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   Table of Contents - Current issue
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April-June 2020
Volume 30 | Issue 2
Page Nos. 49-123

Online since Tuesday, August 18, 2020

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EDITORIAL  

In memory of antonio pezzano, master and friend Highly accessed article p. 49
Giuseppe Gullace
DOI:10.4103/jcecho.jcecho_89_20  
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ORIGINAL ARTICLES Top

Discordant echocardiographic grading in low gradient aortic stenosis (DEGAS study) from the Italian society of echocardiography and cardiovascular imaging research network: Rationale and study design Highly accessed article p. 52
Andrea Barbieri, Francesco Antonini-Canterin, Mauro Pepi, Ines Paola Monte, Giuseppe Trocino, Agata Barchitta, Quirino Ciampi, Alberto Cresti, Sofia Miceli, Licia Petrella, Frank Benedetto, Concetta Zito, Giovanni Benfari, Francesca Bursi, Alessandro Malagoli, Ylenia Bartolacelli, Francesca Mantovani, Marie-Annick Clavel
DOI:10.4103/jcecho.jcecho_68_20  
Background: Low-gradient aortic stenosis (LG-AS) is characterized by the combination of an aortic valve area compatible with severe stenosis and a low transvalvular mean gradient with low-flow state (i.e., indexed stroke volume <35 mL/m2) in the presence of reduced (classical low-flow AS) or preserved (paradoxical low-flow AS) ejection fraction. Furthermore, the occurrence of a normal-flow LG-AS is still advocated by many authors. Within this diagnostic complexity, the diagnosis of severe AS remains challenging. Objective: The general objective of the Discordant Echocardiographic Grading in Low-gradient AS (DEGAS Study) study will be to assess the prevalence of true severe AS in this population and validate new parameters to improve the assessment and the clinical decision-making in patients with LG-AS. Methods and Analyses: The DEGAS Study of the Italian Society of Echocardiography and Cardiovascular Imaging is a prospective, multicenter, observational diagnostic study that will enroll consecutively adult patients with LG-AS over 2 years. AS severity will be ideally confirmed by a multimodality approach, but only the quantification of calcium score by multidetector computed tomography will be mandatory. The primary clinical outcome variable will be 12-month all-cause mortality. The secondary outcome variables will be (i) 30-day mortality (for patients treated by Surgical aortic valve replacement or TAVR); (ii) 12-month cardiovascular mortality; (iii) 12-month new major cardiovascular events such as myocardial infarction, stroke, vascular complications, and rehospitalization for heart failure; and (iv) composite endpoint of cardiovascular mortality and hospitalization for heart failure. Data collection will take place through a web platform (REDCap), absolutely secure based on current standards concerning the ethical requirements and data integrity.
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The Relationship between Tumor Necrosis Factor Alpha and Left Ventricular Diastolic Function p. 62
Ahmed Mohamed El Missiri, Anwer S Alzurfi, Viola W Keddeas
DOI:10.4103/jcecho.jcecho_1_20  
Introduction: Left ventricular (LV) diastolic dysfunction is a common condition. Tumor necrosis factor (TNF) alpha is an inflammatory cytokine that plays a role in the development of cardiac structural changes leading to LV diastolic dysfunction. The aim of this study was to examine the relationship between serum levels of TNF alpha levels and LV diastolic function. Methods: A case–control study that included 40 patients with echocardiographic evidence of LV diastolic dysfunction and 40 healthy controls. Standard transthoracic echocardiography was performed to assess LV and left atrial volumes, systolic and diastolic function according to the current recommendations. Serum TNF alpha levels were assessed using a specific enzyme-linked immunosorbent assay kit. Results: Mean serum TNF alpha level was significantly higher in the study group 3.48 ± 1.06 versus 1.22 ± 0.36 pg/ml in the control group,P < 0.001. It was also higher in patients with Grade 2 diastolic dysfunction (n = 16) 3.91 ± 1.21 versus 3.18 ± 0.86 pg/ml in those with Grade 1 diastolic dysfunction (n = 24), P = 0.03. TNF alpha showed a strong correlation with indexed left atrial volume (LAVI) in the study group but not in controls. Mean serum TNF showed a trend toward increase with worsening heart failure symptoms in the form of increased the New York Heart Association functional class. Conclusion: Serum TNF alpha level is elevated in patients with LV diastolic dysfunction and is correlated to LAVI in such patients. Patients with Grade 2 diastolic dysfunction have higher serum levels of TNF alpha compared to those with Grade 1 diastolic dysfunction. TNF alpha levels increase with worsening heart failure symptoms.
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QRS duration as a predictor of left ventricular outflow tract velocity time integral in patient with cardiac resynchronization therapy p. 68
Maha Mohamed Mohamed Khalifa, Ahmed Said, Ayman Mortada, Hassan Shehata
DOI:10.4103/jcecho.jcecho_66_19  
Background: Cardiac resynchronization therapy (CRT) has a morbidity and mortality benefits in moderate to severe heart failure. It reduces mortality and hospitalization and improves cardiac function. It can be used according to the European guidelines in severely depressed left ventricular ejection fraction (i.e., ≤35%) and complete left bundle branch block. However, 30% of patients may show no benefit from CRT therapy. Therefore, prediction of CRT response seems to be an important subject for study in the current researches. We aimed to study the correlation between Surface ECG QRS complex duration (QRS) duration and cardiac output measured by ventricular outflow tract velocity time integral (LVOT VTI) as a predictor of response in patients with CRT implantation. Methods: We studied 100 consecutive patients prospectively with biventricular pacing system. The patients were studied at the pacemaker follow-up clinic. Each patient was subjected to: Full medical history, general and local examination, a 12 lead electrocardiogram and QRS duration in ms was measured. All patients were subjected to a focused transthoracic echocardiographic examination in which a parasternal long axis view was obtained to measure the diameter of the LVOT diameter in mid-systole. The LVOT VTI was measured by pulsed-wave Doppler in the LVOT using a 2-mm sample volume positioned just proximal to the aortic valve in the apical five chamber view. Results: We found a statistically significant difference between CRT responders and nonresponders as regards age, body surface area (BSA), time since CRT implantation and smoking status (P = 0.018, 0.039, 0.002, <0.001). There was negative significant correlation between QRS duration and LVOT VTI and stroke volume index. The optimal cut off values for optimal response to CRT using receiver operating characteristics curves were 130 ms for postimplant QRS duration and 17.1 cm for LVOT VTI. We also found a significant difference between responders and nonresponders as regard CO. It was higher in responders (5.97 vs. 3.34,P < 0.001). Conclusion: CRT response is more in patients with lower BSA, and without previous history of ischemic heart disease or smoking. There is a significant negative correlation between QRS duration and LVOT VTI.
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Effect of obesity on pulmonary vascular hemodynamics p. 75
Mustafa Duran, Murat Ziyrek
DOI:10.4103/jcecho.jcecho_70_19  
Context: Obesity-related pulmonary arterial hypertension (PAH) is associated with hypoxia and metabolic abnormalities. Although right heart catheterization is the gold standard method for the diagnosis of PAH, Doppler echocardiography is more common. On the other hand, there is no definite echocardiographic parameter for PAH diagnosis. Novel echocardiographic parameter, pulmonary pulse transit time (pPTT), is assumed to be a surrogate marker for the assessment of PAH. Aims: The aim was to evaluate whether pPTT might be valuable for evaluating pulmonary vascular hemodynamics in obese patients. Settings and Design: A cross-sectional observational study. Methods: A total of 130 consecutive obese patients and 50 controls were included. Obese patients were divided into three groups according to body mass index (BMI): 25 < BMI <30 kg/m2 formed Group 1, 30 < BMI <35 kg/m2 formed Group 2, and 35 2 formed Group 3. All patients underwent a standard echocardiography including pPTT measurement. pPTT was defined as the interval between R-wave in the electrocardiography and the corresponding peak late systolic pulmonary vein flow velocity measured by pulse wave-Doppler in the pulmonary vein. Statistical Analysis Used: Intergroup differences were analyzed with analysis of variance or Kruskal–Wallis test. Pearson's or Spearman's correlation analysis was used for correlation, multivariate logistic regression analysis, and regression. Results: Statistically significant reduction in pPTT was detected as early as in the first group (361.24 ± 25.54 vs. 391.26 ± 15.07; P = 0.015) and continued throughout Groups 2 and 3 (299.92 ± 35.10 vs. 391.26 ± 15.07;P < 0.0001, and 245.46 ± 11.25 vs. 391.26 ± 15.07;P < 0.0001, respectively). There was a strong negative correlation between pPTT and BMI (r = −0.848, P = 0.001). On linear regression analysis, BMI was found to be an independent risk factor for pPTT (confidence interval: −9.164–6.379, β = −0.525, P = 0.0001). Conclusion: The results of this study suggest that obesity leads to an increase in PAH, and pPTT allows noninvasive determination of the pulmonary hemodynamics in obese patients. pPTT might be a useful parameter in terms of predicting pulmonary hemodynamics and vascular alterations in obese patients. Further studies are warranted to evaluate the association between obesity and PAH.
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A pilot study to predict future cardiovascular events by novel four-dimensional echocardiography global area strain in ST-elevation myocardial infarction patients managed by primary percutaneous coronary intervention p. 82
Yasmin Abdelrazek Ali, Ahmed Mohammed Alashry, Maged Tawfik Saad, Walaa Adel, Azza Abdallah El Fiky
DOI:10.4103/jcecho.jcecho_68_1  
Context: Four-dimensional speckle-tracking echocardiography (4D-STE) is ideal to accurately assess myocardial deformation. The novel 4D global area strain (GAS) uses global longitudinal and global circumferential strains (GCSs) to detect subtle changes in myocardium. Aims: The aim of this study was to determine the predictive value of 4D strain echocardiography for major adverse cardiovascular events (MACEs) in ST-elevation acute myocardial infarction (STEMI) patients after successful reperfusion by primary percutaneous coronary intervention (PCI). Settings and Design: This was a longitudinal study at a single center. Patients and Methods: We enrolled 170 patients who underwent successful primary PCI. Each patient was evaluated with 2D echocardiography and 4D echocardiography with 4D strain parameters and followed up over a year for the occurrence of MACE. Statistical Analysis Used: Chi-square test, independent t-tests, and multivariate logistic regression analysis were used. Results: Over 1 year of follow-up, 32 MACE were recorded. Patients with MACE were more likely to have had percutaneous transluminal coronary angioplasty done during the index primary PCI intervention, multivessel coronary artery disease, higher left ventricular end-diastolic and end-systolic dimensions (left ventricle end diastolic dimension (LVEDD) andleft ventricle end systolic dimension (LVESD), respectively), lower 2D left ventricular ejection fraction (LVEF), higher wall motion score index, higher baseline heart rate, higher end-diastolic and end-systolic volumes, lower 3D-LVEF, higher 4D global longitudinal strain, 4D-GCS, 4D-GAS, and lower 4D global radial strain (4D-GRS) (P < 0.005 for all parameters). The most powerful predictor for MACE among our study population is 4D-GAS, with the best cutoff value of 4D-GAS >−17 (P = 0.008; odds ratio = 20.668; confidence interval = 2.227–191.827). Conclusions: The novel 4D-GAS echocardiography predicts adverse clinical events in STEMI patients managed by successful primary PCI.
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Does aortic valve calcium score still predict death, cardiovascular outcomes, and conductive disturbances after transcatheter aortic valve replacement with new-generation prostheses? p. 88
Alexandre Gamet, Adeline Chatelin, Jean Mergy, Pauline Bécat, Pierre Roumegou, Luc Christiaens
DOI:10.4103/jcecho.jcecho_9_20  
Background: The development of transcatheter aortic valve replacement (TAVR) has led to an improvement in morbidity–mortality in the treatment of severe aortic stenosis in patients at high surgical risk. However, the procedure is not free from life-threatening cardiovascular outcomes and conductive disturbances. The objective of our study was to analyze the prognostic impact of aortic valve calcium score on the occurrence of complications following the procedure. Materials and Methods: Patients who have benefited from TAVR with the implantation of new-generation Sapien 3 and Evolut R aortic valve prostheses between January 2017 and July 2018 with the prior realization of a cardiac computed tomography with measurement of the aortic valve calcium score were retrospectively analyzed. Primary endpoint was a composite of death, stroke, and myocardial infarction within a period of 1 month after TAVR. Relation between valvular calcium and conductive disturbances was secondarily analyzed over the same period, and occurrences of high-degree atrioventricular block (paroxysmal or permanent), new-onset left bundle branch block, and the need for permanent or transient cardiac stimulation were associated with the secondary endpoint. Results: Overall, 144 patients were included. The aortic valve calcium score was not significantly higher in patients who reached the primary endpoint (2936 ± 1235 vs. 3051 ± 1440, P = 0.93). Among the 106 patients analyzed after excluding subjects with a prior pacemaker or left bundle branch block, aortic valvular calcium score was not statistically associated with the occurrence of conduction disturbances (3210 ± 1436 vs. 2948 ± 1223, P = 0.31). Conclusion: Our results suggest that the measurement of aortic valve calcium score has no prognostic value regarding mortality, cardiovascular events, or conductive disturbances after TAVR using the new generation of valves.
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Predictors of spontaneous echo contrast in left heart chambers in patients with dilated cardiomyopathy: Slowing down might not always mean enjoying life p. 93
Aurora Bakalli, Ljubica Georgievska-Ismail, Xhevdet Krasniqi, Basri Sejdiu, Tefik Bekteshi, Adem Grbolar, Shemsedin Sadiku
DOI:10.4103/jcecho.jcecho_18_20  
Introduction: Spontaneous echo contrast(SEC) is usually detected in heart chambers as a result of reduced flow velocity in the cavity. The clinical importance of SEC lies in its association with embolic events. The aim of our study was to determine the frequency of SEC in left heart chambers in sinus rhythm patients with dilated cardiomyopathy and predictors for its emergence. Materials and Methods: This was a prospective cross-sectional transesophageal echocardiography study conducted in 101 sinus rhythm patients with dilated heart and mild-to-moderate systolic dysfunction. Results: Moderate-degree SEC was found in the left ventricle(LV) in around 9% of patients, in the left atrium(LA) in 12% and in left atrial appendage(LAA) in 40%. Multiple regression analysis showed that lower heart rate(95% confidence interval[CI]: 0.845–0.978; P = 0.011) and larger LV end-systolic diameter(LVESD)(95% CI: 1.034–1.394; P = 0.017) were independent predictors for LV SEC presence. Lower LV ejection fraction(LVEF) (95% CI: [−0.079]–[−0.037]; P = 0.0001) was the only independent predictor for SEC in the LA. Whereas, independent predictors for SEC in LAA were lower heart rate(95% CI:[−0.030]–[−0.003]; P = 0.018), greater LA indexed diameter (95% CI: 0.016–0.116; P = 0.010), and higher value of C-reactive protein(CRP)(95% CI: 0.0026–0.031; P = 0.027). Conclusions: SEC in left heart chambers is a frequent finding in patients with dilated cardiomyopathy in sinus rhythm. Lower heart rate and LVEF, larger LVESD and LA, as well as higher CRP, predict the presence of SEC in left heart chambers. Lower heart rate might be an essential predictor for SEC presence and severity in these patients.
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CASE REPORTS Top

Right atrial myxoma with coexistent coronary artery disease – A rare combination p. 100
Ashok Garg, Deepak Agrawal, GL Sharma
DOI:10.4103/jcecho.jcecho_73_19  
Atrial myxomas are the most common primary heart tumors. Two-dimensional echocardiography is the diagnostic procedure of choice. The majority of myxomas are located in the left atrium. Myxoma in the right atrium is an uncommon location. The co-occurrence of right atrial myxoma with atherosclerotic coronary artery disease (CAD) is uncommon. In our case, right atrial myxoma was associated with CAD, which makes it a unique case because very few cases of right atrial myxoma coexistent with CAD are described in literature.
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Two barricades in a row mixed lesion of dynamic left ventricular outflow tract obstruction and aortic stenosis: Finding the culprit for decision making p. 104
Bayushi Eka Putra, Renan Sukmawan, Rina Ariani, Amiliana M Soesanto, Ario Soeryo Kuncoro
DOI:10.4103/jcecho.jcecho_58_19  
Concurrent lesions of dynamic left ventricular outflow tract obstruction (DLVOTO) with aortic stenosis pose a challenge in the measurement of the pressure gradient and severity of each lesion. Determining the true culprit lesion is difficult and challenging. The establishment of true culprit lesion is crucial in deciding the future course of action. We present two cases of concurrent DLVOTO and aortic stenosis. Although the composition of lesions is similar, the severity of each lesion was different and described a variety of technical problems. Finding the culprit through the shape of the stenotic jet from the continuous wave Doppler as well as other different technical approaches is the critical point of this case report. The first patient showed nonsignificant DLVOTO with severe aortic stenosis in which transthoracic echocardiography (TTE) alone was sufficient to find the culprit. Meanwhile, the second patient concluded to have significant DLVOTO with moderate aortic stenosis based on TTE and transesophageal echocardiography examination data. Jet morphology from Doppler examination is a crucial finding to differentiate DLVOTO with aortic stenosis, along with other parameters that might help find the dominant lesion. Multiple modalities with several tailor-made technical considerations might be needed to establish a culprit lesion.
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Pulmonary embolism in COVID-19 pneumonia: An overlapping diagnosis or a misdiagnosis? p. 110
Eleonora Secco, Maria Cristina Pasqualetto, Fausto Rigo
DOI:10.4103/jcecho.jcecho_43_20  
Coronavirus pneumonia (COVID-19) is a novel infectious disease with a high mortality rate due to severe acute respiratory syndrome. A 57-year-old woman was admitted to the emergency department (ED) with fever, cough, atypical chest pain, and dyspnea. She remained in the ED for about 48 h while waiting for the result of the COVID-19 oropharyngeal swab. Once she tested positive, she was hospitalized in the pneumological department with a diagnosis of pneumonia based on a chest X-ray and biochemical tests. Although azithromycin and hydroxychloroquine were promptly administered, she had a worsening of dyspnea even with a high-flow oxygen mask. D-dimer was increased, and a computed tomography scan with pulmonary and leg angiogram was positive for bilateral pulmonary embolism, deep-venous thrombosis, and multiple consolidated opacities in the lung parenchyma. This case highlights the fact that, in a pandemic situation, there is a potentially fatal risk of overlooking an alternative diagnosis in a COVID-19 patient who is generally considered as suffering only from pneumonia.
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The importance of ultrasound in a case of stroke caused by left atrial myxoma p. 113
Vincenzo Francesco Tripodi, Carmelo Massimiliano Rao, Angelo Covino, Pasquale Fratto, Frank Antonio Benedetto
DOI:10.4103/jcecho.jcecho_51_20  
Myxoma is one of the most common cardiac tumors. It is relatively straightforward to diagnose by echocardiography. Sometimes, It can causes cardiac syncope and thromboembolic events. A woman without comorbidities was admitted to our hospital with stroke symptoms: left-sided hemiplegia and dysarthria. After brain computed tomography (CT) and angio-CT value, she was initially treated with pharmacological thrombolysis. Due to persisting symptoms, cerebral angiography and thrombectomy were then performed. At the end of this procedure, the patient had a complete neurological recovery, but she developed new symptoms, such as dyspnea and orthopnea. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Therefore, an urgent cardiac surgery was performed in order to remove the mass. Histological examination confirmed cardiac myxoma. Our experience could show the importance of echocardiography to early diagnosis.
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A 26-year-old woman with worsening dyspnea: Look closer, think critically p. 116
Yavuzer Koza, Oguzhan Birdal, Berhan Pirimoglu, Hakan Tas
DOI:10.4103/jcecho.jcecho_24_20  
Pulmonary hypertension due to congenital heart disease continues to be a diagnostic challenge despite modern diagnostic modalities. Herein, we report a 26-year-old woman with an incidentally documented patent ductus arteriosus and Eisenmenger syndrome. She presented with progressive dyspnea and exercise intolerance which was initially attributed to pulmonary embolus. She was started on macitentan and tadalafil therapy aiming to reduce the pulmonary vascular resistance with consideration for heart–lung transplantation should any further deterioration occur.
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Multimodality imaging for diagnosis and characterization of a cardiac hydatid cyst p. 119
Giovanni Maria de Matteis, Luca Arcari, Marina Mustilli, Priscilla Fina, Angela Maria Stingone, Paolo Preziosi, Giuseppe Ferraiuolo
DOI:10.4103/jcecho.jcecho_14_20  
Here, we report the case of a young patient admitted to the emergency department because of abdominal pain. Computed tomography revealed a mass within her right heart. Through serial multimodality imaging testing, including computed tomography, three-dimensional (2D)- and three-dimensional echocardiography, as well as cardiac magnetic resonance, the diagnosis of cardiac involvement in the course of Echinococcus granulosus infection was hypothesized.
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Citrobacter freundii: A cause of cardiac tamponade and empyema thoracis in a Nigerian child p. 121
Isaac Elon Warnow, Yekeen Ayodele Ayoola, Apollos Daniel, Mercy Poksireni Raymond, Mohammed Lano Abubakar, Rabo Yasangrah Adeniji, Zwabragi Joel, Halima Abdulkarim, Muhammad Manga, Henry I Okolie
DOI:10.4103/jcecho.jcecho_4_20  
Citrobacter infection is an uncommon but serious, difficult to treat infection associated with high mortality. Accumulation of pus or fluid in a pericardial space causes restriction of cardiac filling and consequent decrease in cardiac output. We herein report Citrobacter freundii, a rare infectious cause of this uncommon disorder. Our patient is a 10yr old male referred with complaints of cough productive of mucoid sputum and associated chest pain of two weeks duration, difficulty in breathing and orthopnoea for one week. He was acutely ill looking in respiratory distress with tachypnoea and tachycardia. Blood pressure was normal with pulsus alternans, there was increased jugular venous pressure, diffused apex beat and distant heart sounds with pericardial rub. Retroviral screening and gene Xpert for Mycobacterium tuberculosis were negative. Chest radiograph showed enlarged heart of “water bottle” appearance with cardiothoracic ratio of 0.77 and right sided pleural effusion which was drained. Transthoracic Echocardiogram confirm pyopericardium with multiples echoes in cardiac temponade. Echo-guided percutaneous pericardiocentesis yielded 600mls of purulent aspirates. Citrobacter freundii Sensitive to gentamycin, co-amoxiclav but resistant to cefuroxime and cefixime was cultured from pericardial aspirates and sputum. Patient recovered fully after pericardiocentesis and intravenous antibiotics. In this case report, we describe Citrobacter freundii causing cardiac temponade and empyema in a Nigerian immunocompetent child which to our knowledge has thus far not been reported. Pyopericardium may follow rare causes as Citrobacter freundii which require high index of suspicion.
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