Mechanisms, pathophysiology, and diagnostic imaging of left ventricular outflow tract obstruction following mitral valve surgery and transcatheter mitral valve replacement.

Left ventricular outflow tract obstruction is a serious complication of mitral valve surgery (repair and replacement) and transcatheter mitral valve replacement. An appreciation of the various mechanisms which cause outflow obstruction in these settings is critical to avoiding this complication and to initiating appropriate treatment. This article discusses the mechanisms, pathophysiology, and imaging of left ventricular outflow tract obstruction which can arise following insertion of a variety of mitral valve prosthetics.

Guidance of post myocardial infarction ventricular septal defect and pseudoaneurysm closure.

Left ventricular pseudoaneurysm and ventricular septal defect are rare but devastating complications of myocardial infarction. With medical treatment alone, the majority of patients will die from these complications. Until recently, the recommended treatment was surgical closure. These surgeries carried extreme risk due to abnormal hemodynamics, necrotic substrates and the comorbidities of these patients. Recently, trans-catheter closure was shown to be an acceptable alternative to open surgical intervention. 3D echocardiography identifies the location, size, and shape of the defect and can assess, guide, and follow up the closure procedure.

Review of surgical prosthetic paravalvular leaks: diagnosis and catheter-based closure.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with surgical prosthetic valve implantation. Paravalvular leak can have significant clinical consequence such as congestive heart failure, haemolytic anaemia, and infective endocarditis. Recently, transcatheter therapy has been applied to the treatment of this disorder with reasonable procedural and clinical success. This review discusses the current state of PVLs, the utilization of multi-modality imaging in their diagnosis and treatment, and the available therapeutic options. Further aim of this review is to examine transcatheter therapy of PVLs including the principles, outcomes, and procedural-related complications.

Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation.

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

Interventional echocardiography in structural heart disease.

Over the past decade, catheter based treatments of an increasing variety of cardiac diseases have expanded dramatically. These advancements became available through new developments and improvements in available devices, as well as increasing expertise of operators. However, arguably it is the innovation and progress in imaging techniques, and in particular in echocardiography, that allowed for such a surge in available percutaneous procedures. In this paper, current echocardiographic techniques, imaging protocols and recommendations will be reviewed and clinical examples will be shown to illustrate the use and importance of echocardiographic imaging in catheter based procedures for structural heart disease.

Characterization of Myocardial Injury in Patients With COVID-19.

BACKGROUND: Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data. OBJECTIVES: This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19. METHODS: We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization. RESULTS: A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities. CONCLUSIONS: Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.

Percutaneous closure of a post-myocardial infarction ventricular septal defect guided by real-time three-dimensional echocardiography.

We present an adult patient who had an acute myocardial infarction complicated by a ventricular septal defect and had it repaired percutaneously. Real-time three-dimensional echocardiography (RT3D) before and during the closure procedure were performed. RT3D provided anatomical and functional information of the defect as well as real-time guidance during the procedure. This case highlights the utility of three-dimensional echocardiography in guiding transcatheter procedures.

Non-Doppler two dimensional strain imaging for evaluation of coronary artery disease.

Over the recent years, strain echocardiography has emerged as a quantitative technique for the evaluation of global and segmental cardiac function. Strain is a measure of deformation, expressed as a percent change in a segment's length compared to its predeformation length. Strain rate (SR) is the local rate of deformation or strain per unit time. Recently non-Doppler two dimensional strain imaging has been developed. This technique is based on tracking ultrasonic speckles from the two dimensional echocardiographic images. These speckles are followed over a number of successive frames, and myocardial velocity is calculated by measuring frame-to-frame changes. This technique is independent of the Doppler angle of incidence and allows measurement of several vectors of strain within myocardial tissue. Non-Doppler strain is a powerful tool, enabling detection of subtle abnormalities in myocardial function. Current evidence shows that non-Doppler strain imaging may allow identification of the early changes that occur with ischemic insult to the myocardium. It may also provide a tool for identification of scarred, non-viable myocardium, with similar accuracy to that of cardiac MRI. Non-Doppler strain imaging is likely to become a standard tool in the evaluation of patients with ischemic heart disease.

Evaluation of a posterior mitral valve leaflet aneurysm by real time three-dimensional transesophageal echocardiography.

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE.

Three-dimensional transthoracic echocardiographic evaluation of cor triatriatum.

We present an adult patient with cor triatriatum (CTT) due to a left atrial (LA) membrane. Two-dimensional and real-time three-dimensional transthoracic echocardiography (3DE) were performed as well as echocardiographic examination after exercise. These non-invasive modalities provided a comprehensive anatomic and hemodynamic evaluation of the anomaly.

Fibrinous material in a pericardial effusion mimicking intraatrial thrombus.

A 74-year-old woman presented with an acute cerebrovascular infarct involving multiple vascular territories, suggestive of an embolic event. The initial transesophageal images create the impression of an echogenic mass in the left atrial appendage. A small pericardial effusion was also seen surrounding the left atrial appendage. After further views were obtained, the echogenic mass appeared to be in this fluid-filled space rather than in the appendage itself. To confirm this finding, echo contrast (Definity) was administered. After contrast injection, the left atrial appendage was opacified, while the effusion around the appendage and the echodensity within this space were not opacified. Our case highlights the utility of contrast-enhanced echocardiography in clearly delineating the boundaries of the endocardium in cases, when a pericardial effusion surrounds the left atrial appendage.

Right Atrial Vacuum-Assisted Thrombectomy: Single-Center Experience.

BACKGROUND: Right heart thrombus in the absence of structural heart disease, atrial fibrillation, or intracardiac catheter is rare. It typically represents a thrombus migrating from the venous system to the lung, known as thrombi-in-transit, and can lead to a life-threatening pulmonary embolism. The optimal therapy for thrombi-in-transit remains controversial. We report our experience using percutaneous removal of right heart thrombus using vacuum aspiration. METHODS: Patients with right atrial mass who were hemodynamically stable and underwent vacuum thombectomy using the AngioVac system (AngioDynamics) at our institution were included in this analysis. Between December 2012 and August 2014, a total of 7 patients (2 men, 5 women) with a mean age of 51.5 years (range, 20-83 years) underwent right atrial thrombectomy. Data during the procedure and follow-up period were collected and analyzed. RESULTS: All patients were hemodynamically stable before the procedure. The procedure was considered successful in 6 patients. All patients survived through hospitalization. No periprocedural bleeding, stroke, or myocardial infarction occurred. One patient developed cardiogenic shock after the procedure that required extracorporeal membrane oxygenation support for <24 hours. There was no recurrent venous thromboembolism at a mean follow-up of 9 months. CONCLUSION: Vacuum-assisted thrombectomy can be a potential treatment option for hemodynamically stable patients with large right-sided intracardiac thrombus who are not surgical candidates.

Transcatheter Therapies for the Treatment of Valvular and Paravalvular Regurgitation in Acquired and Congenital Valvular Heart Disease.

Transcatheter therapies in structural heart disease have evolved tremendously over the past 15 years. Since the introduction of the first balloon-expandable valves for stenotic lesions with implantation in the pulmonic position in 2000, treatment for valvular heart disease in the outflow position has become more refined, with newer-generation devices, alternative techniques, and novel access approaches. Recent efforts into the inflow position and regurgitant lesions, with transcatheter repair and replacement technologies, have expanded our potential to treat a broader, more heterogeneous patient population. The evolution of multimodality imaging has paralleled these developments. Three- and 4-dimensional visualization and concomitant use of novel technologies, such as fusion imaging, have supported technical growth, from pre-procedural planning and intraprocedural guidance, to assessment of acute results and follow-up. A multimodality approach has allowed operators to overcome many limitations of each modality and facilitated integration of a multidisciplinary team for treatment of this complex patient population.

Percutaneous complete repair of failed mitral valve prosthesis: simultaneous closure of mitral paravalvular leaks and transcatheter mitral valve implantation - single-centre experience.

AIMS: Structural deterioration and paravalvular leak (PVL) are complications associated with surgically implanted prosthetic valves, historically requiring reoperation. We present our experience of complete transcatheter repair of a degenerated mitral bioprosthesis. METHODS AND RESULTS: From March 2012 to October 2012, we reviewed consecutive, high-risk surgical patients (n=5) who underwent transcatheter repair of a failed mitral bioprosthesis with severe paravalvular regurgitation (PVR). Manufacturer valve sizes ranged from 27 to 33 mm, regurgitation (n=1), stenosis (n=1), or both (n=3). Percutaneous transapical and transseptal access were achieved with PVL closure performed transapically. An arteriovenous rail was created for transseptal delivery of a Melody valve. All patients had successful PVL closure with no residual PVR. Valve-in-valve (ViV) implantation was successful in four patients. Overall, mean transvalvular mitral gradient was 11.2 mmHg pre-procedure which improved to 5 mmHg post-procedure. Improvement of NYHA Class ≥2 was achieved in all patients (19±3 months). One patient had controlled Melody valve embolisation which required emergent surgical replacement. Inner valve diameter was 26 mm, too large for Melody valve implantation. CONCLUSIONS: Complete transcatheter repair of a degenerated mitral bioprosthesis with PVR can be performed in the high-risk patient. Accurate measurement is necessary prior to intervention, with concern for embolisation among the larger valve sizes (>31 mm).

Ambulatory pulse pressure is a relatively sleep-independent variable.

OBJECTIVES: Characterization of sleep-induced pulse and mean arterial pressure (MAP) dip. DESIGN: Prospective study of consecutive referred patients. SETTING: Hypertension unit of community university hospital. PARTICIPANTS: A total of 500 consecutive subjects referred to our unit for ambulatory blood pressure (BP) monitoring. There were 200 men and 300 women, the majority of which were treated hypertensives. Mean age was 59.7 +/- 16.6 years. MAIN OUTCOME MEASURES: Effect of sleep on MAP and pulse pressure (PP). RESULTS: Twenty-four hour MAP was 98 +/- 10 mmHg. Awake and asleep MAPs were 101 +/- 11 and 87 +/- 11 mmHg, respectively. Twenty-four hour, awake and asleep pulse pressures were 60 +/- 13, 61 +/- 13 and 58 +/- 13 mmHg, respectively. MAP dip was 14%, 95% confidence interval (CI) 13.4-14.6, whereas PP dip was 5%, 95% CI 4.1-5.8. Thus, the MAP dip was almost three times the PP dip (P < 0.0001). This held true for normotensives, hypertensives (treated and untreated), men, women and diabetic subjects. CONCLUSIONS: Although pulse pressure is derived from BP, it is more stable during a 24-h period, with a lesser effect of sleep compared with MAP. This more rigid nature of the PP could explain its better prognostic value, compared to that of MAP.

Sex differences in the effect of heart rate on mortality in the elderly.

OBJECTIVES: To examine the association between heart rate and mortality risk in the elderly. DESIGN: Longitudinal cohort. SETTING: Outpatient. PARTICIPANTS: Four hundred twenty-two people, aged 70 upon entry, were surveyed and followed for 6 years. MEASUREMENTS: Pulse rate was measured manually, while sitting and standing, and heart rate was measured from electrocardiogram recordings. The population was divided into quartiles of heart rate, with the top quartile comprising those with heart rate greater than 77 beats per minute (bpm) and the bottom quartile those with heart rate less than 60 bpm. RESULTS: After controlling for possible confounders, there was a clear correlation (r) between heart rate and all-cause mortality in elderly women (r=0.25, P=.0003). The correlation in women was observed using the three different methods for measuring heart rate. Heart rate was associated with all-cause and cardiovascular mortality. There was no relationship between heart rate and level of exercise or smoking status. In multiple regression analysis, the increased risk of death in the women was independent of previous cardiovascular or cerebrovascular disease, hypertension, anemia, congestive heart failure, smoking, and level of exercise or activities of daily living (relative odds ratio (ROR)=3.37, 95% confidence interval (CI)=0.96-11.8). When women using beta-blockers were excluded, this relationship became even stronger (ROR=8.5, 95% CI=1.19-60.1). CONCLUSION: Elevated heart rate is related to increased mortality in elderly women, thus representing a simple index of general health status in this population. Elevated heart rate did not predict mortality in elderly men.

Pulse pressure is more susceptible to the white coat effect than is systolic blood pressure: observations from real-life ambulatory blood pressure monitoring.

BACKGROUND: Pulse pressure is a derivative of arterial stiffness. We have previously demonstrated ambulatory pulse pressure to be relatively independent from the blood pressure (BP) lowering during sleep, and thus of a neurogenic effect. On the other hand, white coat BP effects are thought to involve neurogenic activation. The aim of this work was to analyze white coat induced variability in pulse pressure. METHODS: Percent clinic-awake differences in systolic BP (SBP) and pulse pressure (white coat effects) were calculated for 688 consecutive subjects (mean age 60 +/- 16 years, 58% female). Of the subjects, 23% had controlled hypertension, 45% uncontrolled hypertension, 8% normotension, and 4% isolated office hypertension; all were referred to our unit for 24 h ambulatory BP monitoring. RESULTS: Pulse pressure highly correlated with SBP (r = 0.82, P <.00001). We found a larger white coat effect on pulse pressure than on SBP (8.3% and 5.2%, respectively, P < or =.0001). This was true in all subgroups except in normotensive subjects. Specifically, the magnitude of the white coat effect on pulse pressure was greater than on SBP in subjects with treated hypertension, untreated hypertension, and isolated office hypertension, and in young hypertensive subjects, older subjects, and those with diabetes. CONCLUSIONS: Although pulse pressure is related to the mechanical properties of large arteries, it is also influenced by the white coat effect, a neurogenic process. Furthermore, in hypertensive but not in normotensive subjects, the white coat effect on pulse pressure is significantly more pronounced than on SBP.

Successful first-in-man percutaneous transapical-transseptal Melody mitral valve-in-ring implantation after complicated closure of a para-annular ring leak.

AIMS: Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure. METHODS AND RESULTS: A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients. CONCLUSIONS: Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation.

CT angiography-fluoroscopy fusion imaging for percutaneous transapical access.

OBJECTIVES: The aim of this proof-of-principle study is to validate the accuracy of fusion imaging for percutaneous transapical access (TA). BACKGROUND: Structural heart disease interventions, including TA, are commonly obtained under fluoroscopic guidance, which lacks important spatial information. Computed tomographic angiography (CTA)-fluoroscopy fusion imaging can provide the 3-dimensional information necessary for improved accuracy in planning and guidance of these interventions. METHODS: Twenty consecutive patients scheduled for percutaneous left ventricular puncture and device closure using CTA-fluoroscopy fusion guidance were prospectively recruited. The HeartNavigator software (Philips Healthcare, Best, the Netherlands) was used to landmark the left ventricular epicardium for TA (planned puncture site [PPS]). The PPS landmark was compared with the position of the TA closure device on post-procedure CTA (actual puncture site). The distance between the PPS and actual puncture site was calculated from 2 fixed reference points (left main ostium and mitral prosthesis center) in 3 planes (x, y, and z). The distance from the left anterior descending artery at the same z-plane was also assessed. TA-related complications associated with fusion imaging were recorded. RESULTS: The median (interquartile range [IQR]) TA distance difference between the PPS and actual puncture site from the referenced left main ostium and mitral prosthesis center was 5.00 mm (IQR: 1.98 to 12.64 mm) and 3.27 mm (IQR: 1.88 to 11.24 mm) in the x-plane, 4.48 mm (IQR: 1.98 to 13.08 mm) and 4.00 mm (IQR: 1.62 to 11.86 mm) in the y-plane, and 5.57 mm (IQR: 3.89 to 13.62 mm) and 4.96 mm (IQR: 1.92 to 11.76 mm) in the z-plane. The mean TA distance to the left anterior descending artery was 15.5 ± 7.8 mm and 22.7 ± 13.7 mm in the x- and y-planes. No TA-related complications were identified, including evidence of coronary artery laceration. CONCLUSIONS: With the use of CTA-fluoroscopy fusion imaging to guide TA, the actual puncture site can be approximated near the PPS. Moreover, fusion imaging can help maintain an adequate access distance from the left anterior descending artery, thereby, potentially reducing TA-related complications.

Mitral annular plane systolic excursion as a surrogate for left ventricular ejection fraction.

BACKGROUND: Assessing left ventricular function is a common indication for echocardiography. It generally requires expert echocardiographer estimation and is somewhat subjective and prone to reader discordance. Mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement for left ventricular function. The aim of this study was to examine the accuracy of MAPSE for predicting left ventricular ejection fraction (EF) on the basis of a large cohort of consecutive echocardiograms. METHODS: The study design was a retrospective analysis of 600 two-dimensional echocardiographic studies performed in a single laboratory. MAPSE measurement was performed by an untrained observer and compared with the EF as determined by an expert echocardiographer. The first 300 studies served as a calibration cohort to establish an algorithm for predicting EF on the basis of MAPSE measurement. The following 300 studies served as a verification cohort to test the accuracy of the established algorithm. RESULTS: Using the first 300 studies, an algorithm was developed to predict EF. Cutoff values for normal EF (≥11 mm for women and ≥13 mm for men) and severely reduced EF (<6 mm for men and women) were identified. For the intermediate-range MAPSE values, a gender-specific regression equation was calculated to generate a predicted EF. Using this algorithm, predicted EFs were determined for the 300 patients in the verification cohort. By comparing the predicted EF and the expert-reported EF, positive and negative predictive values, sensitivity (73%-92%), specificity (81%-100%), and accuracy (82%-86%) of MAPSE for predicting EF were calculated. CONCLUSIONS: MAPSE measurement by an untrained observer was found to be a highly accurate predictor of EF.