Re-emphasising the importance of histopathological diagnosis in suspected bacterial endocarditis.

Infective endocarditis (IE) carries a high risk of morbidity and mortality. Timely diagnosis, effective treatment and prompt recognition of complications are essential to favourable patient outcomes. A collaborative, multidisciplinary team approach to the management of IE has been shown to improve prognosis. However, the clinical heterogeneity of IE and atypical presentations pose challenges to the endocarditis team. We present a case highlighting the role of valve histopathology in suspected IE, where there may be diagnostic uncertainty.

Can TAVR Be Effectively and Safely Performed Without Intraprocedural TEE?

PURPOSE OF REVIEW: The TAVR procedure is a well-established therapy for patients with severe aortic stenosis at intermediate/high risk for surgery and a potential treatment for low-risk patients. It is much less invasive with short hospital stays and presents similar results compared with SAVR. Different "minimalist approach strategies" were proposed in order to obtain this performance. In these settings, transesophageal echocardiography (TEE) became less relevant for the TAVR procedure. The present review provides an update regarding the safety of TAVR without intraprocedural TEE. RECENT FINDINGS: Transthoracic echocardiography and fluoroscopy are the primary imaging tools during TAVR. Several studies proved that TAVR under local anesthesia without TEE is as safe as that performed under TEE guidance. However, not all patients have a proper window for TTE, and particular cases with complex anatomy can benefit from TEE support during the intervention. Intraprocedural TEE no longer plays a crucial role in the TAVR procedure, but in some instances, it remains of great help to detect and avoid complications.

Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland.

BACKGROUND: Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. METHODS: All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. RESULTS: Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002). CONCLUSION: Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

Percutaneous closure of postinfarction ventricular septal defect: in-hospital outcomes and long-term follow-up of UK experience.

BACKGROUND: Postinfarction ventricular septal defect carries a grim prognosis. Surgical repair offers reasonable outcomes in patients who survive a healing phase. Percutaneous device implantation represents a potentially attractive early alternative. METHODS AND RESULTS: Postinfarction ventricular septal defect closure was attempted in 53 patients from 11 centers (1997-2012; aged 72±11 years; 42% female). Nineteen percent had previous surgical closure. Myocardial infarction was anterior (66%) or inferior (34%). Time from myocardial infarction to closure procedure was 13 (first and third quartiles, 5-54) days. Devices were successfully implanted in 89% of patients. Major immediate complications included procedural death (3.8%) and emergency cardiac surgery (7.5%). Immediate shunt reduction was graded as complete (23%), partial (62%), or none (15%). Median length of stay after the procedure was 5.0 (2.0-9.0) days. Fifty-eight percent survived to discharge and were followed up for 395 (63-1522) days, during which time 4 additional patients died (7.5%). Factors associated with death after postinfarction ventricular septal defect closure included the following: age (hazard ratio [HR]=1.04; P=0.039), female sex (HR=2.33; P=0.043), New York Heart Association class IV (HR=4.42; P=0.002), cardiogenic shock (HR=3.75; P=0.003), creatinine (HR=1.007; P=0.003), defect size (HR=1.09; P=0.026), inotropes (HR=4.18; P=0.005), and absence of revascularization therapy for presenting myocardial infarction (HR=3.28; P=0.009). Prior surgical closure (HR=0.12; P=0.040) and immediate shunt reduction (HR=0.49; P=0.037) were associated with survival. CONCLUSIONS: Percutaneous closure of postinfarction ventricular septal defect is a reasonably effective treatment for these extremely high-risk patients. Mortality remains high, but patients who survive to discharge do well in the longer term.

Utility of speckle tracking echocardiography to characterize dysfunctional myocardium in patients with ischemic cardiomyopathy referred for cardiac resynchronization therapy.

BACKGROUND: Assessment of transmural scar at the site of latest mechanical activation is relevant to maximize outcomes in cardiac resynchronization therapy (CRT). Few studies have assessed the ability of speckle tracking echocardiography (STE)-derived short-axis strain to identify segmental myocardial scar, defined by contrast-enhanced cardiac magnetic resonance imaging (CMR), in patients referred for CRT. METHODS: A total of 26 patients with ischemic cardiomyopathy who underwent preprocedure echocardiography and CMR were studied. Extent of transmural scar was assessed using contrast-enhanced CMR and corresponding peak segmental radial and circumferential strains were derived using two-dimensional (2D) STE. Total left ventricle (LV) scar volume was compared with parameters of global strain. CRT response was defined as >15% reduction in LV end systolic volume (LVESV) at 6 months. RESULTS: Speckle tracking short-axis strain analysis was technically possible in over 90% of LV segments. Applying a segmental radial strain cutoff value of 10% distinguished segments with >50% scar area with a high negative predictive value (98%). Global longitudinal strain <-5% predicted CRT response. CONCLUSIONS: Two-dimensional STE offers potential to characterize dysfunctional myocardium and define segmental scar offering an integrated imaging approach to guide LV lead placement for CRT.

Contrast echocardiography: a practical guideline from the British Society of Echocardiography.

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

The pivotal role of echocardiography in cardiac sources of embolism.

Stroke is a leading cause of morbidity and mortality and is the third commonest cause of death in Europe. Clinical history examination and basic investigations including an electrocardiogram may shed light on the potential cardiac cause. Echocardiography plays a pivotal role in the assessment of embolic stroke. The hierarchy of echocardiography investigations begins with a standard transthoracic echocardiography study and may be proceeded by a bubble contrast transthoracic and a transoesophageal echo study. This article discusses the crucial role echocardiography has assumed in the assessment of stroke patients and describes the cardiac sources responsible.

Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography.

The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.

Restricted Use of Echocardiography in Suspected Endocarditis during COVID-19 Lockdown: A Multidisciplinary Team Approach.

BACKGROUND: Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes. METHODS: All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study. RESULTS: In total, 38 patients were referred for ET review (71% male, median age 54 [interquartile range 48, 65.5] years). At the time of ET discussion, 21% had no echo imaging, 16% had point-of-care ultrasound only, and 63% had formal TTE. In total, only 16% underwent TOE. The ability of echocardiography, in those where it was performed, to affect IE diagnosis according to the Modified Duke Criteria was significant (p=0.0099); however, sensitivity was not affected. All-cause mortality was 17% at 30 days and 25% at 12 months from ET discussion in those with confirmed IE. CONCLUSION: Limiting echocardiography in patients with a low pretest probability (not probable or definite IE according to the Modified Duke Criteria) did not affect the diagnostic ability of the Modified Duke Criteria to rule out IE in this small study. Moreover, restricting nonessential echocardiography, and importantly TOE, in patients with suspected IE through use of the ET did not impact all-cause mortality.

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology.

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

Anatomy of the mitral valve: understanding the mitral valve complex in mitral regurgitation.

Imaging the mitral valve requires an understanding of the normal anatomy and how this complex structure is altered by disease states. Mitral regurgitation is increasingly prevalent. Despite the fall in rheumatic disease, it is the second most common valvular lesion seen in adults in Europe. In this review, the morphology of the normal and abnormal valve is reconsidered in relation to the key structures, with a view to aiding the reader in understanding how this might relate to echocardiographic identification of abnormalities.

Three-dimensional imaging of the atrial septum and patent foramen ovale anatomy: defining the morphological phenotypes of patent foramen ovale.

Patent foramen ovale (PFO) is known to occur with greater prevalence in those with cryptogenic stroke. These observations support the role of a PFO as a channel for paradoxical embolism and a mechanism for cerebral ischaemic events. Transcatheter closure of PFO may be indicated in this setting. A prerequisite of procedural success is achieving complete closure of the shunt. Studies have shown a varying degree of successful shunt closure. Residual shunts are usually the result of a mismatch between the device shape and PFO anatomy. In this article, we review the features of PFO and their surrounding structures as seen by three-dimensional transoesophageal echocardiography in patients undergoing transcatheter closure and relate these to the variations in morphology on anatomical specimens for a better appreciation of their suitability for closure devices. The salient features of the anatomical variations seen in adults undergoing transcatheter device closure have been summarized and used to produce a practical pre-procedural checklist.

Author Correction: Percutaneous management of paravalvular leaks.

In the version of this article initially published online, the Paravalvular Leak Device (PLD; Occlutech) was incorrectly described as having a "proximal disc that is slightly larger than the distal disc", whereas the distal disc is actually slightly larger than the proximal disc. This error has been corrected for the HTML, PDF and print versions of the article.

Percutaneous management of paravalvular leaks.

Paravalvular leak (PVL) is a complication that occurs in 5-17% of patients after surgical prosthetic valve implantation. Whereas PVLs can be benign, some PVLs are associated with substantial morbidity and mortality. Percutaneous closure using occluders specifically designed to improve closure and reduce procedural complications has now become the first-line treatment for PVL. In this Review, we first detail the frequency and clinical consequences of PVL closure. The role of cardiac imaging in the assessment and management of PVL, including echocardiographic imaging and adjunctive techniques such as CT, is then discussed, together with important considerations for the percutaneous closure of PVL, such as access site and device selection. Finally, we summarize the clinical evidence for percutaneous closure of PVL, including large national registries from Ireland, Spain and the UK, as well as head-to-head data comparing this procedure with surgical closure.

Patent Foramen Ovale Closure in 2019.

Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people it is a benign finding; however, in some the PFO can open widely, enabling a paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised controlled trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this review considers the evidence for PFO closure in cryptogenic stroke. The review also addresses other potential indications for closure, including systemic embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. It lays out the pre-procedural investigations and preparation for the procedure. Finally, it gives an overview of the procedure itself, including discussion of closure devices.

Antithrombotic Therapy and Device-Related Thrombosis Following Endovascular Left Atrial Appendage Closure.

OBJECTIVES: The aim of this study is to review the evidence on the use of antithrombotic therapy and risk of device-related thrombosis after left atrial appendage closure. BACKGROUND: Left atrial appendage closure (LAAC) is increasingly performed for stroke prevention in patients with nonvalvular atrial fibrillation, especially those who cannot tolerate or are ineligible for oral anticoagulation. METHODS: After device implantation for LAAC, different antithrombotic regimens with varying duration of therapy are currently used. Such selection depends on patients' risk for bleeding and physicians' choice. RESULTS: Device-related thrombosis remains an Achilles' heel of LAAC, and the etiology remains incompletely understood. Dual-antiplatelet therapy, and direct oral anticoagulation may have similar safety and device-related thrombosis occurrence in real-world LAAC registries compared with warfarin and aspirin. Device imaging surveillance should be routinely performed to assess for device-related thrombosis, which if diagnosed should be treated aggressively, as it is associated with higher thromboembolic risks. CONCLUSIONS: Given the uncertainties and therapeutic dilemma, the authors provide an in-depth discussion of the options and rationale for antithrombotic therapy post-LAAC.

Tricuspid regurgitation and the right ventricle in risk stratification and timing of intervention.

Tricuspid regurgitation natural history and treatment remains poorly understood. Right ventricular function is a key factor in determining prognosis, timing for intervention and longer-term outcome. The right ventricle is a thin walled chamber with a predominance of longitudinal fibres and a shared ventricular septum. In health, the low-pressure pulmonary circulation results in a highly compliant RV well equipped to respond to changes in preload but sensitive to even small alterations in afterload. In Part 1 of this article, discussion focuses on key principles of ventricular function assessment and the importance of right ventricular chamber size, volumes and ejection fraction, particularly in risk stratification in tricuspid regurgitation. Part 2 of this article provides an understanding of the causes of tricuspid regurgitation in the contemporary era, with emphasis on key patient groups and their management.

Echocardiography guidance of atrial septal defect closure.

Transcatheter procedures offer less invasive approaches allowing rapid recovery and earlier hospital discharge. A number of international guidelines have defined the role of echocardiography spanning diagnosis, detailed anatomical assessment, device sizing and selection, peri-procedure guidance and post device surveillance. This review discusses the role of echocardiography in transcatheter atrial septal defect (ASD) closure. It describes a systematic approach to assessment including the crucial role of three dimensional echo and provides the reader with key information required during device sizing and procedure guidance.

Left Atrial Function Is Associated with Earlier Need for Cardiac Surgery in Moderate to Severe Mitral Regurgitation: Usefulness in Targeting for Early Surgery.

BACKGROUND: The aim of this study was to determine whether assessment of left atrial (LA) function helps identify patients at risk for early deterioration during follow-up with mitral valve prolapse and mitral regurgitation. METHODS: Patients with moderate to severe mitral regurgitation but no guideline-based indications for surgery were retrospectively identified from a dedicated clinical database. Maximal and minimal LA volumes were used to derive total LA emptying fraction ([maximal LA volume - minimal LA volume]/maximal L volume × 100%). Average values of peak contractile, conduit, and reservoir strain were obtained using two-dimensional speckle-tracking imaging. The study outcome was time to mitral surgery. RESULTS: One hundred seventeen patients were included; median follow-up was 18 months. Sixty-eight patients underwent surgery. Receiver operating characteristic curves were used to derive optimal cutoffs for TLAEF (>50.7%) and strain (reservoir, >28.5%; contractile, >12.5%). Using Cox analysis, TLAEF and contractile, reservoir, and conduit strain were univariate predictors of time to event. After multivariate analysis, TLAEF (hazard ratio, 2.59; P = .001), reservoir strain (hazard ratio, 3.06; P < .001), and contractile strain (hazard ratio, 2.01; P = .022) remained independently associated with events, but conduit strain did not. Using Kaplan-Meier curves, event-free survival was considerably improved in patients with values above the derived thresholds (TLAEF: 1-year survival, 78 ± 5% vs 28 ± 8%; 3-year survival, 68 ± 6% vs 13 ± 5%; P < .001 for both; reservoir strain: 1-year survival, 79 ± 5% vs 29 ± 7%; 3-year survival, 67 ± 6% vs 15 ± 6%; P < .001 for both; contractile strain: 1-year survival, 80 ± 5% vs 41 ± 7%; 3-year survival, 69 ± 6% vs 24 ± 6%; P < .001 for both). CONCLUSION: LA function is independently associated with surgery-free survival in patients with mitral valve prolapse and moderate to severe mitral regurgitation. Quantitative assessment of LA function may have clinical utility in guiding early surgical intervention in these patients.