Saudi Arabian Society of Echocardiography Recommendations for Echocardiography Service During Corona Virus Disease 2019 (COVID-19) Outbreak.

We are summarizing the recommendations for the use of Echocardiography in patients during COVID-19 pandemic. The patient risk for COVID-19 should be assessed according to the Saudi CDC guidelines. Echocardiography should only be performed of considered appropriate and will likely alter the clinical decision. In COVID-19 suspected/confirmed patients, echocardiography study should be performed bedside and in infection control approved area with airborne precaution. Limited focused imaging is recommended to minimize contact time. A dedicated machine for COVID-19 suspected/confirmed cases is recommended. Transesophageal echocardiography is considered an aerosol generating procedure; therefore, an alternative modality should be strongly considered. In COVID-19 suspected/confirmed patients, a transesophageal echocardiogram should be done only under strict airborne precaution. In low risk patient for COVID-19, Transesophageal echocardiography should be done with a minimum of droplet precaution, however; N95 respirator is preferred to surgical mask in this situation.

The Echocardiography Society of Saudi Heart Association Recommendation on Quality and Laboratory Accreditation Guideline and Standards.

OBJECTIVE: To create the Saudi Arabian Society of Echocardiography Accreditation Commission Guidelines and Standards. METHOD: A review of available the North American and European accreditation guidelines was conducted and a model, locally appropriate for Saudi echocardiography laboratories and applicable in the current settings, was developed. RESULTS: The document specifies the organizational setting as well as the following categories of personnel: medical director, technical director, medical staff, and technical staff. The guideline team also examined aspects related to the facility and the facility safety policies and protocols. Examination and procedural issues for Adult transthoracic echocardiography including instrumentation, archiving media, examination interpretation and reports are also included as well as the required components for the Adult transthoracic echocardiography report. The last section of the guidelines focuses on Key Performance Indicators. A similar approach was taken regarding the Adult Stress Echocardiography, Transesophageal Echo, and monitoring of the patients during the procedures. CONCLUSION: The development of the Saudi Echocardiography Guidelines and Standards is a basic requirement for accreditation and also mandatory to improve the quality and utilization of such an important investigation.

Tidal peritoneal dialysis versus ultrafiltration in type 1 cardiorenal syndrome: A prospective randomized study.

BACKGROUND: Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of peritoneal dialysis in patients with acute decompensated heart failure complicated by acute cardiorenal syndrome. METHODS: We randomly assigned a total of 88 patients with type 1 acute cardiorenal syndrome to a strategy of ultrafiltration therapy (44 patients) or tidal peritoneal dialysis (44 patients). The primary endpoint was the change from baseline in the serum creatinine level and left ventricular function represented as ejection fraction, as assessed 72 and 120 h after random assignment. Patients were followed for 90 days after discharge from the hospital. RESULTS: Ultrafiltration therapy was inferior to tidal peritoneal dialysis therapy with respect to the primary endpoint of the change in the serum creatinine levels at 72 and 120 h (p = 0.041) and ejection fraction at 72 and 120 h after enrollment (p = 0.044 and p = 0.032), owing to both an increase in the creatinine level in the ultrafiltration therapy group and a decrease in its level in the tidal peritoneal dialysis group. At 120 h, the mean change in the creatinine level was 1.4 ± 0.5 mg/dL in the ultrafiltration therapy group, as compared with 2.4 ± 1.3 mg/dL in the tidal peritoneal dialysis group (p = 0.023). At 72 and 120 h, there was a significant difference in weight loss between patients in the ultrafiltration therapy group and those in the tidal peritoneal dialysis group (p = 0.025). Net fluid loss was also greater in tidal peritoneal dialysis patients (p = 0.018). Adverse events were more observed in the ultrafiltration therapy group (p = 0.007). At 90 days post-discharge, tidal peritoneal dialysis patients had fewer rehospitalization for heart failure (14.3% vs 32.5%, p = 0.022). CONCLUSION: Tidal peritoneal dialysis is a safe and effective means for removing toxins and large quantities of excess fluid from patients with intractable heart failure. In patients with cardiorenal syndrome type 1, the use of tidal peritoneal dialysis was superior to ultrafiltration therapy for the preservation of renal function, improvement of cardiac function, and net fluid loss. Ultrafiltration therapy was associated with a higher rate of adverse events.

Appropriateness of dabigatran dosing in patients with nonvalvular atrial fibrillation (NVAF): A retrospective study conducted in a tertiary care university hospital in the eastern province of Saudi Arabia.

BACKGROUND: Establishment of thromboembolism prevention remains a challenge despite the widespread consensus that thromboprophylaxis safely reduces patient morbidity and mortality. Dabigatran is a nonvitamin K antagonist oral anticoagulant (NOAC) which reduces the risk of thromboembolism. Proper dosing is important to achieve the maximum prophylactic benefit with a maintained safety profile. OBJECTIVE: To evaluate the appropriateness of dabigatran dosing for stroke and systemic embolism prevention in patients with nonvalvular atrial fibrillation (NVAF). METHODS: This is a retrospective cohort study of adults with NVAF. The data were collected from the electronic filing system of the hospital. Patients receiving dabigatran therapy were divided into two treatment groups according to the dose of dabigatran received. The indications for dabigatran as an oral direct anticoagulant, including age, risk of bleeding, creatinine clearance (CrCl), were collected. Appropriateness of dose reduction included any of the following factors: HAS-BLED score >2 points, age ≥75 years, or CrCl of 30-50 mL/min. The two groups were evaluated according to dose appropriateness. RESULTS: Dabigatran dose of 110 mg was found to be inappropriately low in a large number of patients (31.3%). Multivariate regression analysis showed significant association of age and dose appropriateness (p < 0.001). CONCLUSION: This study revealed inappropriate prescription of reduced doses of dabigatran in a large number of patients. Age was identified as the main driving factor for underdosing. Physicians' and pharmacists' awareness regarding this type of high-risk medication should be improved to ensure appropriate and safe use of this commonly used drug.

Reverse Atrial Remodeling and Resolution of Mitral Regurgitation after Rhythm Control in Atrial Fibrillation: A Case Report.

Atrial fibrillation is a common cardiac arrhythmia worldwide. In patients with hyperthyroidism, atrial fibrillation is the most common comorbid cardiac condition. Here, the authors report a case of a 47-year-old female with no significant medical history who presented with heart failure symptoms. Further analysis confirmed atrial fibrillation with a dilated atria and severe mitral regurgitation. In addition, she was found to be hyperthyroid. Accordingly, electrical cardioversion treatment was initiated, and her hyperthyroidism was managed. This resulted in her normal sinus rhythm being restored and subsequently being maintained. A repeat echocardiography 6 months later showed resolution of mitral regurgitation, improvement of atrial size and normalization of the left ventricular systolic function. Therefore, based on this case report, the authors suggest that atrial remodeling and functional mitral regurgitation secondary to atrial dilatation can be reversed by restoring and maintaining the sinus rhythm.

Prospective Study of Tricuspid Regurgitation Associated With Permanent Leads After Cardiac Rhythm Device Implantation.

BACKGROUND: Tricuspid regurgitation (TR) has been associated with cardiac rhythm device (CRD) implantation with intracardiac lead insertion. However, data on the incidence of postdevice TR are limited and largely from retrospective studies. We hypothesized that permanent lead implantation would be associated with an increase in TR. METHODS: We prospectively included consecutive patients with a clinical indication for CRD. Patients underwent transthoracic echocardiography 1 month before and 1 year after CRD implantation. RESULTS: A total of 328 patients were prospectively enrolled (69 ± 15 years, 38% female). Echocardiograms before and 1 year after CRD were available in 290 patients (15 died, 23 lost to follow-up). Compared with baseline, there was a significant change in TR grade 1 year after CRD insertion (no/trivial TR: 66% vs 29%; mild TR: 29% vs 61%; moderate TR: 3% vs 8%; severe TR 2% vs 2%; P < 0.001 for an increase in TR by at least 1 grade). Compared with baseline, there was a higher prevalence of moderate or severe TR in the 247 patients with CRD without cardiac resynchronization therapy (4% vs 10%, P = 0.004), but no progression in the 43 patients who received cardiac resynchronization therapy (14% vs 11%, P = 1). Multivariable analysis in the patients with less than moderate TR at baseline (n = 274) showed that only a history of atrial fibrillation was independently associated with progression to moderate or severe TR after correction for baseline TR grade (P = 0.013). CONCLUSIONS: One year after endocardial lead insertion, there was a 5% increase in the prevalence of moderate or severe TR, which may be clinically relevant.

Mitral Chordae Rupture as a Possible First-Time Presentation for Graves’ Disease.

Graves' disease is a common cause of hyperthyroidism that can lead to multiple cardiovascular complications. Herein is described the case of a 44-year-old male who presented with new-onset atrial fibrillation and mitral regurgitation secondary to flail anterior mitral leaflet with chordae tendineae rupture. This is a rare complication for Graves' disease, and has been reported only twice previously. It was hypothesized that this complication is secondary to Graves'-associated myxomatous degeneration of the mitral valve in the presence of a hyperdynamic circulation.

Alcohol Septal Ablation after Suboptimal Surgical Septal Myomectomy.

•The ideal therapy for HCM after failed surgical myomectomy is not established.•ASA after failed surgical myomectomy is a safe and effective therapeutic option.•Agitated saline is a safe alternative when contrast agent is not available.

Significant left ventricular outflow tract obstruction secondary to systolic anterior motion in a patient without hypertrophic cardiomyopathy: An echocardiographic study.

Dynamic left ventricular outflow tract obstruction (LVOTO) can be hemodynamically significant and can adversely affect the heart and quality of life. It is caused by systolic anterior motion (SAM) of the anterior mitral valve into the LVOT. The mechanism underlying SAM has been an area of special interest. However, SAM occurrence in the absence of septal hypertrophy is exceedingly uncommon. Here we present a case of a young male patient who sought medical care with a complaint of exertional dyspnea, New York Heart Association functional Class 2-3, and was found to have SAM and severe LVOTO at rest without hypertrophic cardiomyopathy. Continuous wave Doppler signal showed a peak velocity of 4.96 m/s along the LVOT, with a pressure gradient at rest of 98.44 mmHg, calculated using the modified Bernoulli equation. The patient is not known to have any medical conditions, nor had a family history of cardiac condition or sudden death. Trans-thoracic echocardiography showed concentric remodeling of the LV without hypertrophy. Trans-esophageal echocardiography was performed for further assessment of the anatomy. The anterior mitral leaflet (AML) and posterior mitral leaflet (PML) lengths were 3.7 cm and 1.3 cm, respectively (normal AML < 3 cm; normal PML < 1.5 cm). In our patient, the LVOTO is significant enough to result in a decreased cardiac output, which explains the symptoms experienced, due to which he developed concentric remodeling. The only finding in this patient explaining SAM is an elongated AML.

Chronic Severe Mitral Regurgitation with Normal Left Ventricular Size - A Case with Coexisting Atrial Septal Defect.

Severe chronic mitral regurgitation (MR) is known to cause left ventricular volume overload and subsequently left ventricular dilatation. Here, we present a case of a 68-year-old man with severe chronic MR which happened to coexist with atrial septal defect of secundum type leading to the right ventricular dilatation.

Aortic Valve Myxoma Presenting with a Stroke: A case report and review of the literature.

Myxomas originating from the aortic valve are rare. We report a 40-year-old male patient who presented to the King Fahd Hospital of the University, Khobar, Saudi Arabia, in 2017 with a stroke. Transoesophageal echocardiography indicated a mobile mass measuring 6 × 2 mm attached to the right coronary cusp of the aortic valve and a mobile interatrial septum with a small patent foramen ovale (PFO). The patient underwent surgical excision of the mass and direct closure of the PFO. Histopathology confirmed the mass to be a myxoma. Despite their rarity, the recognition and treatment of valvular myxomas is very important; moreover, clinicians should be aware that affected patients may present with an embolic stroke.

Valsalva maneuver in echocardiography.

The Valsalva maneuver is an easily performed maneuver with an interesting hemodynamic effect which can be used to aid accurate echocardiographic diagnosis. However, correct adequate performance is often missed. Here, we aim to describe the performance of an adequate Valsalva maneuver and the correct interpretation of its effect. The Valsalva hemodynamic effect consists of four basic phases which can be used in echocardiography to yield an accurate diagnosis. Valsalva is used to decrease preload and provoke left ventricular outflow tract (LVOT) gradient in dynamic LVOT obstruction. In addition, a decrease in E/A ratio in mitral inflow >50 % with Valsalva correlates with increased LV filling pressure and diastolic dysfunction. Valsalva also momentarily increases RA pressure and helps to unmask a patent foramen ovale with the use of saline contrast.

Factors Associated with Low Flow in Aortic Valve Stenosis.

BACKGROUND: Low-flow low-gradient aortic stenosis (AS) is a predictor of worse outcome compared with normal-flow AS. Although depressed left ventricular ejection fraction (LVEF) is associated with low flow, there is less evidence to support the role of other indices of cardiac structure and function. METHODS: Clinical and echocardiographic data from patients with native AS and valve areas ≤ 1.0 cm(2) were retrospectively analyzed to identify characteristics that are associated with low-flow low-gradient AS. RESULTS: In total, 941 patients were included. On multivariate analysis, factors independently associated with low flow (stroke volume index < 35 mL/m(2)) included worse right ventricular systolic function, atrial fibrillation, lower LVEF, and higher left ventricular mass, with moderate or severe mitral regurgitation independently associated with low flow in the 694 patients (74%) with preserved LVEFs. CONCLUSIONS: Right ventricular dysfunction and atrial fibrillation are independently associated with low-flow low-gradient AS, while moderate or severe MR is independently associated with low flow in patients with preserved LVEF. These associations with low flow in AS are clinically important to recognize, to avoid underestimation of AS severity.

Inferior vena cava stenosis: Echocardiographic diagnosis in Marfan syndrome.

Marfan syndrome is a genetic disease with variable clinical presentation. This case describes a 36-year-old lady who was diagnosed with Marfan syndrome based on revised Ghent criteria. She was found to have bicuspid aortic valve and sensorineural hearing loss. Inferior vena cava stenosis was suspected on echocardiography due to high velocity flow and visualization of a focal narrowing in the inferior vena cava proximal to hepatic vein entry. Inferior vena cava stenosis was confirmed by computed tomography. Echocardiographic features suggestive of inferior vena cava stenosis include detection of a focal narrowing and high turbulent flow, peak velocity > 1.5 m/s and S/D wave fusion on spectral Doppler.

Prospective study of tricuspid valve regurgitation associated with permanent leads in patients undergoing cardiac rhythm device implantation: Background, rationale, and design.

Given the increasing numbers of cardiac device implantations worldwide, it is important to determine whether permanent endocardial leads across the tricuspid valve can promote tricuspid regurgitation (TR). Virtually all current data is retrospective, and indicates a signal of TR being increased after permanent lead implantation. However, the precise incidence of moderate or greater TR post-procedure, the exact mechanisms (mechanical, traumatic, functional), and the hemodynamic burden and clinical effects of this putative increase in TR, remain uncertain. We have therefore designed a multicenter, international, prospective study of 300 consecutive patients (recruitment completed, baseline data presented) who will undergo echocardiography and clinical assessment prior to, and at 1-year post device insertion. This prospective study will help determine whether cardiac device-associated TR is real, what are its potential mechanisms, and whether it has an important clinical impact on cardiac device patients.

After more than 300 defibrillation shocks, patient still alive 12 years later refractory torsade de pointes due to polypharmacy and persistent vomiting.

Acquired torsade de pointes ventricular tachycardia (TdP) is a rare but serious life-threatening arrhythmia caused by an array of cardiac and non-cardiac drugs. It is often refractory to pharmacological therapy and may result in death or require frequent defibrillations. In our case study a young female patient with no underlying heart disease developed very frequent sustained TdP requiring frequent defibrillations without which she would have certainly died. The ventricular arrhythmia in this patient was of multifactorial origin - cisapride, drug-drug interaction and persistent vomiting resulting in electrolyte disturbance and malnutrition. The patient survived after more than 300 defibrillation shocks over a period of 5 days and she is still alive 12 years later.