Giant left atrial appendage aneurysm compressing the left anterior descending coronary artery.

Left atrial appendage aneurysm (LAAA) is a rare congenital structural heart disease. It is often diagnosed by echocardiography; however, other imaging modalities can add to its diagnosis and its potential effects on the surrounding structures. A 16-year-old boy presented with dyspnea and palpitation. Transthoracic echocardiography showed a large LAAA communicating with the LA through a narrow neck with impaired left ventricular (LV) systolic function. Multidetector cardiac tomography showed that the LAAA is compressing the left anterior descending artery. The LAAA was surgically resected followed by improvement of the LV systolic function.

Ventricular remodeling and hemodynamic changes in heart failure patients with non-ischemic dilated cardiomyopathy following dapagliflozin initiation.

BACKGROUND: In heart failure with reduced ejection fraction (HFrEF), sodium-glucose co-transporter inhibitors (SGLT-2i) have persistently shown cardiovascular benefits through different trials. However, their impact on ventricular remodeling and cardiac hemodynamics has not been sufficiently studied. This study aimed to study how SGLT-2i initiation affects invasive hemodynamics and cardiac magnetic resonance imaging (CMR)-derived ventricular volumes, function, and fraction of the extracellular volume (ECV) in HFrEF patients with non-ischemic dilated cardiomyopathy (NIDCM). RESULTS: In this study, 23 patients with HFrEF and a mean age of 42, including 82.6% males, all have NIDCM and underwent right heart catheterization and CMR at the initiation of dapagliflozin and at 6-month follow-up. The addition of dapagliflozin resulted in significant reductions in the following invasive hemodynamic parameters compared to baseline: left ventricular end-diastolic pressure (23.4 vs 19.7 mmHg, p = 0.003), mean pulmonary artery pressure (31.3 vs 27.7 mmHg, p = 0.03), and systemic vascular resistance (18 vs 15 Wood units, p = 0.047). Among the studied CMR-derived measurements, only the percentage of extracellular volume fraction was significantly less at follow-up (33.7 vs 32.16%, p = 0.001). Additionally, functional class showed significant improvement with a notable reduction of the NT-proBNP level and a considerable decrease in diuretic dose (median: 40 vs 80 mg, p = 0.01). CONCLUSION: Adding dapagliflozin to patients with HFrEF due to NIDCM improved invasively measured hemodynamics and significantly reduced left ventricular extracellular volume fraction measured by CMR, with no significant change in ventricular volumes or ejection fraction.

Prevalence and characteristics of patent foramen ovale in a sample of Egyptian population: a computed tomography study.

BACKGROUND: The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population. RESULTS: This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features-defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm "ASA", or redundant septum)-were found in 51.5% of PFOs' population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann's bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02). CONCLUSION: The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.

Validation of angiography-derived Murray law-based quantitative flow reserve (µQFR) against pressure-derived instantaneous wave-free ratio for assessing coronary lesions, a single-center study in Egypt.

BACKGROUND: Instantaneous wave-free ratio (iwFR) is a well-validated method for functional evaluation of intermediate coronary lesions. A recently developed Murray law-based QFR (µQFR) allows wire-free FFR estimation using a high-quality single angiographic projection. We aim to determine the diagnostic accuracy of µQFR as compared to wire-based iwFR for physiological assessment of coronary lesions in a sample of Egyptian patients. RESULTS: Over a one-year period, patients who previously underwent iwFR assessment of an intermediate coronary stenosis (40-90%) were retrospectively included. µQFR analysis was then performed offline using a dedicated artificial intelligence (AI)-aided computation software. All the measurements were performed blinded to iwFR results, and the agreement between iwFR and µQFR values was tested. Forty-nine patients (mean age 57.9 ± 9 years, 72.9% males) were included. Mean value of iwFR and µQFR was 0.90 ± 0.075 and 0.79 ± 0.129, respectively. There was a significant moderate positive linear correlation between µQFR and iwFR (r = 0.47, p = 0.001; 95% CI 0.22-0.68) with moderate-to-substantial agreement between the two methods (Kappa 0.6). In assessing the diagnostic accuracy of µQFR, the receiver operating characteristic (ROC) curve yielded an area under the curve (AUC) of 0.84 (95% CI 0.717-0.962) for predicting functionally significant lesions defined as iwFR < 0.89. The sensitivity and specificity of µQFR < 0.8 for detecting physiological significance of coronary lesions were 89% and 74% with positive and negative predictive values of 70 and 91%, respectively. CONCLUSION: µQFR has good diagnostic accuracy for predicting functionally significant coronary lesions with moderate correlation and agreement with the gold standard iwFR. Angiography-derived µQFR could be a promising tool for improving the utilization of physiology-guided revascularization.

Agreement between 4D transesophageal echocardiography and multi-detector computed tomography in measuring aortic root dimensions and coronary ostia heights.

Multi-detector computed tomography (MDCT) is the gold standard non-invasive tool for evaluating aortic root dimensions. We assessed the agreement between 4D TEE and MDCT-derived aortic valve annular dimensions, coronary ostia height, and minor dimensions of sinuses of Valsalva (SoV) and sinotubular junction (STJ). In this prospective analytical study, we measured the annular area, annular perimeter, area-derived diameter, area-derived perimeter, left and right coronary ostial heights, and minor diameters of the SoV and the STJ using ECG-gated MDCT and 4D TEE. TEE measurements were calculated semi-automatically by the eSie valve software. We enrolled 43 adult patients (27 males, median age: 46 years). We found strong correlations and good agreement between the two modalities in annular dimensions (area, perimeter, area-derived diameter, and perimeter-derived diameter), left coronary ostial height, minimum STJ diameter, and minimum SoV diameters. Moderate correlations, and agreement, with relatively large differences between the 95% LOA, were demonstrated for the right coronary artery ostial height. 4D TEE correlates well with MDCT in measuring aortic annular dimensions, coronary ostial height, SoV minor diameter, and sinotubular junction minor diameter. Whether this can affect clinical outcomes is unknown. It could replace MDCT if the latter is unavailable or contraindicated.

Left Ventricular Remodeling Following Balloon Mitral Valvuloplasty in Rheumatic Mitral Stenosis: Magnetic Resonance Imaging Study.

Background: Rheumatic heart disease affects primarily cardiac valves, it could involve the myocardium either primarily or secondary to heart valve affection. The influence of balloon mitral valvuloplasty (BMV) on left ventricular function has not been sufficiently studied. Aim: To determine the influence of balloon mitral valvuloplasty (BMV) on both global and regional left ventricular (LV) function. Methods: Thirty patients with isolated rheumatic mitral stenosis (MS) were studied. All patients had cardiac magnetic resonance imaging (CMR) before, 6 months and 1 year after successful BMV. LV volumes, ejection fraction (EF), regional and global LV deformation, and LV late gadolinium enhancement were evaluated. Results: At baseline, patients had median EF of 57 (range: 45-69) %, LVEDVI of 74 (44-111) ml/m2 and LVESVI of 31 (14-57) ml/m2 with absence of late gadolinium enhancement in all myocardial segments. Six months following BMV, there was a significant increase in LV peak systolic global longitudinal strain (GLS) (-16.4 vs. -13.8, p < 0.001) and global circumferential strain (GCS) (-17.8 vs. -15.6, p = 0.002). At 1 year, there was a trend towards decrease in LVESVI (29 ml/m2, p = 0.079) with a significant increase in LV EF (62%, p < 0.001). A further significant increase, compared to 6 months follow up studies, was noticed in GLS (-17.9 vs. -16.4, p = 0.008) and GCS (-19.4 vs. -17.8 p = 0.03). Conclusions: Successful BMV is associated with improvement in global and regional LV systolic strain which continues for up to 1 year after the procedure.

Left atrial structural and functional remodeling following balloon mitral valvuloplasty.

Mitral stenosis (MS) is associated with left atrial (LA) functional and morphological changes as a result of chronic increase in LA pressure. Relieving the mitral obstruction via balloon mitral valvuloplasty (BMV) might be associated with LA structural and functional remodeling. To study alterations of LA volume and functions 1 year following successful BMV in patients with isolated rheumatic severe mitral stenosis. Thirty patients (median age 33 years, 22 women) with severe rheumatic MS were included in the study. Using biplane method, trans-thoracic 2D echocardiography was used to estimate LA volume indexed to body surface area (BSA). Maximal, minimal and pre-A left atrial volumes were measured and indexed to BSA. LA volumetric functions were then assessed and the measurements were repeated 6 months and 1 year after successful valvuloplasty. At baseline, median mitral valve area (MVA) was 0.9 (0.6-1.3) cm2 measured by planimetry with a mean pressure gradient of 12.5 (8-24) mmHg. Following BMV, a significant regression of left atrial volume index was noticed at 6 months compared to baseline (51 vs. 60 ml/m2, p = 0.001) with a further decrease at 1 year (48 vs. 51 ml/m2, p = 0.03). At 6 months, volumetric assessment of left atrial functions showed a significant improvement in LA total emptying fraction (42% vs 30%, p = 0.001) as well as in LA passive emptying fraction (26% vs 14%, p = 0.033) and LA active emptying fraction (20% vs. 18%, p = 0.016). All these indices showed further improvement at 1 year [47% (P = 0.02), 29% (p = 0.03) and 31% (p = 0.001) respectively]. In patients with isolated rheumatic MS, mitral valvuloplasty was associated with a significant decline of LA volume accompanied by a significant improvement of its volumetric functions.

Impact of balloon mitral valvuloplasty on left ventricular rotational deformation: Magnetic Resonance Imaging follow up study.

In patients with rheumatic mitral stenosis (MS), some previous studies have investigated the influence of balloon mitral valvuloplasty (BMV) on left ventricular (LV) systolic function. However, the impact of BMV on LV twisting motion in this clinical setting has not been studied before yet. To describe changes in LV torsion in patients with rheumatic MS following BMV. Thirty patients (median age 33 years, 22 women) with isolated severe MS were studied. CMR myocardial tissue tagging was used for assessment of LV rotational deformation. LV torsion was calculated as the twist value (the net difference between apical counterclockwise and basal clockwise rotation) normalized to the length of the ventricle and multiplied by the mean radius at the base and apex. All patients had CMR studies before, 6 months and 1 year after successful BMV. At baseline, patients had a mitral valve area of 0.9 (0.6-1.3) cm2, mean pressure gradient of 12.5 (8-24) mmHg across the valve as measured by transthoracic echocardiography. Median LV ejection fraction (LVEF) estimated by CMR was 57 (range: 45-69) %. A significant improvement in LV base-apex torsion was shown at 6 months (3.3° vs. 2.5°, p < 0.001) with a further improvement at 1 year (4.1° vs. 3.3°, p = 0.05). Similar pattern of change was seen in LV base-mid torsion with a significant increase at 6 months (3.6° vs. 2.3°, p < 0.001) and a further increase at 1 year (4.7° vs. 3.6°, p = 0.007). These changes were associated with a significant increase in LVEF (62% vs. 57%, p < 0.001) at 1 year following BMV. Successful BMV is associated with a significant improvement in LV torsion that is accompanied by a significant improvement in LVEF.

Management of a huge right atrial thrombus in a patient with multiple comorbidities.

BACKGROUND: Floating right heart thrombi (RHT) represent an underdiagnosed, potentially hazardous, and to some extent rare phenomenon in patients presenting with acute pulmonary embolism (APE). Emergent treatment is usually required for such a condition. CASE PRESENTATION: A 19-year-old young lady presented with progressive shortness of breath, marked renal impairment, thrombocytopenia, and a highly oscillating huge right atrial mass. After she was admitted to the intensive care unit, she arrested in asystole and was resuscitated, and her electrocardiogram (ECG) showed evidence of acute anterior myocardial infarction. Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team as the best option of management. Surgery was emergently performed with extra-corporeal membrane oxygenator (ECMO) as a support. Following surgery, mechanical support and vasopressors were successfully weaned and the patient achieved a good recovery. CONCLUSIONS: A pulmonary embolism response team (PERT) approach should always be considered where a multidisciplinary team involving a cardiologist, radiologist, cardio-thoracic surgeon, radiologist, and intensivist shall determine the management strategy for a challenging presentation of a massive pulmonary embolism or floating right heart thrombi causing the hemodynamically unstable clinical condition.

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis.

Left main coronary artery (LMCA) disease is associated with increased morbidity and mortality. Coronary artery bypass grafting surgery (CABG) has always been the standard revascularization strategy for this group of patients. However, with the recent developments in stents design and medical therapy over the past decade, several trials have been designed to evaluate the safety and efficacy of percutaneous coronary intervention (PCI) as an alternative to CABG surgery in patients with LMCA disease. Recently, the results of two major trials, EXCEL and NOBLE, comparing CABG versus PCI in this patient population have been released. In fact, the results of both trials might appear contradictory at first glance. While the EXCEL trial showed that PCI was non-inferior to CABG surgery, the NOBLE trial suggested that CABG surgery is a better option. In the following review, we will discuss some of the similarities and contrasts between these two trials and conclude with lessons to be learned to our daily practice.

Veno-arterial Loop Aiding Mitral Valve Crossing for Balloon Mitral Valvuloplasty in a Patient With a Huge Left Atrium.

Veno-arterial loop is a feasible and safe technique to facilitate mitral valve crossing for balloon mitral valvuloplasty in mitral stenosis patients.