Echocardiography Assessment of Rheumatic Heart Disease: Implications for Percutaneous Balloon Mitral Valvuloplasty.

Echocardiography is an important diagnostic imaging modality in recognizing rheumatic heart disease, a chronic sequelae of acute rheumatic fever. Left-sided heart valves, especially the mitral valve is typically affected, with stenosis or regurgitation as a consequence. Although assessment of valve area by 2D planimetry is the reference method for mitral stenosis severity, 3D planimetry provides more accurate measurement and diagnostic value. Careful selection of patients in terms of echocardiographic criteria is essential to ensure safety and success of the intervention and better long-term outcomes. Several echocardiographic scores based upon mitral valve mobility, thickening, calcification, and subvalvular thickening are developed to assess mitral valve anatomy and the feasibility of percutaneous mitral commissurotomy. 3D transesophageal echocardiography (TEE) provides detailed information of the mitral anatomy (commissural fusions, and subvalvular apparatus) before intervention. In addition, 3D TEE planimetry provides a more accurate measurement of the valve area compared with 2D echocardiography. Generally, huge annular calcification and lack of commissural fusion are unfavorable echocardiographic markers that increase the risk of complications and preclude the feasibility of percutaneous balloon mitral valvuloplasty. More contemporary prospective echocardiography research studies on patients with RHD from low- and middle-income countries are needed.

Incidence, Clinical Presentation, and Management of Myocarditis following mRNA-Based Covid-19 Vaccines: A Brief Report.

BACKGROUND: Recent surveillance studies following nationwide mass vaccination are investigating rare complications such as myocarditis, pericarditis, and thromboembolic events related to mRNA-based Covid-19 vaccines. SUMMARY: In the current report, we present an overview of the incidence, clinical presentation and management of post-mRNA vaccine myocarditis, and pericarditis in view of the currently available data. Our main focus is directed toward myocarditis. KEY MESSAGES: Myocarditis following mRNA-based Covid-19 vaccines is rare, more frequently affects younger men <30 years and is usually of mild severity with spontaneous recovery. The overall benefit of mRNA vaccines in terms of protecting from severe Covid-19 infection and associated cardiovascular complications outweighs the risk of postvaccination myocarditis. Currently, there are no dedicated guidelines for patients with postvaccination myocarditis or pericarditis in terms of the frequency of follow-up including clinical assessment, repeated echocardiography, and cardiac resonance imaging. However, follow-up studies in terms of long-term consequences are underway.

An Unexpected Cause of Severe Hypertension and Bradycardia: The Role of Hemodynamic Assessment by Echocardiography.

Severe hypertension has numerous etiologies. When accompanied by bradycardia, the spectrum of differential diagnoses is greatly narrowed and is commonly seen in patients with increased intracranial pressure. However, other etiologies such as bradycardia-induced hypertension are rarely mentioned. Here we report the case of a 73-year-old woman presenting with symptoms of heart failure, severe hypertension, and bradycardia with a 2:1 atrioventricular block. Echocardiography demonstrated increased left ventricular filling secondary to bradycardia and prolonged diastole, leading to greater ventricular stretch, increased contractile force and greater stroke volume (Frank-Starling mechanism), which subsequently caused elevated systolic blood pressure (BP), low diastolic BP and a wide pulse pressure. Treating the bradycardia by pacing led to an immediate and substantial BP reduction, although complete BP normalization had a slower time course and was probably due to the concomitant effect of the antihypertensive treatment initiation. This pathophysiological mechanism has received little attention in the literature. Further, stimulation of sympathetic afferents located in the heart by distension of the cardiac walls as well as the role of vagally innervated cardiopulmonary receptors due to the increased pressure in the heart and the pulmonary artery should also be kept in mind as alternative hypotheses.

Usefulness of Stress Echocardiography in Assessment of Dynamic Left Ventricular Obstructions: Case Series and Review of the Literature.

Dynamic left ventricular outflow tract obstruction (DLVOTO) or midcavity obstruction in patients with structurally normal hearts is not uncommon in routine clinical practice and can cause significant symptoms mimicking coronary artery disease or heart failure. Although exercise echocardiography is the gold standard for assessing DLVOTO, dobutamine stress echocardiography (DSE) may be valuable diagnostic modality in patients who are unable to exercise or have an uninterpretable 12-lead electrocardiogram. We provide an updated overview of the relevant literature regarding prevalence, pathophysiology, clinical significance, and prognostic impact of DLVOTO and midcavity obstruction in structurally normal hearts. We also present a clinical series of 4 cases of DLVOTO and midcavity obstruction documented by DSE and discuss the value of different kinds of modern stress imaging modalities involving: (1) contrast-enhanced DSE to assess myocardial perfusion and inducible ischemia; (2) adenosine stress echocardiography to assess coronary flow reserve/microvascular dysfunction; and (3) functional imaging with deformation echocardiography to assess subclinical myocardial dysfunction in patients with structurally normal heart and without significant coronary disease. Based upon our own experiences and a critical review of the current literature, we will then present a practical guidance for management of DLVOTO and midcavity obstruction.

Cardiovascular risk assessment in South and Middle-East Asians living in the Western countries.

Nearly a quarter of the world population lives in the South Asian region (India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and the Maldives). Due to rapid demographic and epidemiological transition in these countries, the burden of non-communicable diseases is growing, which is a serious public health concern. Particularly, the prevalence of pre-diabetes, diabetes and atherosclerotic cardiovascular disease (CVD) is increasing. South Asians living in the West have also substantially higher risk of CVD and mortality compared with white Europeans and Americans. Further, as a result of global displacement over the past three decades, Middle-Eastern immigrants now represent the largest group of non-European immigrants in Northern Europe. This vulnerable population has been less studied. Hence, the aim of the present review was to address cardiovascular risk assessment in South Asians (primarily people from India, Pakistan and Bangladesh), and Middle-East Asians living in Western countries compared with whites (Caucasians) and present results from some major intervention studies. A systematic search was conducted in PubMed to identify major cardiovascular health studies of South Asian and Middle-Eastern populations living in the West, relevant for this review. Results indicated an increased risk of CVD. In conclusion, both South Asian and Middle-Eastern populations living in the West carry significantly higher risk of diabetes and CVD compared with native white Europeans. Lifestyle interventions have been shown to have beneficial effects in terms of reduction in the risk of diabetes by increasing insulin sensitivity, weight loss as well as better glycemic and lipid control.

Covariables of Myocardial Function in Women and Men with Increased Body Mass Index.

INTRODUCTION: Sex-difference in types of cardiac organ damage has been reported in subjects with increased body mass index (BMI). However less is known about sex-differences in left ventricular (LV) myocardial function assessed by global longitudinal strain (GLS) in these subjects. METHODS: 493 subjects (mean age 47 ± 9 years, 61% women) with BMI > 27.0 kg/m2 and without known cardiac disease underwent 24-hour (24h) ambulatory blood pressure (BP) recording, body composition analysis, carotid-femoral pulse wave velocity (PWV) measurement and echocardiography. LV peak systolic GLS was measured by two-dimensional speckle tracking echocardiography and LV ejection fraction (EF) by biplane Simpson's method. Insulin sensitivity was assessed by homeostatic model of insulin resistance (HOMA-IR). RESULTS: Women had higher prevalence of increased waist circumference (99% vs. 82%), lower prevalence of hypertension (59 vs. 74%), and lower serum triglycerides (1.3 ± 0.7 vs. 1.7 ± 0.9 mmol/L) and carotid-femoral PWV (7.3 ± 1.6 vs. 7.7 ± 1.6 m/s) compared to men (all p < 0.05). Women also had higher (more negative) GLS compared to men (- 19.9 ± 3.0 vs. - 18.6 ± 3.0%, p < 0.001), while EF did not differ between sexes. In multivariable linear regression analyses, lower GLS in women was associated with higher waist circumference and PWV and with lower EF (all p < 0.05). In men, lower GLS was associated with higher waist circumference and HOMA-IR, and with lower EF (all p < 0.05). CONCLUSIONS: Among subjects with increased BMI, GLS was higher in women than men. Lower GLS was associated with abdominal obesity in both sexes, and with impaired glucose metabolism in men, and with higher arterial stiffness in women. TRIAL REGISTRATION: https://www.clinicaltrials.gov NCT02805478, first registered 20.06.16.

Obesity-associated metabolic changes influence resting and peak heart rate in women and men.

OBJECTIVES: To study the relationship between obesity and heart rate (HR) in women and men. DESIGN: We studied 241 overweight and obese subjects without known heart disease. All subjects underwent ergospirometry during maximal exercise testing on treadmill and recording of body composition, electrocardiogram and clinic and ambulatory blood pressure. RESULTS: Women (n = 132) were slightly older and had higher fat mass, but lower weight, blood pressure and prevalence of metabolic syndrome (MetS) than men (n = 109) (all p < 0.05), while prevalences of obesity and hypertension did not differ. A significant interaction between sex and HR was demonstrated (p < 0.05). In multivariate analysis, female sex (ß = 0.99, p < 0.01) predicted higher resting HR independent of confounders. Higher resting HR was particularly associated with presence of MetS, hypertension, higher insulin resistance and lower relative muscle mass in men (all p < 0.05). Female sex also predicted higher peak exercise HR (ß = 0.48, p < 0.01) independent of confounders. Higher peak exercise HR was particularly associated with higher exercise capacity and lower age and self-reported physical activity in men, while lower HbA1c and absence of obesity were the main covariates in women in multivariate analyses (all p < 0.05). CONCLUSIONS: In our study population, obesity and obesity-associated metabolic changes influenced both resting and peak exercise HR.