Myocardial work and left ventricular contractile reserve during stress echocardiography: An angiographic validation.

OBJECTIVE: This study sought to determine the contractile reserve (CR) response to exercise stress echocardiography (ESE) quantified by the novel parameter, non-invasive myocardial work (MW), in subjects with angiographically proven coronary artery disease (CAD). METHODS: CR was measured by the relative change in ejection fraction (EF), global longitudinal strain (GLS) and MW indices from rest to peak exercise in 304 patients referred for clinically indicated ESE. Positive ESE patients proceeded to coronary angiography and further risk stratified based on either percutaneous or surgical intervention. RESULTS: CRGLS and global work index (CRGWI ) significantly decreased with exercise induced ischemia and angiographically proven significant CAD (CRGLS -1.6±3.5%; CRGWI -8.6±511 mm Hg% decrement, p < 0.001) compared to non-ischemic patients (CRGLS 1.4±2.2%; CRGWI 398±404 mm Hg% improvement). Global constructive work (CRGCW ) was significantly higher (p < 0.0001) in non-ischemic (818±457 mm Hg%) and blunted in ischemic patients (208±550 mm Hg%). CRGCW (AUC .81; 95%CI:.75-.86) demonstrated the most association for inducible ischemia followed by CRGLS (AUC .75; 95%CI:.69-.80), CRGWI (AUC .73, 95%CI:.67-.79) and CREF (AUC .71; 95%CI:.65-.77, p < 0.001). Subgroup analysis showed patients requiring surgical revascularization demonstrated a significantly lower CRGWE (-11.5±7.6%, p < 0.05) as a result of reduced CRGCW (281±573 mm Hg%, p < 0.05) and increased global wasted work (CRGWW , 289±151 mm Hg%, p = 0.09). CONCLUSION: Multivessel disease requiring surgical revascularization have the greatest reduction in CR. MW may potentially improve detection of ischemia and further risk stratification during ESE to maximize the benefits of revascularization.

3D printed cardiac fistula: Guiding percutaneous structural intervention.

We present the case of a 21-year-old female with a complex right coronary sinus of valsalva to right atrial fistulae. 3D printing of the fistulae and surrounding anatomy was beneficial in assessment of the anatomy and perioperative planning. Successful percutaneous closure was achieved.

Percutaneous Transvenous Mitral Valve-in-Valve Implantation Using Commercially Available Transcatheter Valve. First Australian Experience.

In patients with a degenerative mitral bioprosthesis and prohibitive surgical risk there is emerging evidence for the feasibility of valve-in-valve procedures via a percutaneous transvenous transseptal approach. This paper describes the first time this procedure has been performed in Australia.

Improved quality of life two-years post Transcatheter Aortic Valve Replacement for a regurgitant aortic homograft.

The limited durability of prosthetic cardiac valves together with an aging population will present ongoing management challenges. This paper describes the case of an 82 year-old male with symptomatic severe regurgitation in an aortic homograft which remains successfully treated with Transcatheter Aortic Valve Replacement (TAVR) at two-year follow-up.

Post-Myocardial Infarction Ventricular Septal Defect Successfully Treated with Impella as Bridge to Cardiac Transplantation.

A 63-year-old female presented late with anterior ST-elevation myocardial infarction and cardiogenic shock. This was complicated by acute ventricular septal defect with large left-to-right shunt. An Impella CP was inserted on day seven with rapid haemodynamic improvement. This facilitated bridge to cardiac transplant on day twelve post-MI.

Early Australian experience with intravascular lithotripsy treatment of severe calcific coronary stenosis: IVL in acute/chronic coronary syndromes.

Aims: Calcified coronary stenoses are a serious impediment to optimal stent expansion and can lead to stent failure and catastrophic adverse outcomes. We hereby present early Australian experience with intravascular lithotripsy for the treatment of calcific lesions in acute and chronic coronary syndromes. Methods and results: This was a single-centre retrospective study of all patients treated with intravascular lithotripsy (IVL) between October 2019 and June 2021. Patient demographics, procedural variables, and treatment safety/efficacy outcomes were evaluated. During this period, there were 40 patients and 41 coronary lesions with IVL-assisted percutaneous coronary intervention (PCI) (70% male; mean age 72.8±9.5 years). Indications for PCI were acute coronary syndromes in 25 patients (62.5%), and stable angina in 15 patients (37.5%). Upfront IVL usage occurred in 5% of cases with the rest being bailout procedures due to suboptimal initial balloon predilatation or stent underexpansion. Angiographic success (<20% residual stenosis) occurred in 37 cases (92.5%), with mean residual stenosis of 8.25%±8.5%. Two patients experienced procedural complications (5%). Conclusions: IVL appears to be a safe and effective modality in modifying coronary calcium to achieve optimal stent expansion in real-world practice. This device obviates the need for more complex lesion preparation strategies such as rotational or orbital atherectomy.

Three-dimensional printed cardiac fistulae: a case series.

BACKGROUND: Three-dimensional (3D) printing of cardiac fistulae allows for immediate understanding of their complex courses and anatomical relations. Models can be used to improve patient understanding, enhance the consenting process, facilitate communication between multidisciplinary staff at heart team meetings, and help plan surgical or percutaneous interventions. CASE SUMMARY: We report four cases where 3D printed models were used as an adjunct with traditional measures in treating patients with complex cardiac fistulae. DISCUSSION: In our cases, overall patient understanding was improved, staff at heart team meetings were more aware of anatomical anomalies and perioperatively planning saw adjustments made that may have ultimately benefited patient outcome. Our cases highlight the additional benefit that 3D printed models can play when treating patients with complex cardiac fistulae.

Reproducibility of global left atrial strain and strain rate between novice and expert using multi-vendor analysis software.

Left atrial (LA) strain is an emerging technique with potential applications including arrhythmia prediction in atrial fibrillation and early identification of atrial dysfunction. The aim of this study was to evaluate reproducibility of LA strain and strain rate (SR) using multi-vendor analysis software between novice and expert. For LA strain to be a reliable tool, the technique must be reproducible by observers with variable experience. Use of multi-vendor analysis software allows serial strain assessment when echocardiographic images are acquired using different vendors. Fifty subjects underwent 2D-Speckle tracking echocardiographic (STE) derived LA strain and SR analysis measured from apical four and two-chamber views. Three strain parameters of LA function were assessed: reservoir (S-LAs, SR-LAs), contractile (S-LAa, SR-LAa) and conduit (S-LAs-S-LAa, SR-LAe). Strain analyses were performed by 2 independent, blinded novice and expert observers using multi-vendor analysis software. Intraobserver and interobserver analyses were performed using intra class correlation coefficients (ICC) and Bland-Altman analysis. LA strain and SR measured by novice observer demonstrated excellent intraobserver reproducibility (ICC for all strain and SR values > 0.88). There was good interobserver agreement of LA strain values between novice and expert (S-LAs:ICC 0.81, S-LAe:ICC 0.82, S-LAa:ICC 0.74). SR values also demonstrated good interobserver agreement (SR-LAs:ICC 0.83, SR-LAe:ICC 0.79, SR-LAa:ICC 0.86). Of all parameters, SR-LAa had the best interobserver and intraobserver agreement (ICC 0.86, 0.96). Global LA strain and SR values were highly reproducible by novice strain reader using multi-vendor analysis software. Interobserver reproducibility between novice and experts were good and acceptable within limits of agreement.

Early Changes of Myocardial Function After Transcatheter Aortic Valve Implantation Using Multilayer Strain Speckle Tracking Echocardiography.

Transcatheter aortic valve implantation (TAVI) is an effective therapeutic option for severe symptomatic aortic valve stenosis (AS) with intermediate or high surgical risk. The purpose of this study was to examine the effects of TAVI on left ventricular (LV) mechanics using multilayer global longitudinal strain (GLS) by 2D speckle-tracking echocardiography. A total of 119 patients (mean age 83 ± 7.0 years, male 54%) with severe symptomatic AS and normal LV ejection fraction (LVEF) underwent echocardiography at baseline and 1 month after TAVI. Global longitudinal strain was measured from the endocardial layer (GLSendo), mid-ventricular layer (GLSmyo), epicardial layer (GLSepi) and full thickness of myocardium (GLSwhole). There was significant improvement in all 3 layers of GLS after TAVI compared with baseline, but there was no significant change in LVEF. The relative % increment in GLS in each layer strain were 11.2 ± 23.4% (GLSendo), 13.4 ± 33.0% (GLSmyo) and 18.0 ± 46.6% (GLSepi) with significant difference between GLSendo and GLSepi (p < 0.05). In conclusion, multilayer GLS is more sensitive than conventional LVEF to detect early improvement in LV systolic function after TAVI in patients with severe AS. There is a disproportional improvement in different layers with least improvement in the endocardium. Multilayer strain analysis may provide new insights into understanding mechanics of AS.