Right ventricular longitudinal fractional shortening: a substitute to right ventricular free wall longitudinal strain?

PURPOSE: Because of its diagnostic and prognostic value, right ventricular strain assessed by speckle-tracking imaging (RVS) has been incorporated into echocardiographic guidelines. However, it suffers from limitations including the need of good image quality and of dedicated software with inter-vendor variability. We hypothesized that RV free wall longitudinal fractional shortening (LFS) could be used as a substitute to RVS, without suffering from the aforementioned limitations. METHODS: We aimed to establish in a series of non-selected consecutive patients in sinus rhythm the value of LFS, calculated as [-(TAPSE/RVdiastolic length)] and of several common echocardiographic and Doppler parameters to predict an abnormal RV function, defined as RVS > - 20.2%. RESULTS: Among 144 consecutive patients, poor image quality precluded the assessment of RVS and of LFS in 31 and 4 patients, respectively (P = 0.0018), resulting in a final study group of 113 patients. The intraclass correlation coefficients for inter- and intra-observer variability were 0.97 (95% CI 0.92; 0.98) and 0.93 (CI 0.92; 0.98) for LFS and RVS, respectively. Among all tested RV function indices, LFS best correlated with RVS (R 0.97, 95% CI 0.81; 0.91). Bland-Altman analysis for the comparison between LFS and RVS showed no systematic bias. The area under the ROC-curve of the various RV function indices to detect abnormal RVS was best for LFS (0.97, 95% CI 0.94-1), with sensitivity, specificity, negative and positive predictive value of 83%, 96%, 96%, and 83%, respectively. CONCLUSION: LFS performs reasonably well to predict abnormal RVS and is more often feasible than RVS.

Predictors of recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation.

AIMS: Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. METHODS AND RESULTS: Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63 years (CHA2DS2VASc 1 [1-3], left atrium diameter 41 ± 6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (P = 0.011). Diagnosis-to-ablation time ≥1 year was associated with a nearly two-fold increased risk for developing AF recurrence. CONCLUSION: The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial.

Evaluation of higher power delivery during RF pulmonary vein isolation using optimized and contiguous lesions.

AIMS: "CLOSE"-guided pulmonary vein isolation (PVI) is based on contiguous (≤6 mm) and optimized radiofrequency (RF) ablation lesions (ablation index [AI] ≥ 400 posteriorly and ≥ 550 anteriorly]. However, the optimal RF power to reach the desired AI is unknown. Therefore we evaluated the efficiency of an ablation strategy using higher power (40 W) during a first "CLOSE"-guided PVI. METHODS: Eighty consecutive patients undergoing "CLOSE"-guided PVI for symptomatic paroxysmal atrial fibrillation were ablated with 40 W (group A). Results were compared with 105 consecutive patients enrolled in the "CLOSE to CURE"-study and were ablated using the same protocol with 35 W (group B). RESULTS: In group A, ablation was associated with shorter ablation procedure time (91 vs 111 minutes; P < .001), shorter fluoroscopy time (5 vs 11 minutes; P < .001), shorter PVI time (48 vs 64 minutes; P < .001), shorter RF time (20 vs 28 minutes; P < .001), lower RF time per application (22 vs 29 seconds; P < .001), less RF applications (52 vs 58; P < .001), and less catheter dislocations (1 vs 2; P = .002). The impedance drop (12 vs 13 Ω; P = .192), first-pass isolation rate (99% vs 93%; P = .141) and acute reconnection rate (6% vs 4%; P > .733) were similar in both groups (groups A and B, respectively). No complications occurred. In group A, a gastroscopy-performed in five patients with esophageal temperature rise more than 42°C-did not reveal any esophageal lesion. Postprocedural recurrence of atrial tachyarrhythmia at 1 year was not significantly different between both groups. CONCLUSIONS: Using the "CLOSE"-protocol, increased power increases the efficiency of PVI without compromising patients' safety.

Evaluation of a simple technique aiming at optimizing point-by-point isolation of the left pulmonary veins: a randomized study.

AIMS: We sought to evaluate the efficacy and the safety of a simple technique for stabilizing the ablation catheter during anterior pulmonary vein (PV) encirclement in patients ablated for paroxysmal atrial fibrillation. This consisted of bending the ablation catheter in the left atrium, creating a loop that was cautiously advanced together with the long sheath at the ostium and then within the left superior PV. The curve was then progressively released to reach a stable contact with the anterior part of the left PVs. METHODS AND RESULTS: Eighty consecutive patients (age 64 ± 11 years, left atrial diameter 43 ± 8 mm) undergoing 'CLOSE'-guided PV isolation were prospectively randomized into two groups depending on whether the loop technique was used or not. When using the loop technique, the encirclement of the left PVs was shorter [20 min (interquartile range, IQR 17-24) vs. 26 min (IQR 18-33), P < 0.01] with a high rate of first pass isolation [(100%) vs. (97%), P = 0.9] and adenosine proof isolation [(93%) vs. (95%), P = 0.67]. Most specifically, at the anterior part of the left PVs, there were less dislocations [0 (IQR 0-0) vs. 1 (IQR 0-4), P < 0.001], radiofrequency duration was shorter (272 ± 85 s vs. 378 ± 122 s, P < 0.001), force-time integral was higher [524 gs (IQR 427-687) vs. 398 gs (IQR 354-451), P < 0.001], average contact force was higher [20 g (IQR 13-27) vs. 11g (IQR 9-16), P < 0.001], and impedance drop was higher [12 Ω (IQR 9-19) vs. 10 Ω (IQR 7-14), P < 0.001]. CONCLUSION: This study describes a simple technique to facilitate catheter stability at the anterior part of the left PVs, resulting in more efficient left PV encirclement without compromising safety.

Left superior pulmonary vein connected to superior vena cava vein in a patient with situs inversus totalis: A challenging diagnosis.

We herein describe the previously unreported combination of partial anomalous venous connection to the superior vena cava combined with situs inversus totalis. Following peripheral contrast injection, bubbles appeared initially in the left atrium allowing the diagnosis of a supra-atrial connection to be made using transthoracic echocardiography, but this timing was not anymore reproduced during transesophageal echocardiography performed minutes later. Cardiac computed tomography allowed the final diagnosis to be made. This case emphasizes the importance of performing bubble studies both during transesophageal and transthoracic echocardiography.

The clinical challenge of concomitant aortic and mitral valve stenosis.

The coexistence of mitral and aortic stenosis is not exceptional. Whereas rheumatic fever is currently plummeting in the Western countries, the incidence of degenerative disease is inversely increasing. The haemodynamic interactions which may interfere both with the usual echocardiographic parameters and with the invasive assessment may render the diagnosis difficult. The therapeutic challenges raised by this entity should not be underestimated. The increased morbidity and mortality of multivalvular surgery has to be balanced with the risk of a second operation down the line if one valvular involvement, deemed of a lesser importance, is neglected. This complex situation requires the multidisciplinary approach of a heart team involving surgeons, cardiologists, geriatrists if need be and imaging specialists.

Quantification of low-gradient severe aortic stenosis using a hybrid approach combining Doppler echocardiography and thermodilution.

BACKGROUND AND AIM OF THE STUDY: Estimation of stroke volume in the left ventricular outflow tract (LVOT) is a main limitation to aortic valve area (AVA) calculation by echocardiography when using the continuity equation. In this study, the hypothesis was tested that a hybrid method using thermodilution-derived cardiac output measurement and simultaneous Doppler estimation of the systolic ejection period and transvalvular aortic velocities could be used to accurately assess AVA in patients with low-gradient severe aortic stenosis (AS). METHODS: Eighteen patients with low mean gradient (< 40 mmHg) and nine patients with conventionally defined (> or = 40 mmHg) severe AS (< 1 cm2), as assessed by the echocardiographic continuity equation (baseline echocardiography), underwent catheterization and simultaneous Doppler recording of trans-aortic velocities. RESULTS: The mean pressure gradient was slightly lower by Doppler in the catheterization laboratory (35.8 +/-15.7 mmHg) compared to baseline echocardiography (37.4 +/- 15.2 mmHg) and invasive (38.5 +/- 16.6 mmHg) measurements (both p < 0.05). The AVA values were 0.72 +/- 0.12 cm2 during baseline echocardiography, 0.74 +/- 0.14 cm2 by catheterization, and 0.71 +/- 0.14 cm2 by the hybrid method (bias -0.01 +/- 0.11 cm2 and -0.02 +/- 0.08 cm2, versus echocardiography and catheterization, respectively; both p = NS). CONCLUSION: The hybrid method is reasonably accurate in assessing AVA in patients with low-gradient severe AS. Although the continuity equation should be used in routine clinical practice in most patients, this method could serve as an alternative when the LVOT diameter and/or velocities seem questionable.

Looking at the frame after the picture: "retrocardiac echocardiography".

We report three cases of mediastinal structures encroaching on the left atrium without haemodynamic compromise. These cases emphasize the potential role of echocardiography for the diagnosis and the management of several extracardiac mediastinal abnormalities.

Chagas disease: don't forget it in Latin American patients with heart block!

Chagas disease is caused by the parasite Trypanosoma cruzi, and mostly affects poor rural populations of central and south America. It is mainly acquired by bugs (triatoma) but also by ingestion of the parasite (fresh fruit juices) or by foetal-maternal blood passing. Despite an important decrease in transmission during the last decades in several countries, millions of patients are still chronically infected and most of them are asymptomatic. In 2012-2013, two cases were admitted in our cardiac intensive care unit (ICU) with heart block due to Chagas cardiomyopathy. Diagnosis was established by echocardiography and positive serological results for Trypanosoma cruzi. This report underlines that in cases of heart failure and conduction abnormalities of unclear aetiology, Chagas disease should be taken into consideration, even in patients originating from non-endemic countries.

Papillary muscle rupture without severe mitral regurgitation following percutaneous balloon mitral commissurotomy: a case report.

Background: Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting. Case summary: A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery. Discussion: We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.

Prevalence and Outcomes of Patients With Discordant High-Gradient Aortic Stenosis.

BACKGROUND: Conflicting prognostic results have been reported in patients with discordant high-gradient aortic stenosis ([DHG-AS] the combination of a mean pressure gradient ≥40 mm Hg and an aortic valve area [AVA] >1 cm2). Moreover, existing studies only included selected patients without concomitant aortic regurgitation. OBJECTIVES: The authors assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center. METHODS: A total of 3,547 adult patients with AVA ≤1.5 cm2 and peak aortic jet velocity ≥2.5 m/s or mean gradient ≥25 mm Hg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium (AVC) score were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all-cause mortality during follow-up. RESULTS: DHG-AS was observed in 163 patients (11.6% of patients with a high gradient). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of patients with concordant severe aortic stenosis (HR: 0.98 [95% CI: 0.66-1.44]; P = 0.91), and patients with discordant low-gradient aortic stenosis (HR: 0.85 [95% CI: 0.58-1.26]; P = 0.42), and higher than concordant moderate aortic stenosis (HR: 0.54 [95% CI: 0.36-0.81]; P = 0.003). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. AVC was higher than in patients with concordant moderate aortic stenosis and discordant low-gradient aortic stenosis, and not significantly different from that of concordant severe aortic stenosis. CONCLUSIONS: DHG-AS is not uncommon. Whereas AVA >1.0 cm2 is often seen as moderate aortic stenosis, a high-pressure gradient conveys a poor prognosis, whatever the AVA and the severity of concomitant aortic regurgitation.

Infective Endocarditis in Belgium: Prospective Data in Adults from the ESC EORP European Endocarditis Registry.

(1) Background: infective endocarditis (IE) is a significant health concern associated with important morbidity and mortality. Only limited, often monocentric, retrospective data on IE in Belgium are available. This prospective study sought to assess the clinical characteristics and outcomes of Belgian IE patients in the ESC EORP European endocarditis (EURO-ENDO) registry; (2) Methods: 132 IE patients were identified based on the ESC 2015 criteria and included in six tertiary hospitals in Belgium; (3) Results: The average Belgian IE patient was male and 62.8 ± 14.9 years old. The native valve was most affected (56.8%), but prosthetic/repaired valves (34.1%) and intracardiac device-related (5.3%) IE are increasing. The most frequently identified microorganisms were S. aureus (37.2%), enterococci (15.5%), and S. viridans (15.5%). The most frequent complications were acute renal failure (36.2%) and embolic events (23.6%). Cardiac surgery was effectively performed when indicated in 71.7% of the cases. In-hospital mortality occurred in 15.7% of patients. Predictors of mortality in the multivariate analysis were S. aureus (HR = 2.99 [1.07-8.33], p = 0.036) and unperformed cardiac surgery when indicated (HR = 19.54 [1.91-200.17], p = 0.012). (4) Conclusion: This prospective EURO-ENDO ancillary analysis provides valuable contemporary insights into the profile, treatment, and clinical outcomes of IE patients in Belgium.

P2Y(4) nucleotide receptor: a novel actor in post-natal cardiac development.

Communication between endothelial cells and cardiomyocytes is critical for cardiac development and regeneration. However the mechanisms involved in these endothelial-cardiomyocyte interactions remain poorly understood. Nucleotides are released within the heart, especially under ischemia or pressure overload. The function of P2Y nucleotide receptors in cardiac development has never been investigated. Here we show that adult P2Y(4)-null mice display microcardia. P2Y(4) nucleotide receptor is expressed in cardiac endothelial cells but not in cardiomyocytes. Loss of P2Y(4) in cardiac endothelial cells strongly inhibits their growth, migration and PDGF-B secretion in response to UTP. Proliferation of microvessels and cardiomyocytes is reduced in P2Y(4)-null hearts early after birth, resulting in reduced heart growth. Our study uncovers mouse P2Y(4) receptor as an essential regulator of cardiac endothelial cell function, and illustrates the involvement of endothelial-cardiomyocyte interactions in post-natal heart development. We also detected P2Y(4) expression in human cardiac microvessels. P2Y(4) receptor could constitute a therapeutic target to regulate cardiac remodelling and post-ischemic revascularisation.

Ischemic mitral regurgitation: not only a bystander.

Ischemic mitral regurgitation (MR) is a common complication of left ventricular (LV) dysfunction related to chronic coronary artery disease. This complex multifactorial disease involves global and regional LV remodeling, as well as dysfunction and distortion of the components of the mitral valve including the chordae, the annulus, and the leaflets. Its occurrence is associated with a poor prognosis. The suboptimal results obtained with the most commonly used surgical strategy, involving mitral valve annuloplasty with coronary bypass grafting, emphasize the need to develop alternative surgical techniques targeting the causal mechanisms of the disease. A comprehensive preoperative assessment of mitral valve configuration and LV geometry and function and an accurate quantification of MR severity at rest and during exercise may contribute to improve risk stratification and to tailor the surgical strategy according to the individual characteristics of the patient.

Diagnostic Role of Incidental Premature Contractions During Doppler Echocardiography.

Cardiac sonographers often perceive premature beats as a limiting factor during echocardiography because they alter filling and contractility, and loops recorded during or after a premature contraction are often discarded. Here we present 2 cases in which the incidental occurrence of premature beats on Doppler echocardiography contributed to the diagnosis. (Level of Difficulty: Intermediate.).

Sarcoidosis presenting as acute pericarditis. A case report and review of pericardial sarcoidosis.

Cardiac sarcoidosis typically involves the myocardium. Pericardial effusion is uncommon, and symptomatic pericardial disease is even more infrequent. We report the case of a patient presenting with pericarditis as the first manifestation of sarcoidosis. A 50-year-old previously healthy man presented with chest pain and dyspnoea. The electrocardiogram confirmed the diagnosis of pericarditis. Computed tomography of the thorax showed pulmonary infiltrates with mediastinal and hilar adenopathies. Histological analysis of a lymph node biopsy was consistent with sarcoidosis. There was no evidence of myocardial involvement on Magnetic Resonance Imaging (MRI). We reviewed the available English literature and identified 31 cases with sarcoidosis and pericardial involvement. The majority of cases presented as pericardial effusion, which was often the first clinical manifestation of the disease. Pathological diagnosis usually occurs at extra-cardiac locations. Myocardial involvement, an important cause of morbidity and mortality, was found in 25.8% (8/31) of cases. Sarcoidosis should be considered in the differential diagnosis of patients presenting with pericardial disease. The optimal treatment regimen and long-term outcome remain largely unknown. Research in cardiac sarcoidosis should include pericardial disease as a separate manifestation in order to improve the management of this rare but likely underdiagnosed condition.

Role of imaging for diagnosis and management of aortic valve papillary fibroelastoma and cardiac amyloid light chain amyloidosis: a case report.

BACKGROUND: We report the case of a patient who presented with concomitant aortic valve papillary fibroelastoma (PFE) and cardiac amyloidosis. Although histologically benign, PFE confers an increased thromboembolic risk, and surgical excision is often indicated. However, outcomes of cardiac surgery are poor in patients with cardiac amyloidosis. CASE SUMMARY: A 61-year-old man with complaints of dyspnoea and weight loss of 10 kg developing over the past 5 months was evaluated in the cardiology clinic. Echocardiography revealed sessile aortic valve PFE and was also highly suggestive of cardiac amyloidosis. The diagnosis of amyloid light chain amyloidosis secondary to indolent multiple myeloma was eventually confirmed. Therapy with daratumumab, bortezomib, cyclophosphamide, and dexamethasone allowed full remission over a 6-month period and resulted in marked improvement in symptoms and cardiac function as evaluated by global longitudinal strain. Further workup with cerebral magnetic resonance revealed multiple vascular sequelae. Surgical removal of the aortic fibroelastoma with bioprosthetic aortic valve replacement was performed successfully and the patient had an uneventful recovery. DISCUSSION: Papillary fibroelastoma and cardiac amyloidosis are rare and most likely unrelated entities. Concomitant presentation of both conditions in the same patient presents a unique therapeutic challenge. By allowing cardiac function to be monitored during chemotherapy, speckle-tracking echocardiography can prove instrumental in determining the optimal timing of surgical intervention.