Standardization and validation of neoLVOT assessment using three-dimensional trans-esophageal echocardiography before trans-catheter mitral valve replacement.

BACKGROUND: Trans-catheter mitral valve replacement (TMVR) procedures had emerged as an alternative solution for patients who are at high risk for mitral valve surgery. Although cardiac computed tomography (CT) remains the standard method for procedural planning, there is no full agreement on the best systolic phase for quantitation of the neoLVOT. Furthermore, a new three-dimensional trans-esophageal echocardiography (3DTEE) based software was developed to serve as filter and or an alternative for patients who cannot have CT due to any contraindication. AIM: To determine the systolic phase of the cardiac cycle that shows the narrowest NeoLVOT area in order to standardize the way of using these software and then to validate the 3DTEE-based software against the CT-based one as a gold standard, in mitral valve annulus (MA) and NeoLVOT assessment. METHODS: A single center, observational, retrospective study. Initially, a sample of 20 patients (age 62 ± 4 years, 70% men) had CT-based analysis at mid-diastole (80%), early-systole (10%), mid-systole (20%), late-systole (30%-40%), in order to detect the best systolic phase at which the neoLVOT area is the narrowest after TMVR. Then, the end systolic phase was standardized for the analysis of 49 patients (age 57 ± 6 years, 60% men), using both the commercially available CT-based software and the newly available 3DTEE-based software (3mensio Structural Heart, Pie Medical Imaging, The Netherlands). The 3DTEE derived parameters were compared with the gold standard CT-based measurements. RESULTS: The neoLVOT area was significantly narrower at end-systole (224 ± 62 mm2), compared to early-systole (299 ± 70 mm2) and mid-systole (261 ± 75 mm2), (p = .005). Excellent correlation was found between 3DTEE and CT measurements for MA AP diameter (r = .96), IC diameter (r = .92), MA area (r = .96), MA perimeter (r = .94) and NeoLVOT area (r = .96), (all p-values < .0001). Virtual valve sizing was based on annulus measurement and was identical between CT and 3DTEE. Interobserver and intraobserver agreements were excellent for all the measurements with ICCs > .80. CONCLUSIONS: End-systole is the phase that shows the narrowest neoLVOT and hence should be the standard phase used during the analysis. The 3DTEE based analysis using this new software is reliable compared to the CT-based analysis and can be serve as an alternative analysis tool in patients who cannot have CT for any clinical contraindication or as a screening test and/or filter for all patients before proceeding to a detailed CT scan.

Combined intra-cavitary course of left anterior descending artery and myocardial bridge of right coronary artery in right ventricle hypertrophy: a case report.

Background: Intra-cavitary (IC) coronary course is a rare anatomical variant that has become more commonly reported in the last decade. While the condition is generally benign and often discovered incidentally during coronary computed tomography angiography (CCTA), these arteries are vulnerable to injury during cardiac interventions. It is unclear whether right ventricle (RV) pathology, such as dilatation or hypertrophy, plays a role in this condition. Case summary: A patient in their fifties with a medical history of rheumatic heart disease and atrial fibrillation presented with dyspnoea and orthopnea but denied any previous chest pain. Upon examination, the patient exhibited slow atrial fibrillation and generalized anasarca. Echocardiography revealed severe mitral stenosis, tricuspid regurgitation, pulmonary hypertension, and a significantly dilated and impaired RV. Before surgery, a CCTA was performed and revealed an abnormal mid-left anterior descending (LAD) course through the RV cavity with complete systolic attenuation. This finding was later confirmed through invasive angiography. Additionally, the right coronary artery (RCA) showed a mid-segment myocardial bridge (MB). The patient was scheduled for mitral and tricuspid valves' surgery with no planned intervention to the LAD or RCA. Discussion: Coronary IC course is a rare finding that poses a risk of arterial injury during invasive cardiac procedures. It is important for all cardiac interventionists to be familiar with this diagnosis and the potential hazards during cardiac interventions. Further research is needed to determine whether RV dilatation or hypertrophy can exacerbate coronary IC course or MB.

Assessment of left and right atrial geometrical changes in patients with stable coronary artery disease: Left and right atrial strain and strain rate imaging study.

OBJECTIVE: In patients with coronary artery disease (CAD), there are several studies that assessed the left ventricular (LV) function by strain (S) and strain rate (SR) imaging. The aim of this study is to evaluate the function of both atria in patients with CAD using strain and strain rate imaging, and to correlate this with the severity of CAD. METHODS: We conducted a prospective, single center case control study for 40 consecutive patients who presented to our department with chronic stable angina and were candidates for invasive coronary angiography. We enrolled patients from December 2013 to May 2014 and each patient was subjected to echocardiographic assessment of E/e' of mitral valve, left atrial volume index (LAVI), right atrial volume index (RAVI), and peak atrial longitudinal strain (es) and strain rate (SR) during LV systole. This was followed by invasive coronary angiography for assessment of the severity of CAD using Gensini score. Patients were classified according to angiographic results into 3 groups: Group I (Gensini score = zero), Group II (Gensini score > 0 and < 20) and Group III (Gensini score ≥ 20). RESULTS: There was no statistically significant difference between the three groups in either LA volumes (Vmin, Vmax) and distensibility with p value of 0.272, 0.126, and 0.243 respectively or RA volumes and distensibility with a p value of 0.671, 0.183, and 0.259 respectively. On the other hand, LA & RA systolic S and SR were significantly lower among CAD patients in comparison with the group of normal coronaries. Mean LA S and SR was decreased in group III than group II (15.97 ±â€¯3.73, 21.8 ±â€¯6.75 % and 1.11 ±â€¯0.30, 1.81 ±â€¯1.23 s-1) with p value of 0.005&0.041 respectively. RA systolic S and SR were significantly lower in the 2 groups with CAD than the group with normal coronaries with a p value of 0.001 and 0.002 respectively. CONCLUSION: In patients with CAD and normal EF, borderline E/e' ratio and normal atrial size, there are decreased LA and RA systolic S and SR parameters with no effect on atrial volumes or distensibility. Accordingly, this could prove that atrial wall deformation occurs early in CAD even before any changes in atrial volumes or dimensions.