Echocardiographic Differentiation of Pericardial Constriction and Left Ventricular Restriction.

PURPOSE OF REVIEW: Overlapping hemodynamics in constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM) often pose difficulties in establishing accurate diagnosis. Echocardiography is the first-line imaging modality used for this purpose, but no single echocardiographic parameter is sufficiently robust for distinguishing between the two conditions. The newer developments may improve the diagnostic accuracy of echocardiography in this setting. RECENT FINDINGS: Recent studies have validated multiparametric algorithms, based on conventional echocardiographic parameters, which enable high sensitivity and specificity for distinguishing between CP and RCM. In addition, myocardial deformation analysis using speckle-tracking echocardiography has revealed distinct pattern of abnormalities in the two conditions. CP is characterized by impaired left ventricular apical rotation with relatively preserved longitudinal strain, esp. of ventricular and atrial septum. In contrast, RCM results in global and marked impairment of left ventricular longitudinal strain with initially preserved circumferential mechanics. Combining multiple echocardiographic parameters into step-wise algorithms and incorporation of myocardial deformation analysis help improve the diagnostic accuracy of echocardiography for distinguishing between CP and RCM. The use of machine-learning may allow easy integration of a wide range of echocardiographic and clinical parameters to permit accurate, automated diagnosis, with less dependence on the user expertise.

Radiation-Induced Pan-Valvular Involvement: A Rare Case Report.

Radiotherapy is an important treatment modality for various thoracic malignancies but is associated with long-term risk of radiation-associated valve disease (RAVD). We hereby report a case of a lady who had received radiotherapy 30 years back for carcinoma breast and was now found to be having clinically significant RAVD involving all the four cardiac valves. Simultaneous involvement of all the four valves in RAVD is extremely rare and has not been reported previously.

Left Ventricular Thrombus and Cardioembolic Stroke in a Patient with Ulcerative Colitis: A Case Report.

Left ventricular (LV) thrombi usually occur in the setting of global or regional LV systolic dysfunction and are extremely rare in the absence of LV wall motion abnormalities. We report here a case of a 23-year-old female who presented with cardioembolic stroke due to ulcerative colitis. To determine the cause of stroke, several investigations and evaluations were carried out, but the results were mostly normal or unremarkable. Transthoracic echocardiography revealed an oscillating pedunculated globular mass, which was eventually resected due to recurrent transient ischemic attacks. The histopathology of the excised mass revealed it to be an organized thrombus with acute and chronic inflammatory cells and fibroblasts. The uncommon etiology combined with the unusual appearance of the thrombus presented a major diagnostic and therapeutic dilemma for this exceedingly rare cause for intracardiac thrombus formation. Therefore, it would be useful to have a low threshold for screening patients with active inflammatory bowel disease for possible ventricular thrombosis before discharge, especially if other risk factors are present.

Normative values of cardiac chamber dimensions and global longitudinal strain in Indians: the Indian Normative Data of Echocardiography Analyzed (INDEA) study.

Ethnic-specific normal reference ranges for various echocardiographic measurements are essential for accurate diagnostic interpretation and clinical decision-making. Unfortunately, such normative data for Indians is lacking. A total of 880 healthy volunteers (mean age 39.7 ± 12.3 years, 63.8% men) from six centers across different regions of India were enrolled in this study. Comprehensive transthoracic echocardiographic study was performed in all subjects, in accordance with the existing guideline recommendations. Cardiac chamber dimensions [Left ventricular (LV) end-diastolic diameter and volume; right ventricular (RV) basal diameter, left atrial volume] were obtained and indexed to body surface area. LV ejection fraction, LV global longitudinal strain (LVGLS) and measures of RV systolic function were also obtained. The subjects were divided into 3 age groups (35 years or less, 36-55 years and 56 years or above) for analysis. Age- and gender-specific reference values for various clinically relevant echocardiographic parameters were derived. Compared with women, men had larger cardiac chamber dimensions and volumes, but not when indexed. In contrast, the women had higher LV systolic function, but right ventricular systolic function was not different. The indexed LV volumes in our study were much smaller than those recommended in the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) 2015 chamber quantification guidelines but were similar to those reported in the Indian patients included in the recent World Alliance Societies of Echocardiography (WASE) Normal Values Study. LVGLS was also comparable with the WASE data. INDEA study is the first, multi-centric study to provide normal echocardiographic references values for Indian adults. Our findings underscore the need to follow India-specific reference values, instead of those recommended by the ASE/EACVI, which are largely applicable to the western populations.

Aortic pulse wave velocity and its relationship with transaortic flow and gradients in patients with severe aortic stenosis undergoing aortic valve replacement.

BACKGROUND: Low-flow, low-gradient severe aortic stenosis (LFLGAS) is a common clinical entity and is associated with poor prognosis. Increased left ventricular (LV) afterload is one of the mechanisms contributing to low LV stroke volume index (SVi) in these patients. Aortic stiffness is an important determinant of LV afterload, but no previous study has evaluated its relationship with LVSVi in patients with AS. METHODS: Fifty-seven patients (mean age 66 ± 8 years, 71.9% men) with severe AS [aortic valve area (AVA) < 1.0 cm2] undergoing aortic valve replacement (AVR) were included in this study. Echocardiographic parameters of AS were correlated with carotid-femoral pulse wave velocity (cfPWV), a measure of aortic stiffness, derived using PeriScope® device. RESULTS: Mean AVA was 0.63 ± 0.17 cm2 with mean and peak transvalvular gradient 56.5 ± 18.8 mmHg and 83.2 ± 25.2 mmHg, respectively. Nearly half (26 of 57, 45.6%) of the subjects had SVi <35 mL/m2, indicative of low-flow severe AS. These subjects had lower AVA, lower aortic valve gradient, and LV ejection fraction. CfPWV was numerically lower in these subjects [median 1467 (interquartile range 978, 2259) vs 1588 (1106, 2167)] but the difference was not statistically significant (p = 0.66). However, when analyzed as a continuous variable, cfPWV had significant positive correlation with SVi (Pearson's r 0.268, p = 0.048) and mean aortic valve gradient (Pearson's r 0.274, p = 0.043). CONCLUSIONS: In patients with severe AS undergoing AVR, aortic stiffness measured using cfPWV is not a determinant of low-flow state. Instead, an increasing cfPWV tends to be associated with increasing transvalvular flow and gradient in these patients.

An unusual left ventricular outflow tract mass in a patient with systemic lupus erythematosus.

A 25-year-old female, with systemic lupus erythematosus and antiphospholipid antibody syndrome, presented with exertional dyspnoea. Echocardiography showed a large (2.0 cm × 1.1 cm), echogenic, heterogeneous mass in the left ventricular outflow tract, under the aortic valve, attached to the ventricular aspect of the anterior mitral leaflet. Tiny flagellar, frond-like structures were seen attached to the surface of the mass. There was mitral regurgitation. These echocardiographic features were suggestive of a papillary fibroelastoma, but the histopathology of the excised mass revealed it to be a thrombus, which was consistent with a diagnosis of non-bacterial thrombotic endocarditis (NBTE). This case represents a rare histopathologically confirmed NBTE presenting as an unusually large mass in the left ventricular outflow tract.

Myocardial fatigue in recreational marathon runners: A speckle-tracking echocardiography study.

BACKGROUND: Prolonged aerobic exercise such as marathon running produces supraphysiological hemodynamic stress that can potentially affect the athlete's cardiac homeostasis. While cardiac structural and functional adaptations in professional athletes are well characterized, only a limited information is available for recreational runners undergoing this supraphysiological stress. METHODS: Premarathon and post-marathon echocardiography was performed in 50 recreational marathon runners [age 40.8 ± 7.5 years, 44 (88%) males; running distance 42.195 km]. All the runners received 4-month training for the marathon. The baseline echocardiogram and N-terminal B-type natriuretic peptide (NT-proBNP) were obtained before training, whereas the post-marathon study was performed within 10 days (7.27 ± 0.92 days) of completion of marathon. Two-dimensional speckle-tracking echocardiography was used for characterizing the changes in myocardial mechanics. RESULTS: There was a significant reduction in heart rate post-marathon, whereas the levels of NT-proBNP increased significantly (86.0 ± 9.5 pg/ml vs 106.5 ± 24.2 pg/ml, p = 0.001). The left ventricular (LV) end-diastolic volume (61.8 ± 16.5 ml vs 72.8 ± 5.1 ml, p < 0.001), LV mass (120.2 ± 30.0 gm vs 160.3 ± 43.0 gm, p < 0.001), and LV ejection fraction (64.9 ± 5.6% vs 72.0 ± 5.7%, p < 0.001) also increased significantly. However, there was a significant attenuation in LV global longitudinal (-19.3 ± 2.71% vs -16.5 ± 4.6%, p = 0.003) and circumferential strain (-17.2 ± 2.41% vs -15.2 ± 2.6%, p = 0.001) post-marathon. The LV global radial strain showed a nonsignificant reduction. CONCLUSION: Recreational marathon runners have reduced longitudinal and circumferential shortening of the left ventricle with elevation of NT-proBNP. However, the LV ejection performance remains maintained because of an increase in the LV end-diastolic volume and mass. These changes suggest the possibility of "myocardial fatigue" occurring in response to supraphysiological hemodynamic stress of marathon running.

Quantification of coronary artery motion and internal risk volume from ECG gated radiotherapy planning scans.

BACKGROUND: Radiotherapy for carcinoma of breast and thoracic structures involves inadvertent radiation to heart and coronary arteries (CA). Coronary artery stenosis in high radiation dose segments has been documented. Cardiac and respiratory motion induced displacement of CA and internal risk volume (IRV) margin remains inadequately quantified. MATERIAL AND METHODS: Twenty cases of carcinoma breast, lung and lung metastasis were enrolled in this study. ECG gated intravenous contrast enhanced computed tomography (CECT) scans were performed in inspiratory breath hold (IBH) and expiratory breath hold (EBH). The images were segregated into inspiratory systole (IS), inspiratory diastole (ID), expiratory systole (ES) and expiratory diastole (ED) sets. Left anterior descending (LAD), limited segment of LAD close to chest wall (short LAD), right coronary artery (RCA), Left circumflex artery (LCX) and left ventricle (LV) were delineated in all four sets. Mean displacements in systole versus diastole and inspiration versus expiration were calculated in three co-ordinates [anterio-posterior (Z), left-right (X) and cranio-caudal (Y)]. RESULTS: Mean of displacement (mm) between systole and diastole (IS versus ID; and ES versus ED) in X, Y, Z co-ordinates were: LAD 3.0(±1.6), 2.8(±1.5), 3.6(±2.0); Short-LAD 3.0(±1.1), 0.8(±0.4), 2.4(±0.6); LV 2.4(±1.6), 1.7(±1), 5.0(±1.5); LCX 4.9(±1.6), 2.9(±1.3), 5.1(±1.9); RCA 6.6(±2.2), 3.6(±2.1), 5.9(±2.2). Mean displacement between inspiration and expiration (IS versus ES; and ID versus ED) in X, Y, Z axes were: LAD 3.3(±1.5), 8.0(±3.4), 3.8(±1.8); Short-LAD 2.7(±1), 12.2(±4.4), 3.3(±1.5); LV 2.9(±1.4), 9.8(±3.3), 4.7(±1.9); LCX 2.9(±.8), 9.7(±3.2), 6.2(±2.5); RCA 2.6(±1.3), 7.6(±2.5), 3.8(±1.7). CONCLUSION: Radial (RM), cranio-caudal margin (CC) of 7mm, 4mm in breath-hold radiotherapy whereas RM, CC of 7mm, 13mm respectively in free breath radiotherapy will cover the range of motions of CA, LV and can be recommended as IRV for these structures.