Percutaneous heart valves demonstrating long-term durability: A case series of Melody valves in the pulmonary position lasting up to 19 years.

It is uncertain how long catheter delivered percutaneous heart valves may last. In congenital cardiology, stenosis and regurgitation of right ventricular to pulmonary artery conduits and valves is common, leading to repeated operations for young patients with concomitant mortality and morbidity. It has also been unclear whether percutaneous pulmonary valves last as long as surgical pulmonary valves. When the current generation of the percutaneous pulmonary valve was first implanted in the United Kingdom from 2003, randomized trials were initially not performed, decided on a case-by-case basis in congenital cardiology, nor long-term registries kept. We describe three cases where such percutaneous heart valves have lasted up to 19 years. All valves were working without significant stenosis and minor degrees of regurgitation on long-term echocardiographic follow-up, patients being asymptomatic. This demonstrates that percutaneous pulmonary valves can achieve long-term durability and may prevent the need for otherwise high-risk surgery in congenital cardiac patients.

High-frequency speckle tracking echocardiography in the assessment of left ventricular function and remodeling after murine myocardial infarction.

The objectives of this study were to assess the feasibility and accuracy of high-frequency speckle tracking echocardiography (STE) in a murine model of myocardial infarction (MI). STE is used clinically to quantify global and regional cardiac function, but its application in mice is challenging because of the small cardiac size and rapid heart rates. A high-frequency micro-ultrasound system with STE (Visualsonics Vevo 2100) was compared against magnetic resonance imaging (MRI) for the assessment of global left ventricular (LV) size and function after murine MI. Animals subjected to coronary ligation (n = 46) or sham ligation (n = 27) were studied 4 wk postoperatively. Regional and global deformation were also assessed. STE-derived LV ejection fraction (EF) and mass correlated well with MRI indexes (r = 0.93, 0.77, respectively; P < 0.001), as did STE-derived mass with postmortem values (r = 0.80, P < 0.001). Higher STE-derived volumes correlated positively with MRI-derived infarct size (P < 0.01). Global strain parameters were significantly reduced after MI (all P < 0.001) and strongly correlated with LV mass and MRI-derived infarct size as promising surrogates for the extent of remodeling and infarction, respectively (both P < 0.05). Regional strain analyses showed that radial strain and strain rate were relatively preserved in anterior basal segments after MI compared with more apical segments (P < 0.001); however, longitudinal strain and strain rate were significantly impaired both basally and distally (P < 0.001). Strain-derived parameters of dyssynchrony were significantly increased in the MI group (P < 0.01). Analysis time for STE was 210 ± 45 s with acceptable inter- and intraobserver variability. In conclusion, high-frequency STE enables quantitative assessment of regional and global function in the remodeling murine LV after MI.

A novel device for atrial septal defect occlusion (GORE CARDIOFORM).

The GORE CARDIOFORM atrial septal defect (ASD) Occluder (GCA) is composed of a platinum-filled nitinol wire frame covered with expanded polytetrafluoroethylene, making it softer and more conformable compared with nitinol mesh devices. After the ASSURED clinical study confirmed the efficacy and safety of the device, it received U.S. Food and Drug Administration approval and a European conformity mark. Our aim was to understand the learning curve implicated in using the GCA for ASD closure in paediatric and adult patients as well as to study the early outcomes. To this end, a review of ASD device closures with GCA in 4 UK centres was conducted between January 2020 and January 2023. Implantation success was the primary outcome; the secondary outcomes were serious adverse events, including new onset arrhythmia. In all, 135 patients were included, and 128 (95%) had successful ASD device closure with GCA. The median patient age was 49 years, the median defect size was 18 mm, and the median device size was 37 mm. The median follow-up time was 6 months (interquartile range 1-14). One device embolisation occurred, and 15 patients (12% of GCA implantations) developed new onset arrhythmia - this was not related to patient age, defect diameter or device oversizing but was positively associated with device size. With growing experience using GCA, the device can be applied to a wide variety of ASD sizes and morphologies. Given the number of successful implantations with an absence of aortic erosion, as well as the ability to perforate through the device should procedures be required in the left atrium, the GCA device is an important addition for interventionists who close atrial septal defects.

Systemic inflammation and oxidative stress contribute to acute kidney injury after transcatheter aortic valve implantation.

BACKGROUND: Acute kidney injury (AKI) is a frequent complication of transcatheter aortic valve implantation (TAVI) and has been linked to preexisting comorbidities, peri-procedural hypotension, and systemic inflammation. The extent of systemic inflammation after TAVI is not fully understood. Our aim was to characterize the inflammatory response after TAVI and evaluate its contribution to the mechanism of post-procedural AKI. METHODS: One hundred and five consecutive patients undergoing TAVI at our institution were included. We analyzed the peri-procedural inflammatory and oxidative stress responses by measuring a range of biomarkers (including C-reactive protein [hsCRP], cytokine levels, and myeloperoxidase [MPO]), before TAVI and 6, 24, and 48 hours post-procedure. We correlated this with changes in renal function and patient and procedural characteristics. RESULTS: We observed a significant increase in plasma levels of pro-inflammatory cytokines (hsCRP, interleukin 6, tumor necrosis factor alpha receptors) and markers of oxidative stress (MPO) after TAVI. The inflammatory response was significantly greater after transapical (TA) TAVI compared to transfemoral (TF). This was associated with a higher incidence of AKI in the TA cohort compared to TF (44% vs. 8%, respectively, p < 0.0001). The incidence of AKI was significantly lower when N-acetylcysteine (NAC) was given peri-procedurally (12% vs. 38%, p < 0.005). In multivariate analysis, only the TA approach and no use of NAC before the procedure were independent predictors of AKI. CONCLUSIONS: TAVI creates a significant post-procedural inflammatory response, more so with the TA approach. Mechanisms of AKI after TAVI are complex. Inflammatory response, hypoperfusion, and oxidative stress may all play a part and are potential therapeutic targets to reduce/prevent AKI.

The additive value of three-dimensional derived left atrial volume and carotid imaging in dobutamine stress echocardiography.

AIMS: to evaluate whether the three-dimensional (3D) left atrial volume index (LAVI) and/or the presence of carotid plaques (CP) can predict the result of dobutamine stress echocardiography (DSE), thereby aiding interpretation. METHODS AND RESULTS: we studied 130 patients (52 male, mean age 63 ± 11 years) with normal resting wall motion (WM) undergoing DSE. All patients had the end-systolic 2D and 3D LAVI measured, as well as bilateral carotid scanning. DSE was reported as abnormal in 50 (38.5%) patients. 3D end-systolic LAVI measurements were significantly higher (31.5 ± 8.2 vs 27.4 ± 7.4 mL/m(2), P = 0.004) in those with an abnormal DSE. The two groups did not differ significantly on the 2D derived maximum LAVI measurements (36.2 ± 9.5 vs 34.2 ± 11.2, P = 0.299) and the presence of plaques in the carotid arteries (89.1 vs. 76.2%, P = 0.100). Receiver operating characteristic curves were created to define cut-offs that could predict the DSE result for the 3D LAVI. A 3D LAVI of >24.5 mL/m(2) had a sensitivity of 80% for predicting an abnormal DSE, whereas a value of >36.0 mL/m(2) had a specificity of 93% for the same cause. Intra-observer (r = 0.997, P < 0.0001) and inter-observer (r = 0.961, P < 0.0001) variability for 3D LAVI measurements was found to be excellent. CONCLUSION: three-dimensional (but not 2D) assessment of LAVI may offer additional information in predicting the result of DSE. Carotid scanning did not offer additional information for the same cause.

Myocardial abscess: a rare complication of valvular endocarditis demonstrated by 3D contrast echocardiography.

Myocardial abscess is a rare and often fatal complication of valvular endocarditis. We present a case of a patient with aortic valve endocarditis whose post-operative course was complicated by a large left ventricular abscess. The spatial location of the defect was difficult to assess with 2D transthoracic echocardiography (TTE); however, real-time 3D contrast TTE allowed us to visualize the full extent of the defect and its precise anatomical location, prior to successful surgical resection.

Left ventricular hypertrophy in athletes.

Participation in regular intensive exercise is associated with a modest increase in left ventricular wall thickness (LVWT) and cavity size. The magnitude of these physiological changes is predominantly determined by a variety of demographic factors which include age, gender, size, ethnicity, and sporting discipline. A small minority of male athletes participating in sporting disciplines involving intensive isotonic and isometric exercise may exhibit substantial increases in cardiac size that overlap with the phenotypic manifestation of the cardiomyopathies. The most challenging clinical dilemma incorporates the differentiation between physiological left ventricular hypertrophy (LVH) (athlete's heart) and hypertrophic cardiomyopathy (HCM), which is recognized as the commonest cause of non-traumatic exercise related sudden cardiac death in young (<35 years old) athletes. This review aims to highlight the distribution and physiological upper limits of LVWT in athletes, determinants of LVH in athletes, and echocardiographic methods of differentiating athlete's heart from HCM.

The potential impact of contemporary transthoracic echocardiography on the management of patients with native valve endocarditis: a comparison with transesophageal echocardiography.

BACKGROUND: Between 1987 and 1994, several studies demostrated transthoracic echocardiography (TTE) to be less sensitive than transesophageal echocardiography (TEE) in detecting native valve endocarditis. Recent technologic advances, especially the introduction of harmonic imaging and digital processing and storage, have improved TTE image quality. The aim of this study was to determine the diagnostic accuracy of contemporary TTE. METHODS: Between 2003 and 2007, 75 patients underwent both TTE and TEE for clinically suspected infective endocarditis. The diagnostic accuracy of TTE was assessed using transesophageal echocardiography as the gold standard for diagnosis of endocarditis. RESULTS: Of the 75 patients in this study, 33 were found to be positive by TEE. The sensitivity for detection of infective endocarditis by TTE was 81.8%. It provided good image quality in 81.5% of cases; in these patients sensitivity was even greater (89.3%). CONCLUSION: Contemporary TTE has improved the diagnostic accuracy of infective endocarditis by ameliorating image quality; it provides an accurate assessment of endocarditis and may reduce the need for TEE.

TAVI for Pure Native Aortic Regurgitation: Are We There Yet?

Treatment of degenerative aortic stenosis has been transformed by transcatheter aortic valve implantation (TAVI) over the past 10-15 years. The success of various technologies has led operators to attempt to broaden the indications, and many patients with native valve aortic regurgitation have been treated 'off label' with similar techniques. However, the alterations in the structure of the valve complex in pure native aortic regurgitation are distinct to those in degenerative aortic stenosis, and there are unique challenges to be overcome by percutaneous valves. Nevertheless some promise has been shown with both non-dedicated and dedicated devices. In this article, the authors explore some of these challenges and review the current evidence base for TAVI for aortic regurgitation.

Echo determinants of dyssynchrony (atrioventricular and inter- and intraventricular) and predictors of response to cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) has revolutionized not only the treatment of chronic heart failure but also how we assess left ventricular (LV) dysfunction on echo. Increasingly, it has become clear that identifying and quantifying delays in events during the cardiac cycle is an important assessment in LV dysfunction as it has prognostic implications for patients undergoing CRT. The delays in atrioventricular, right-to-left ventricular, and LV segmental contraction have been shown to be important components in cardiac performance, and this review provides an overview of the commonest methods used for these assessments and their implications for selecting patients for biventricular pacing.

Optimization of cardiac resynchronization therapy.

Cardiac resynchronization is now an accepted and widespread therapy for patients with left ventricular (LV) systolic dysfunction. However, there are still a significant number of patients that do not appear to gain benefit, and this is currently the focus of a great deal of research. Contemporary resynchronization devices allow manipulation of both atrioventricular (AV) and ventricular-to-ventricular (VV) delays and there is evidence that optimization of these delays has a positive effect on hemodynamics. However, there are many ways that optimization can be performed and there is little consensus on how, if at all, it should be incorporated into clinical practice.

Percutaneous extraction of an embolized progesterone contraceptive implant from the pulmonary artery.

The Nexplanon® implant is a commonly used radiopaque contraceptive device that contains progestogen associated with an ethylene vinyl-acetate copolymer resulting in a slow release of the active hormonal ingredient. It is inserted into the subdermal connective tissue and provides contraceptive efficacy for up to 3 years. Device removal for clinical, personal or device "end-of-life span" reasons is straightforward. In rare cases, implant migration can occur locally within centimeters of the insertion site. Distant device embolization is extremely rare and can result in complications including chest pain, dyspnoea, pneumothorax and thrombosis or prevent conception until the active ingredient is depleted. We present one such case, where a Nexplanon® implant embolized into the pulmonary artery of a young female patient. We describe the initial "missed" diagnosis of embolized device on a chest radiograph and subsequent successful percutaneous removal once distant embolization was diagnosed.

Pulmonary Haemodynamics in Sickle Cell Disease Are Driven Predominantly by a High-Output State Rather Than Elevated Pulmonary Vascular Resistance: A Prospective 3-Dimensional Echocardiography/Doppler Study.

AIMS: Patients with sickle cell disease have significant morbidity and mortality. Pulmonary hypertension is suggested to be an important contributor but its nature and severity in these patients and how best to non-invasively assess it are controversial. We hypothesised that a high-output state rather than primary pulmonary vascular pathology may be the major abnormality in sickle cell disease. This study aimed to evaluate the characteristics and severity of pulmonary hypertension in patients with sickle cell disease using detailed echocardiography. METHODS AND RESULTS: We undertook a prospective study in 122 consecutive stable outpatients with sickle cell disease and 30 age, gender and ethnicity-matched healthy controls. Echocardiographic evaluation included 3D ventricular volumes, sphericity, tissue Doppler, and non-invasive estimation of pulmonary vascular resistance. 36% of patients had a tricuspid regurgitant velocity ≥2.5 m.s(-1) but only 2% had elevated pulmonary vascular resistance and the prevalence of right ventricular dysfunction was very low. Patients with raised tricuspid regurgitant velocity had significantly elevated biventricular volumes and globular left ventricular remodelling, related primarily to anaemia. In a subgroup of patients who underwent cardiac catheterization, invasive pulmonary haemodynamics confirmed the echocardiographic findings. CONCLUSIONS: Elevated cardiac output and left ventricular volume overload secondary to chronic anaemia may be the dominant factor responsible for abnormal cardiopulmonary haemodynamics in patients with sickle cell disease. 3D echocardiography with non-invasive estimation of pulmonary vascular resistance represents a valuable approach for initial evaluation of cardiopulmonary haemodynamics in sickle cell disease.

Review of Data and Discussion - Who Should Undergo Patent Foramen Ovale Closure in 2014?

A patent foramen ovale is a relatively common finding in the general population and is associated with a number of conditions, including cryptogenic stroke. In 2014, percutaneous patent foramen ovale (PFO) closure is a frequently performed procedure; the bulk of these procedures being carried out for secondary prevention of cryptogenic stroke, along with other indications, such as prevention of decompression illness, platypnoea-orthodeoxia syndrome and migraine. Of these conditions the largest body of evidence available is for cryptogenic stroke and there is ongoing debate of the benefit of PFO closure over medical therapy. This article will review the available evidence of PFO closure in each of these contexts, with a particular focus on randomised controlled trials, and endeavour to outline in whom the evidence suggests closure should be considered.

Real-time three-dimensional transesophageal echocardiography adds value to transcatheter aortic valve implantation.

BACKGROUND: Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. METHODS: TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. RESULTS: Procedural success was achieved in 99% of 256 patients (mean age, 82.9 ± 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 ± 11.2%; mean aortic valve area, 0.63 ± 0.19 cm(2)), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 ± 1.9 mm, 22.5 ± 2.2 mm (P < .001), and 23.0 ± 2.0 mm (P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. CONCLUSIONS: A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.

Successful transcatheter aortic valve implantation (TAVI) is associated with transient left ventricular dysfunction.

OBJECTIVE: To investigate early haemodynamic changes after transfemoral transcatheter aortic valve implantation (TAVI) and the relationship with myocardial injury and neurohormonal activation. DESIGN: Single-centre prospective observational study. SETTING: Tertiary cardiac centre. PATIENTS: 42 patients undergoing transfemoral TAVI were included in this study. MAIN OUTCOME MEASURES: Haemodynamic measurements and echocardiography-derived indices characterising myocardial function were recorded at baseline, 6 and 24 h postprocedure. Postprocedural myocardial injury was quantified using serum troponin I and CK-MB levels. In addition, biomarkers of myocardial dysfunction/heart failure and neurohormonal activation were measured. RESULTS: 6 h Post-TAVI there was a significant deterioration in both systolic and diastolic function as measured by dP/dt(max)/EDV, myocardial performance index and mean E/e' index. Recovery of myocardial function was observed at 24 h. These haemodynamic changes were associated with a significant increase in both troponin I (0.07±0.01 vs 1.59±0.21 µg/l, p<0.005) and CK-MB (1.99±0.19 vs 6.82±0.7 ng/ml, p<0.005). There was a positive correlation among myocardial injury and NT-BNP (r=0.34, p<0.0005), aldosterone (r=0.56, p<0.0001) and ST2 levels (r=0.21, p<0.05). CONCLUSIONS: This is the first study to demonstrate that procedurally successful TF-TAVI results in a transient depression of both systolic and diastolic left ventricular function within the first 24 postoperative hours, despite impressive relief of previously severe, chronic pressure overload. The rise in the markers of myocardial damage suggests that this may be due to periprocedural myocardial injury. Complete recovery of contractility is generally observed after 24 h.

Real-time 3D echo in patient selection for cardiac resynchronization therapy.

OBJECTIVES: this study investigated the use of 3-dimensional (3D) echo in quantifying left ventricular mechanical dyssynchrony (LVMD), its interhospital agreement, and potential impact on patient selection. BACKGROUND: assessment of LVMD has been proposed as an improvement on conventional criteria in selecting patients for cardiac resynchronization therapy (CRT). Three-dimensional echo offers a reproducible assessment of left ventricular (LV) structure, function, and LVMD and may be useful in selecting patients for this intervention. METHODS: we studied 187 patients at 2 institutions. Three-dimensional data from baseline and longest follow-up were quantified for volume, left ventricular ejection fraction (LVEF), and systolic dyssynchrony index (SDI). New York Heart Association (NYHA) functional class was assessed independently. Several outcomes from CRT were considered: 1) reduction in NYHA functional class; 2) 20% relative increase in LVEF; and 3) 15% reduction in LV end-systolic volume. Sixty-two cases were shared between institutions to analyze interhospital agreement. RESULTS: there was excellent interhospital agreement for 3D-derived LV end-diastolic and end- systolic volumes, EF, and SDI (variability: 2.9%, 1%, 7.1%, and 7.6%, respectively). Reduction in NYHA functional class was found in 78.9% of patients. Relative improvement in LVEF of 20% was found in 68% of patients, but significant reduction in LV end-systolic volume was found in only 41.5%. The QRS duration was not predictive of any of the measures of outcome (area under the curve [AUC]: 0.52, 0.58, and 0.57 for NYHA functional class, LVEF, and LV end-systolic volume), whereas SDI was highly predictive of improvement in these parameters (AUC: 0.79, 0.86, and 0.66, respectively). For patients not fulfilling traditional selection criteria (atrial fibrillation, QRS duration <120 ms, or undergoing device upgrade), SDI had similar predictive value. A cutoff of 10.4% for SDI was found to have the highest accuracy for predicting improvement following CRT. CONCLUSIONS: the LVMD quantification by 3D echo is reproducible between centers. SDI was an excellent predictor of response to CRT in this selected patient cohort and may be valuable in identifying a target population for CRT irrespective of QRS morphology and duration.

Percutaneous closure of an atrial septal defect guided by live three-dimensional transesophageal echocardiography.

A 55-year-old man with a history of cryptogenic stroke presented to the authors' department for investigation. On transthoracic echocardiography, he was found to have a small secundum atrial septal defect, and transesophageal echocardiography was performed for a more detailed assessment. Following this, the defect was deemed suitable for percutaneous closure. The case demonstrates the utility and benefits of live three-dimensional transesophageal echocardiography for the assessment of this type of defect and guidance of transcatheter closure.