Percutaneous transthoracic needle biopsy of lung lesions is a safe method associated with a very low risk of pleural recurrence.

AIM: Percutaneous transthoracic needle biopsy (PTNB), an alternative to bronchoscopic confirmation of lung lesions, is today being associated with a risk of pneumothorax and hemorrhage. Further, there are no data on the possible risk of malignant disease spreading to the pleura at the site of the PTNB. Previous studies have dealt with this risk in stage I non-small cell lung cancer only. The aim of this study was thus to assess the risk of pleural recurrence for all types of lung lesions. Secondary objectives included assessment of diagnostic yield and safety with respect to the incidence of pneumothorax and hemorrhage. METHODS: Clinical data of all patients from the University Hospital in Pilsen who had undergone PTNB of lung lesions between 1.1.2018 and 31.12.2022 were included in this retrospective study. RESULTS: Following PTNB, ipsilateral pleural effusion occurred in 4.8% of patients without prior pleural infiltration. The effusion was confirmed as malignant in one patient (0.7%). Diagnostic yield of the method was 86.6%. We recorded pneumothorax or hemorrhage in the lung parenchyma or pleural space requiring medical intervention in 3.4% and 1.1% of patients, respectively. CONCLUSION: In our study, percutaneous transthoracic needle biopsy of lung lesions showed high sensitivity and low degree of acute complications requiring an invasive solution. The risk of pleural recurrence after a biopsy was very low. Consequently, we continue to consider this method to be an alternative to bronchoscopy biopsies.

The Agreement Between Transthoracic and Transesophageal Echocardiography in the Assessment of Right Ventricular Diastolic Dysfunction Grades in Adult Patients Undergoing Cardiac Surgery: A Prospective Observational Study.

Introduction The importance of right ventricular (RV) diastolic function in cardiac surgery cannot be overstated, as it significantly affects prognosis and long-term outcomes. Conventionally, RV diastolic dysfunction (RVDD) is assessed and graded using criteria from either the American Society of Echocardiography (ASE) or the British Society of Echocardiography (BSE), with measurements done by transthoracic echocardiography (TTE). However, during cardiac surgery, perioperative echocardiographic evaluation is done predominantly by transesophageal echocardiography (TEE). This study aimed to assess the agreement between TTE and TEE in grading RVDD using both ASE and BSE criteria. Methods Key two-dimensional (2D) and Doppler parameters were measured in 81 patients undergoing cardiac surgery by both TTE and TEE after anesthesia induction within 10 minutes of each other, under similar hemodynamic, anesthetic, and ventilatory conditions. RVDD gradings were done separately by TTE and TEE with both ASE and BSE criteria using the measured values of the key parameters by TTE and TEE, respectively. RVDD gradings derived from TTE were compared with those derived from TEE. The tricuspid inflow Doppler and tricuspid annular tissue Doppler parameters were measured in TEE in both mid-esophageal RV inflow-outflow (MERVIO) and deep transgastric RV inflow-outflow (DTGRVIO) views. Gradings were done separately for both views of TEE by using the Doppler values measured in the respective views (TEE-MERVIO and TEE-DTGRVIO). The TTE-derived RVDD grades were compared with those derived by both TEE-MERVIO and TEE-DTGRVIO. Weighted κ values were used to assess observed agreement beyond chance. Inter-rater reliability of the RVDD grades derived by both TTE and TEE (both views) was also checked. Individual 2D and Doppler parameters were compared between TTE and TEE in terms of Bland-Altman limits of agreement. Results As per ASE criteria, disagreement of RVDD by ≥1 grade was seen in 43 (53.1%) patients and by 2 grades in eight (9%) patients when comparing TTE and TEE-MERVIO, yielding a weighted κ of 0.14 (p=0.123). Disagreement by ≥1 grade was observed in 32 (39.5%) patients and by 2 grades in 10 (12.3%) patients when comparing TTE and TEE-DTGRVIO, yielding a weighted κ of 0.3 (p=0.002). Using the BSE Criteria, disagreement of RVDD grades occurred in nine (11.1%) patients when comparing TTE and TEE-MERVIO, yielding an unweighted κ of 0.25 (p=0.295). Disagreement occurred in 12 (14.8%) patients when comparing TTE and TEE-DTGRVIO, yielding an unweighted κ of 0.260 (p=0.187). There was almost perfect agreement between independent raters regarding both TTE- and TEE-derived RVDD grades per the ASE criteria, and substantial to almost perfect agreement per BSE criteria. Bland-Altman analysis of paired data between the TTE- and TEE-measured values of individual 2D and Doppler parameters showed wide limits of agreement. Conclusions This study revealed, at best, only fair agreement between TTE and TEE in grading RVDD. The measured 2D and Doppler echocardiographic parameters showed wide limits of agreement between TTE and TEE. We recommend further research to develop a TEE-based algorithm for grading RVDD, and to evaluate the prognostic effectiveness of perioperative TEE for predicting adverse clinical outcomes associated with RVDD.

The nodule-pleura relationship affects pneumothorax in CT-guided percutaneous transthoracic needle biopsy: avoiding to cross pleural tail sign may reduce the incidence of pneumothorax.

OBJECTIVES: To explore the role of nodule-pleural relationship, including nodule with pleural tail sign (PTS), nodule with pleural contact and nodule with pleural unrelated in CT-guided percutaneous transthoracic needle biopsy (PTNB)-induced pneumothorax, and whether employing different puncture routes has an impact on the incidence of pneumothorax in PTNB of nodules with PTS. METHODS: Between April 1, 2019, to June 30, 2021, 775 consecutive PTNB procedures of pulmonary nodules in the Peking University Cancer Hospital were retrospectively reviewed. The univariate and multivariate regression analysis were used to identify the risk factors for pneumothorax in PTNB. RESULTS: The nodule with pleural contact group has a lower incidence of pneumothorax than the nodule with PTS group (p = 0.001) and the nodule with pleural unrelated group (p = 0.002). It was observed that a higher incidence of pneumothorax caused by crossing PTS compared with no crossing PTS (p < 0.001). Independent risk factors for pneumothorax included crossing PTS (p < 0.001), perifocal emphysema (p < 0.001), biopsy side up (p < 0.001), longer puncture time (p < 0.001), deeper needle insertion depth (intrapulmonary) (p < 0.001) and nodules in the middle or lower lobe (p = 0.007). CONCLUSION: Patients with crossing PTS, a nodule in the middle or lower lobe, longer puncture time, biopsy side up, deeper needle insertion depth (intrapulmonary), and perifocal emphysema were more likely to experience pneumothorax in PTNB. When performing the biopsy on a nodule with PTS, selecting a route that avoids crossing through the PTS may be advisable to reduce the risk of pneumothorax.

Biotronik Implantable Cardioverter Defibrillator for Measurement of Intrathoracic Impedance: A Report of Two Cases.

OBJECTIVES: Two patients were received ICDs (Biotronic Iforia7 VR-TDX). Holter analysis revealed pacing spikes, which occurred regularly at 100 ms intervals following QRS complexes, with consecutive 1024 test pulses at hourly intervals during a specific time, and the VP was 0%. METHODS: By analyzing the dynamic electrocardiogram and consulting relevant literature, it was found that this is a feature of the ICD that measures thoracic impedance. RESULTS: This phenomenon is a special function for the purpose of transthoracic impedance measurement, which can monitor the heart failure. CONCLUSIONS: This phenomenon should not be regarded as an interference signal or an abnormal sign of pacemaker malfunction.

Graded transthoracic contrast echocardiography after pulmonary arteriovenous malformation embolization: can chest CT be avoided in patients with a low grade shunt?

BACKGROUND: Pulmonary arteriovenous malformations (PAVMs) are direct connections between the pulmonary artery and vein, creating right-to-left shunting (RLS). Embolization is indicated to prevent complications. Guidelines recommend follow-up chest CTs to confirm persistent occlusion and embolization of all treatable PAVMs. Graded transthoracic contrast echocardiography (TTCE) after PAVM embolization may offer a reliable alternative in a subgroup of patients while preventing radiation exposure. RESEARCH QUESTION: Can TTCE predict the need for additional embolotherapy in the post-embolization population as accurately as it does in treatment-naïve population? STUDY DESIGN AND METHODS: Since 2018, follow-up after PAVM embolization at the study institution includes both TTCE and chest-CT after 6-12 months and every 3-5 years thereafter. Patients who underwent at least one follow-up TTCE and chest-CT were included. The indication for additional embolotherapy was discussed in a multidisciplinary team meeting. The primary outcome was the indication for additional embolotherapy in each RLS-grade. Additionally, the association between the RLS-grade and indication for additional embolotherapy was investigated. RESULTS: 339 patients with 412 embolization procedures were included, median time to follow-up TTCE was 7.5 months. A RLS was present in 399 post-embolization TTCEs (97%): RLS grade 1 in 93 patients (23%), grade 2 in 149 patients (36%) and grade 3 in 157 patients (38%). In patients with a RLS grade 0-1, no treatable PAVMs were found on CT. In patients with RLS grade 2-3, 22 (15%) and 72 (46%) underwent additional embolizations. INTERPRETATION: This study shows chest CT might be forgone in patients with an RLS grade 0-1 after PAVM embolization.

Unmasking Rheumatic Heart Disease Decades Later in a Patient With a Remote History of Rheumatic Fever Despite Prolonged Antibiotic Prophylaxis.

Rheumatic heart disease (RHD) is one of the leading causes of valvular heart disease worldwide and still persists in the USA, particularly among vulnerable populations with limited healthcare. Depending on the risk, severity, and types of valve involvement, treatment includes guideline-directed medical therapy (GDMT) and surgical interventions like valve repair or replacement. Here, we present a unique case of a patient in his late fifties who presented with worsening heart failure symptoms and several heart murmurs. A transthoracic echocardiogram (TTE) revealed moderate to severe mitral regurgitation (MR), aortic regurgitation (AR), and mild aortic stenosis (AS) with a bicuspid aortic valve. However, coronary angiography and right heart catheterization showed no blockages, right ventricular dysfunction, or pulmonary hypertension. Furthermore, no valvular vegetation was noticed on the transesophageal echocardiogram. The patient had a history of acute rheumatic fever (RF) in adolescence and was treated until age 21. Despite potential alternative causes like myocardial infarction or endocarditis, the lack of ischemic findings, negative blood cultures, and absence of valvular vegetation suggested that RHD was the possible cause of his valvular issues. This case highlights the rare occurrence of RHD impacting multiple valves despite proper antibiotic prophylaxis and draws attention to the importance of considering RHD when diagnosing multiple valvular problems, as many patients are identified too late for surgical intervention.

Unveiling Congenital Heart Disease in an Octogenarian: A Case of Late Diagnosis of Patent Ductus Arteriosus Presenting With Heart Failure With a Preserved Ejection Fraction.

We present the case of an 88-year-old female with a history of chronic obstructive lung disease, atrial fibrillation, and type 2 diabetes mellitus, initially investigated for iron deficiency anemia. Despite inconclusive endoscopic and radiological investigations for occult bleeding, the subsequent evaluation revealed pulmonary hypertension and right heart enlargement on CT of the thorax. Further assessment by echocardiography unveiled dilated pulmonary arteries, right ventricle enlargement, and a left-to-right shunt, consistent with patent ductus arteriosus (PDA), a rare finding in the elderly. Remarkably, the patient recalled being informed of a "weak heart" at birth, suggesting undiagnosed congenital heart disease. Management commenced with heart failure therapy, resulting in significant improvement in dyspnea. This case highlights the importance of considering congenital heart anomalies in elderly patients presenting with heart failure symptoms, emphasizing the value of thorough history-taking and advanced imaging techniques in diagnosis and management.

Efficacy and Safety of Transthoracic Versus Transesophageal Echocardiography for Monitoring Closure of Atrial or Ventricular Septal Defects: A Systematic Review and Meta-Analysis.

PURPOSE: For the repair of atrial/ventricular septal defects (ASD/VSD), transthoracic echocardiography (TTE) is easy to perform, cost-effective, and does not require general anesthesia and intubation. Still, TTE is not universally accepted. To compare efficacy and safety of TTE versus transesophageal echocardiography (TEE) to guide percutaneous ASD/VSD closure. METHODS: PubMed, Embase, and the Cochrane library were searched for articles published from their inception to December 2023. The primary outcome was the procedural success rate. The secondary outcomes were residual shunt, late complications, procedure time, and fluoroscopy time. All meta-analyses were performed using a random-effects model. RESULTS: Eight studies and 1295 patients were included. There were no significant differences between TTE and TEE regarding the procedural success rate (OR = 1.93, 95% CI: 0.90-4.13, p = 0.092; I2 = 52.2%, Pheterogeneity = 0.063) and residual shunt rate (OR = 0.81, 95% CI: 0.38-1.76, p = 0.600; I2 = 0%, Pheterogeneity = 0.518). Compared with TEE, TTE reduced the frequency of late complications (OR = 0.25, 95% CI: 0.14-0.43, p < 0.001; I2 = 13.8%, Pheterogeneity = 0.326), reduced the procedure time (WMD = -8.92, 95% CI: -12.08, -5.75, p < 0.001; I2 = 87.4%, Pheterogeneity < 0.001), and reduced the fluoroscopy time (WMD = -5.08, 95% CI: -9.59, -0.56, p = 0.028; I2 = 95.6%, Pheterogeneity < 0.001). The sensitivity analyses showed that the results of the meta-analyses were robust. CONCLUSION: Compared with TEE, TTE showed no differences regarding the rates of success and residual shunt, but there were lower rates of late complications and shorter procedure and fluoroscopy times.

Analysis of risk factors for intraoperative bleeding in patients with Siewert type II esophagogastric junction adenocarcinoma treated by two minimally invasive surgeries and its influence on prognosis: a retrospective study.

Background: The present study aimed to analyze the independent risk factors for intraoperative bleeding in Siewert II adenocarcinoma of the esophagogastric junction (AEG) using two minimally invasive surgical approaches, namely, the laparoscopy-assisted abdominal trans-hiatal (LTH) method and transthoracic-laparoscopic esophagectomy (TLE). Methods: The clinical data of 100 patients with SiewertII AEG admitted to our hospital from October 2017 to October 2020 were retrospectively analyzed. According to the type of surgery, the patients were divided into LTH approach group and TLE approach group. The differences between the clinical characteristics of the patients in different groups and the differences in the intraoperative bleeding and prognosis between different surgical procedures were analyzed and compared using the t-test and chi-squared test. Multiple linear regression was used to identify the independent risk factors affecting the amount of intraoperative bleeding in patients. Results: The results of this study showed that patients in the LTH group had significantly less intraoperative bleeding and operative time and significantly better postoperative recovery than the TLE group. The results of multivariate linear regression showed that the combined trans-thoracic-abdominal approach (P=0.000), advanced age (P=0.014), larger BMI (P=0.000), and larger tumor diameter (P=0.001) were the independent risk factors influencing the increase in intraoperative bleeding. Conclusion: In addition to the conventional factors that affect intraoperative bleeding, such as the patient's general condition, operation time, and tumor size, LTH surgery is another way to avoid intraoperative bleeding for Siewert type II AEG patients and can significantly improve postoperative recovery.

Diagnostic accuracy of percutaneous transthoracic needle biopsy among peripheral pulmonary lesions: a multicenter observational study.

Introduction: The diagnosis of peripheral pulmonary lesions (PPL) poses a significant challenge, prompting the widespread utilization of various modalities to ensure the precision in diagnosis. This study aims to assess the diagnostic accuracy of computed tomography-guided percutaneous transthoracic needle biopsy (CT-PTNB) in the context of pulmonary malignancy. Methods and materials: This multicenter retrospective observational study, included 1317 cases of CT-PTNB performed on adult patients with PPLs from January 2018 to December 2022 in Mashhad, Iran. The pathology results of CT-PTNB from 94 cases were compared to the definitive pathology results obtained through methods such as surgery to assess the sensitivity, specificity, and overall accuracy of CT-PTNB in diagnosing of pulmonary malignancy. Results: CT-PTNB exhibits an accuracy of 82.98%, with sensitivity and specificity rates of 75.41 and 91.43%, respectively. This study underscores the issue of false-negative results in CT-PTNB and underscores the importance of integrating clinical, radiological, and additional diagnostic modality to guide diagnostic decisions. Conclusion: In this large-scale multicenter study, the accuracy of CT-PTNB for diagnosis of pulmonary malignancy is acceptable but fairly low compared to previous studies.

Long-Standing Chronic Recurrent Pericarditis Managed With Advanced Diagnostic and Therapeutic Methods.

A 65-year-old woman with a history of idiopathic pericarditis presented with chronic recurrent pericarditis. Because of the inability to taper off anakinra without recurrent flares, she transitioned to rilonacept, which led to symptom abatement. Her positive response to rilonacept therapy correlated with an improvement in inflammatory changes noted on cardiac magnetic resonance imaging.

A Patient With Symptomatic Pheochromocytoma and Very Severe Aortic Valve Stenosis: Diagnostic and Management Approach.

Preoperative management of a pheochromocytoma involves α-adrenergic receptor blockers and volume expansion followed by ß-adrenergic receptor blockers and then adrenalectomy, which in the presence of very severe aortic valve stenosis would be challenging. We describe a patient with this rare combination who underwent pharmacotherapy followed by transcatheter aortic valve replacement and then adrenalectomy, culminating in a successful outcome for this patient.

Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography.

How to cite this article: Kumar V. Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography. Indian J Crit Care Med 2024;28(9):813-815.

Post myocardial infarction left ventricular intramyocardial dissecting hematoma penetrated right ventricular outflow tract: a rare complication report.

BACKGROUND: Intramyocardial dissecting hematoma (IDH) is a rare mechanical complication following myocardial infarction (MI), and only a few isolated cases have been reported to date. IDH presents with diverse clinical manifestations, often resulting in missed or misdiagnosed cases due to limited physician understanding. The diagnosis and treatment of IDH is a major challenge. CASE PRESENTATIONS: We report a case of acute extensive anterior MI in a 73-year-old woman, who underwent percutaneous coronary intervention (PCI); the left ventricular intramyocardial dissecting hematoma (LVIDH) penetrated the right ventricular outflow tract (RVOT), resulting in thrombus formation and subsequent RVOT obstruction. Clinically insignificant IDH was detected by transthoracic echocardiography (TTE) at 3 days, 43 days, and 75 days post-PCI, with characteristic changes in the left ventricular wall ultrasound images. This unusual case highlights the important role of continuous transthoracic echocardiography in identifying this rare complication of LVIDH. After a detailed discussion with the patient, the choice between conservative or surgical management of IDH depends on factors such as the size of the hematomae, left ventricular systolic function, and the patient's clinical and haemodynamic status. In this particular case, conservative management was chosen by the patient who declined surgery but unfortunately succumbed to cardiogenic shock. CONCLUSIONS: This case describes a rare complication of acute myocardial infarction (AMI) and also focuses on the utility of TTE in the diagnosis of this rare complication. Whether LVIDH is treated conservatively or surgically requires careful evaluation to achieve the best prognosis for the patient.

Effect of cross-platform variations on transthoracic echocardiography measurements and clinical diagnosis.

Aims: Accurate cardiac chamber quantification is essential for clinical decisions and ideally should be consistent across different echocardiography systems. This study evaluates variations between the Philips EPIQ CVx (version 9.0.3) and Canon Aplio i900 (version 7.0) in measuring cardiac volumes, ventricular function, and valve structures. Methods and results: In this gender-balanced, single-centre study, 40 healthy volunteers (20 females and 20 males) aged 40 years and older (mean age 56.75 ± 11.57 years) were scanned alternately with both systems by the same sonographer using identical settings for both 2D and 4D acquisitions. We compared left ventricular (LV) and right ventricular (RV) volumes using paired t-tests, with significance set at P < 0.05. Correlation and Bland-Altman plots were used for quantities showing significant differences. Two board-certified cardiologists evaluated valve anatomy for each platform. The results showed no significant differences in LV end-systolic volume and LV ejection fraction between platforms. However, LV end-diastolic volume (LVEDV) differed significantly (biplane: P = 0.018; 4D: P = 0.028). Right ventricular (RV) measurements in 4D showed no significant differences, but there were notable disparities in 2D and 4D volumes within each platform (P < 0.01). Significant differences were also found in the LV systolic dyssynchrony index (P = 0.03), LV longitudinal strain (P = 0.04), LV twist (P = 0.004), and LV torsion (P = 0.005). Valve structure assessments varied, with more abnormalities noted on the Philips platform. Conclusion: Although LV and RV volumetric measurements are generally comparable, significant differences in LVEDV, LV strain metrics, and 2D vs. 4D measurements exist. These variations should be considered when using different platforms for patient follow-ups.

Safety and feasibility of transcatheter closure of atrial septal defects in small children weighing less than 10 kg.

BACKGROUND: When young patients with an oval fossa defect present early with symptoms of heart failure and pulmonary hypertension, surgical treatment is recommended in small bodyweight rather than transcatheter closure. METHODS: Outcomes of device closure in consecutive symptomatic children weighing under 10 kg were compared with young children aged below 4 years but weighing above 10 kg. Transthoracic echocardiography under conscious sedation guided the procedure in all without need for balloon sizing, transesophageal echocardiogram, and intubation anaesthesia. Symptoms, anthropometry, shunt ratio, pulmonary pressures, defect and device size, percentage oversizing, device/body weight ratio, complications, and post-procedural growth spurt were compared. RESULTS: Ninety-six patients weighing under 10 kg were compared with 160 patients weighing above 10 kg. In total, 83.3% of patients in the study group and 25% of controls were severely malnourished. The median indexed defect size was 35.2 mm/sq.m and 27.4 mm/sq.m, and the device was oversized by 8.7% and 14.2% in the study group and controls, respectively. The device/body weight ratio was 1.93 in study group and 1.4 in controls. Procedure was successful in all except one patient weighing under 10 kg who had a device embolisation. Both groups showed significant growth spurts and proportion, with severe malnutrition reduced to 42% and 11% in the two groups. CONCLUSIONS: Device closure was feasible and safe in patients under 10 kg. Transthoracic echocardiographic imaging on conscious sedation provided adequate guidance. Symptoms and growth significantly improved after intervention. Despite a larger defect size, smaller patients had comparable outcomes. In symptomatic children under 10 kg needing early closure, transcatheter intervention should not be deferred.

Comparison Between Endobronchial-Guided Transbronchial Biopsy and Computed Tomography-Guided Transthoracic Lung Biopsy for the Diagnosis of Central Pulmonary Lesions.

BACKGROUND: Lung cancer is one of the most common malignant tumors at present. This study aimed to compare the diagnostic accuracy, complication rates, and predictive values of computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and electronic bronchoscopy-guided transbronchial lung biopsy (TBLB) for patients with central pulmonary lesions (CPLs) with a diameter ≥ 3 cm. METHODS: We retrospectively included 110 patients with CPLs with a diameter ≥ 3 cm who underwent preoperative PTNB and TBLB examinations and ultimately underwent surgery to remove CPLs and obtained pathological results. Detailed information was collected in order to compare whether there was a difference between two groups. Data were processed using SPSS software (Version 26.0; IBM Corp). Data were compared by t-test or chi-square test. p < 0.05 was considered statistically significant. RESULTS: All patients underwent surgical treatment at the department of thoracic surgery and obtained a final pathological diagnosis. The rate of positive predictive value (PPV) was comparable between the two methods, and the negative predictive value (NPV) was significantly higher in the PTNB group compared with the TBLB group (p < 0.05). In addition, PTNB was more sensitive and accurate than TBLB (p < 0.05). However, the PTNB group had a higher probability of complications, and TBLB was a relatively safer examination method. CONCLUSION: PTNB demonstrated a higher accuracy and sensitivity than TBLB in the treatment of CPLs with a diameter ≥ 3 cm, but the complication rates of PTNB are relatively high. These methods exhibited different diagnostic accuracies and therefore should be selected based on different medical conditions.

The Effect of Upright Posture on Left Atrial Strain in Competitive Athletes.

BACKGROUND: Left atrial strain (LAS) assessment by speckle tracking echocardiography (STE) has been shown to be a remarkable means of quantifying LA function as an early marker of LV pathology. As exercise testing is also performed on a treadmill, the aim of this study was to investigate the effect of upright posture on LAS in healthy athletes. METHODS: Fifty male athletes (mean age 25.7 ± 7.3 years) underwent transthoracic echocardiography (TTE) in the upright and left lateral positions. In addition to the conventional echocardiographic parameters, in all athletes, LA conduction strain (LAScd), contraction strain (LASct), reservoir strain (LASr), and maximum LA volume (LAVmax) were assessed by STE in both positions. RESULTS: Comparing upright posture and the left lateral position, LAScd (-14.0 ± 5.9% vs. -27.4 ± 7.1%; p < 0.001), LASct (-4.6 ± 3.5% vs. -11.3 ± 4.1%; p < 0.001), LASr (18.7 ± 7.6% vs. 38.7 ± 8.0%; p < 0.001), and LAVmax (24.4 ± 8.8% vs. 50.0 ± 14.2%) differed significantly. CONCLUSIONS: Upright posture has a significant effect on LA deformation, with decreased LAScd, LASct, and LASr. The results of this study contribute to the understanding of athletes' hearts and must be considered when performing echocardiography in healthy athletes on a treadmill.

Left Atrial Compression by an Intramural Hematoma: A Rare Case of Obstructive Shock.

A 3.5 cm diameter descending aorta focal aneurysm was incidentally found when a computed tomography (CT) was conducted due to persistent pyrexia in an 85-year-old woman hospitalized for a non-obstructive urinary tract infection. Ten days later, whilst fever subsided and inflammation markers decreased, she became hypoxic. CT revealed an aortic intramural hematoma (Stanford type B) increasing the diameter of the thoracic aorta aneurysm to 6.5 cm. A thoracic endovascular aortic repair (TEVAR) surgery was performed. Seven days after the operation she developed respiratory and hemodynamic compromise. CT depicted further enlargement of the aortic intramural hematoma, increasing the aortic diameter to 8 cm. Transthoracic echocardiography provided valuable information showing extrinsic compression of the left atrium and left ventricle inflow obstruction provoking obstructive shock.

The value of CT coronary angiography for a comprehensive assessment of left circumflex artery in Kawasaki disease: 9 years of experience from a tertiary center.

Background: Transthoracic echocardiography (TTE) has traditionally been the primary method for coronary imaging in children with Kawasaki disease (KD). We aimed to evaluate coronary artery lesions (CALs) of the left circumflex artery (LCx) in KD on computed tomography coronary angiography (CTCA). Methods: Over a 9-year period (November 2013-December 2022), 225 children with KD underwent radiation-optimized CTCA on a 128-slice dual-source platform. TTE was performed on the same day, or a day prior or after CTCA. Findings: On CTCA, LCx CALs were seen in 41/225 (18.2%) patients. However, TTE detected CALs in only one third of these patients [15/41 (36.6%)]. CTCA showed 47 LCx CALs in 41 patients-aneurysms in 39 patients (40 fusiform, 2 saccular; 7 giant aneurysms), stenoses in 3, and thrombosis in 2. Thromboses and stenoses were both missed on TTE. Proximal LCx aneurysms were seen in 39 patients-of these, 12 had distal extension. Six patients had distal LCx aneurysms without proximal involvement and 2 non-contiguous multiple aneurysms. Four (9.75%) patients had isolated LCx involvement. Based on CTCA findings, treatment protocols had to be modified in 3/41 (7.3%) patients. Interpretation: This study highlights anatomical findings of LCx involvement in KD. Isolated LCx CALs were noted in 4/41 (9.75%) patients. TTE alone proved inadequate for LCx assessment in children with KD. With abnormalities detected in 18.2% of cases, including those missed by TTE, CTCA emerges as an essential imaging modality. The findings have implications for treatment planning and follow-up strategies in children with KD. Funding: None.