outcome. METHODS: One hundred twenty-three consecutive patients who fulfilled the Duke criteria for definite left-sided native valve infective endocarditis were prospectively enrolled. Poor outcome was defined as serious infectious complications or death. Patients were followed up for 12 weeks after the end of antimicrobial therapy. Multivariate analysis was used to examine the relative importance of the CRP level as a predictor of poor outcome after adjusting for age, abscess, multivalvular involvement, and Staphylococcus aureus infection. RESULTS: After 1 week of therapy, the adjusted odds ratio for poor outcome was 10.3 (95% confidence interval, 2.2-49.4) for patients with CRP levels in the highest tertile (>122 mg/L [to convert to nanomoles per liter, multiply by 9.524]) vs the lowest tertile (1-69 mg/L). A low percentage decline during the first week of treatment was statistically significantly associated with a higher risk of poor outcome (logistic regression coefficient, 1.1; P = .009). At no point in time did CRP level predict the need for cardiac surgery. CONCLUSION: High CRP level after 1 week of treatment and a slow percentage decline in CRP level during the first week of treatment are indicators of poor clinical outcome.

Qualitative observation of left ventricular multiphasic septal motion and septal-to-lateral apical shuffle predicts left ventricular reverse remodeling after cardiac resynchronization therapy.

A multiphasic septal motion and typical septal-to-lateral apical shuffle of the left ventricle can be observed echocardiographically in some patients with left branch bundle block. The relation of both with left ventricular (LV) dyssynchrony according to tissue Doppler and LV reverse remodeling after cardiac resynchronization therapy was investigated. Fifty-three patients (37 men; age 68+/-8 years) with ischemic (n=26) or idiopathic (n=27) cardiomyopathy, baseline QRS duration 171+/-30 ms, LV ejection fraction 21+/-7%, and LV end-diastolic volume 257+/-91 ml were studied. LV dyssynchrony using tissue Doppler was considered present if the SD of the interval between QRS and onset of systolic velocity of 6 basal LV segments was >20 ms. Shuffle was evaluated visually independently by 5 cardiologists and considered present if observed in>or=1 view. LV reverse remodeling, defined as LV end-systolic volume decrease>or=10%, was observed in 37 patients (70%) after 3 months of CRT. Sensitivity and specificity of either shuffle or multiphasic septal motion for all 5 observers (range 90% to 97% and 67% to 83%, respectively) were found to predict LV dyssynchrony. To predict LV reverse remodeling, sensitivity and specificity from 87% to 92% and 69% to 81% were observed, respectively. In conclusion, the qualitative observation of a typical shuffle or multiphasic septal motion predicts LV dyssynchrony and LV reverse remodeling adequately.

Evaluation of prosthetic heart valves by transesophageal echocardiography: problems, pitfalls, and timing of echocardiography.

Transesophageal echocardiography (TEE) is especially suitable for examination of prosthetic valves because of the proximity of the esophagus to the heart and absence of interference with lungs and ribs. This article reviews normal and abnormal morphologic characteristics of prosthetic valves such as spontaneous echocontrast, microbubbles, strands, sutures, vegetations or thrombus. Doppler echocardiographic characteristics of normal and pathologic prosthetic valve function and the management of prosthetic valve pathology is discussed. Physicians taking care of patients with prosthetic valves should be familiar with the characteristics of normal and abnormally functioning prosthetic valves.

[Estimation of the jugular venous pressure]. / Het beoordelen van de centraalveneuze druk.

Estimation of jugular venous pressure (JVP) is valuable for the differentiation between dyspnoea of cardiac or pulmonary origin, and for determining the cause of oedema. JVP assessments are useful for evaluation of treatment of right ventricular failure. The correlation between non-invasive JVP and invasive measurement of the central venous pressure (CVP) is remarkably better than previously reported. Correlation between JVP - determined via the external jugular vein - and CVP is excellent when the outcomes are categorised into low, normal and elevated pressure. Optimal measurement configurations include: extended expiration (without Valsalva manoeuvre), and during ventricular diastole. In the literature, these measurement configurations concerning the respiratory cycle and cardiac cycle have not been applied uniformly. To investigate in detail the correlation between JVP and CVP, the methods need to be standardized, and tests performed simultaneously and correctly.

Diagnostic evaluation and treatment strategy in patients with suspected prosthetic heart valve dysfunction: The incremental value of MDCT.

BACKGROUND: In patients with suspected prosthetic heart valve (PHV) dysfunction, routine evaluation echocardiography and fluoroscopy may provide unsatisfactory results for identifying the cause of dysfunction. This study assessed the value of MDCT as a routine, complementary imaging modality in suspected PHV-dysfunction for diagnosing the cause of PHV dysfunction and proposing a treatment strategy. METHODS: Patients with suspected PHV dysfunction were prospectively recruited. All patients underwent routine diagnostic work-up (TTE, TEE ± fluoroscopy) and additional MDCT imaging. An expert panel reviewed all cases and assessed the diagnosis and treatment strategy, first based on routine evaluation only, second with additional MDCT information. RESULTS: Forty-two patients were included with suspected PHV obstruction (n = 30) and PHV regurgitation (n = 12). The addition of MDCT showed incremental value to routine evaluation in 26/30 (87%) cases for detecting the specific cause of PHV obstruction and in 7/12 (58%) regurgitation cases for assessment of complications and surgical planning. The addition of MDCT resulted in treatment strategy change in 8/30 (27%) patients with suspected obstruction and 3/12 (25%) patients with regurgitation. CONCLUSION: In addition to echocardiography and fluoroscopy, MDCT may identify the cause of PHV dysfunction and alter the treatment strategy.

The optimal intensity of vitamin K antagonists in patients with mechanical heart valves: a meta-analysis.

OBJECTIVES: The purpose of this study was to compare two different intensities of vitamin K antagonists (VKA) among patients with mechanical heart valves using meta-analytic techniques. BACKGROUND: Patients with mechanical heart valves are at increased risk for valve thrombosis and systemic embolism, which can be reduced by VKA. The range of optimal intensity of VKA is still a matter of debate. METHODS: A computerized search in the PubMed database was made for relevant articles. A meta-analysis was performed of all eligible studies with data on the incidences of thromboembolic and bleeding complications in patients with mechanical heart valve prostheses during different intensities of VKA therapy. The studies were classified into low-intensity VKA therapy (mean target international normalized ratio [INR] of 3.0 or lower) or high-intensity VKA therapy (mean target INR above 3.0). RESULTS: Thirty-five eligible studies were identified, including in total 23,145 patients, who were studied for 108,792 patient-years. For patients with an aortic valve, high intensity resulted in a lower incidence of thromboembolic events (risk ratio [RR] = 0.73, p < 0.0001); however, the incidence of bleeding was increased (RR = 1.23, p < 0.0001). In the mitral valve group, the incidence rate for thromboembolism was lower in the high-intensity group (RR = 0.74, p < 0.0001), without a significantly increased bleeding incidence (RR = 1.08, p = 0.0524). The total number of thromboembolic and bleeding events was decreased in the high-intensity group compared with low-intensity VKA therapy for both aortic and mitral valve prostheses (RR = 0.94 [p = 0.0067] and 0.84 [p < 0.0001]), respectively. CONCLUSIONS: This meta-analysis shows that both aortic and mitral valves will benefit from a treatment strategy with a target INR higher than 3.0.