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.

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.

Pathophysiology and management of combined aortic and mitral regurgitation.

The combination of aortic and mitral regurgitation is a typical example of a frequent yet understudied multiple valve disease scenario. The aetiology is often rheumatic or degenerative; less frequently it can be induced by drugs or radiation, or caused by infective endocarditis or congenital valvular lesions. Aortic regurgitation resulting in secondary mitral regurgitation is also not uncommon. There are limited data to guide the management of combined aortic and mitral regurgitation. Left ventricular dysfunction is frequent at initial presentation, and even more so postoperatively, suggesting that surgical management should not be delayed, particularly when symptoms occur or when there is evidence of even subtle left ventricular dysfunction. The decision to operate on one or both valves not only depends on the severity of each lesion, but also on several other factors, including age, co-morbidities and frailty, the increased operative risk of double valve surgery, the increased risk of long-term thrombotic and bleeding complications with multiple mechanical valves, the risk of leaving one valve unoperated and the probability of requiring redo surgery. The role of a multidisciplinary heart valve team is critical in this setting to optimize management and outcomes. The role of transcatheter approaches is currently limited, but technological advances will probably soon change the management paradigm.