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   Table of Contents - Current issue
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October-December 2020
Volume 30 | Issue 4
Page Nos. 187-233

Online since Wednesday, January 20, 2021

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ORIGINAL ARTICLES  

Left ventricular longitudinal global strain to predict severe coronary disease in patients with precordial pain suggestive of non-ST-segment elevation acute coronary syndrome Highly accessed article p. 187
Miguel Angel Tibaldi, Cecilia Ruiz, María Luz Servato, Marcelo Urinovsky, Eduardo Alfredo Moreyra, Pablo Ezequiel Sarmiento, Camila Moreyra, Eduardo Moreyra
DOI:10.4103/jcecho.jcecho_57_20  
Background: Diagnosing non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not always straightforward. Left ventricular global longitudinal strain (LVGLS) is an echocardiographic method capable of detecting subclinical regional and global ventricular contractile dysfunction due to myocardial ischemia. The objectives of this study were to evaluate the efficacy of LVGLS in diagnosing severe coronary disease in patients with chest pain suggestive of NSTE-ACS and to assess the relationships between LVGLS reduction and ultrasensitive troponin T (UsTnT) elevation, electrocardiographic changes suggestive of ischemia, and the number of vessels with severe obstructions. Methods: This prospective, observational study evaluated hospitalized patients with chest pain of presumed coronary etiology. All patients underwent electrocardiography (ECG), UsTnT measurement, Doppler echocardiography, LVGLS measurement, and coronary angiography Coronary angiogram (CA) within 48 h of hospitalization. Results: A total of 75 patients with a mean age of 58 ± 17 years were included, of whom 84% (63 patients) were men. An LVGLS value of <-16.5, as determined by the Youden index proved to be useful for the detection of severe coronary obstructions (lesions >70%). The sensitivity, specificity, and positive and negative predictive values were 96%, 88%, 92%, and 92%, respectively. The number of coronary arteries involved had a direct relationship with the degree of LVGLS reduction (P < 0.001). Elevated UsTnT levels occurred more frequently in patients with reduced LVGLS than in those with normal LVGLS (83% vs. 17%, P < 0.0001). Abnormal strain was not associated with electrocardiographic changes suggestive of ischemia. Conclusions: LVGLS measurement in patients with presumed NSTE-ACS is efficient in predicting the presence of severe coronary disease. The number of coronary arteries involved has a direct relationship with the degree of LVGLS reduction. Abnormal strain is associated with UsTnT elevations but not with electrocardiographic changes suggestive of ischemia.
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Noninvasive predictors of functional capacity in patients with pulmonary hypertension due to congenital heart disease: A pilot echocardiography single-center study p. 193
Amr Mansour, Alaa Roushdy, Bahaaeldin Harb, Heba Attia
DOI:10.4103/jcecho.jcecho_41_20  
Background: Pulmonary hypertension (PH) with congenital heart disease (CHD) affects the functional capacity (FC), quality of life, and survival. However, the importance of different echocardiographic parameters and their correlation with FC is unclear. Methods and Results: A custom-made sheet for 34 consecutive patients with PH due to CHD was made to include patient's demographic data, underlying cardiac disorder, and FC by 6-min walk test (6MWT). The patients were subdivided into Group 1 with 6MWT < 330 m and Group 2 with 6MWT > 330 m. A cutoff value of 330 m was selected because it reflected the survival and outcome of patients in many studies before. Left ventricle global radial strain, baseline saturation, and saturation after 6MWT showed a significant strong positive correlation with 6MWT (r = 0.755, 0.714, and 0.721, P = 0.001, 0.000, and 0.000, respectively). Multiple regression analysis using a multivariate model showed that the mean pulmonary artery pressure (MPAP) and baseline saturation are the most independent predictors of the FC (P = 0.028 and 0.049, respectively), with a cutoff point for MPAP > 30 mmHg (area under the curve [AUC]: 0.85) with a sensitivity and specificity of 69.23% and 95.24%, respectively, and cutoff point for saturation < 94% (AUC: 0.852) with a sensitivity and specificity of 92.31% and 76.19%, respectively. Conclusion: The MPAP and the baseline oxygen saturation were the most independent predictors of impaired FC. They can be used for risk stratification and as surrogate predictors of outcome in this group of patients.
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Diagnostic accuracy of carotid doppler ultrasound for the detection of right-to-left cardiac shunt p. 201
Anna Marenghi, Elisa Ceriani, Elisa Maria Fiorelli, Mattia Bonzi, Nicola Montano, Federico Annoni
DOI:10.4103/jcecho.jcecho_70_20  
Background: Right-to-left cardiac shunt is a condition anatomically related to patent foramen ovale (PFO) and potentially related to cryptogenic cerebrovascular events. As recent studies demonstrated a reduction of recurrent stroke in patients undergoing percutaneous PFO closure after a cryptogenic cerebrovascular event, it is now of pivotal importance to screen these patients for Right-to-left shunt(RLS) presence. At this regard, transcranial color Doppler (TCCD) with contrast has a good sensitivity (97%) and specificity (93%) compared to transesophageal echocardiography and became the test of choice to assess RLS presence, thanks to its noninvasive nature. However, temporal bone window is not accessible in 6%–20% patients. Several approaches have been explored to overcome this limitation with encouraging but not definitive results for extracranial internal carotid artery (ICA) approach, proposed in previous pivotal studies. Aims of this study were to further assess the diagnostic accuracy of ICA Doppler ultrasound with contrast for RLS detection compared to TCCD, with the two tests performed simultaneously. Materials and Methods: Sixty-four patients underwent simultaneously to TCCD and ICA Doppler ultrasound, both performed at rest and after Valsalva maneuver. Diagnosis of RLS was made, both for TCCD and ICA ultrasound, if =1 microembolic signals (MES) were detected during the examination (either at rest or after Valsalva maneuver). Results: ICA Doppler ultrasound sensitivity and specificity resulted respectively of 97% (confidence interval [CI] 95%) and 100% ([CI] 95%), while negative likelihood ratio was 0.03 (CI 95%). Conclusions: ICA Doppler ultrasound represents a valid alternative to TCCD for RLS screening in patients without adequate transcranial acoustic window.
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CASE REPORTS Top

Myocardial work: A modern tool to detect possible compensation mechanism of deformation in acute myocarditis with preserved left ventricular function p. 206
Stephan Stöbe, Andreas Hagendorff, Matthias Gutberlet, Bhupendar Tayal
DOI:10.4103/jcecho.jcecho_48_20  
The architecture of the myocardial fibers defines the different components of left ventricular (LV) contraction. Subendocardial layers are primarily responsible for longitudinal LV deformation and subepicardial layers for circumferential LV deformation. The specific analysis of the different components of LV deformation by echocardiography might offer new diagnostic options in patients with acute myocarditis (?IM). This case report focuses on specific pathological findings of regional LV deformation in a patient with IM and preserved LV systolic function.
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Utilization of the transgastric view of the left atrial appendange for procedural guidance during left atrial appendage clip via video-assisted thoracoscopic surgery p. 211
Mckenzie Hollon, Abimbola Faloye
DOI:10.4103/jcecho.jcecho_45_20  
Left atrial appendage (LAA) ligation is procedure which isolates the LAA and can decrease the risk of thrombus and arrhythmias in patients with atrial fibrillation, allowing patients to come off home anticoagulation medications. This procedure can be done through minimally invasive thoracoscopic surgery and requires guidance by transesophageal echocardiography. Visualization of the LAA and associated intrathoracic structures is vital for the success of the procedure. This echo rounds report describes an under-utilized method for LAA assessment to encourage cardiac anesthesiologists to consider employing it to increase their ability to completely evaluate the LAA.
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Value of three-dimensional echocardiography in assessing double-orifice mitral valve in an asymptomatic patient p. 214
Alaa Alkathiri, Ashraf M Anwar, Youssef F M. Nosir, Schurlyn Alcid
DOI:10.4103/jcecho.jcecho_51_19  
Double-orifice mitral valve (DOMV) is a rare congenital anomaly consisting of an accessory bridge of fibrous tissue, which divides the mitral valve (MV) into two orifices. The mitral leaflets are essentially normal in most cases, but they can be regurgitant or stenotic. It is most commonly associated with a variety of other cardiac anomalies. Isolated DOMV with normal MV function is very rare. We present here a rare case of congenital DOMV in a 25-year-old female diagnosed by real-time three-dimensional echocardiography (RT3DE). RT3DE enabled complete anatomical and functional assessment of MV apparatus. It added much valuable information over conventional 2DE that helped in establishment of the diagnosis, identification of the anatomical type, and selection of the proper management.
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Left ventricular thrombus: An interesting presentation of primary antiphospholipid antibody syndrome with a mini-review of the literature p. 217
G Ravi Kiran, J Shashivardhan, P Chandrasekhar
DOI:10.4103/jcecho.jcecho_52_20  
Antiphospholipid syndrome (APLS) is characterized by recurrent thrombosis. We report the case of a 36-year-old male who had acute right-sided ischemic stroke and right leg ischemia secondary to left ventricular (LV) thrombus caused by primary APLS. The literature review suggested that the LV thrombus presented most commonly with systemic embolism and was associated with a mortality rate of 22.2% with treatment. Thrombophilic workup in young patients with a systemic thromboembolic episode (s) is advised.
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Shock and diffuse ST-elevation in a patient with coronavirus disease-2019 disease p. 223
Maria Cristina Vedovati, Michela Giustozzi, Serenella Conti, Cecilia Becattini
DOI:10.4103/jcecho.jcecho_71_20  
The infection by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with significant cardiovascular morbidity and mortality. Cardiac events require prompt diagnosis and management, also in the SARS-CoV-2 era. A 58-year-old male, heavy smoker and with known SARS-CoV-2 infection, abruptly developed severe hypotension and asthenia. At patients' home, emergency physicians found hemodynamic compromise with diffuse ST-elevation at electrocardiography. The patient was rapidly moved to the cardiac catheterization laboratory, and any contact with other health-care workers was avoided. Coronary angiography excluded coronary artery disease. At admission to the coronavirus disease-2019 unit, an increase in inflammatory markers and liver enzymes with normal troponin levels were observed. Bedside lung ultrasonography showed interstitial syndrome and bilateral pleural effusion, whereas echocardiography showed large and diffuse pericardial effusion with a swinging heart. The hemodynamic status improved after gentle fluid therapy such suggesting potential concomitant sepsis and pericardiocentesis was not performed. At this time, a computed tomography scan showed a widespread neoplasm in the right lung involving the subclavian artery and vein and the thoracic lymph nodes. The histology confirmed the diagnosis of a locally advanced pulmonary adenocarcinoma. One week after admission, the patient died for worsening respiratory failure. Not delayed primary PCI remains the standard of care for patients with suspected ST-elevation myocardial infarction (STEMI) in the SARS-CoV-2 era. A diagnostic deepening for potential STEMI-mimicker (known to be associated with SARS-CoV-2 infection and to patients' comorbidities) should be considered, and a multidisciplinary approach is needed in these patients.
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Atrioventricular discordance with double-outlet right ventricle in mirror imagery and levocardia: A very rare case report p. 227
Silvia Farruggio, Salvatore Agati, Davide Calvaruso, Corrado Di Mambro, Elio Caruso
DOI:10.4103/jcecho.jcecho_65_20  
A newborn without prenatal diagnosis, with bronchial and abdominal situs inversus in levocardia, was referred to our hospital for accurate evaluation; echocardiography showed venoatrial connections in mirror-image arrangement, atrioventricular (AV) discordance, and double-outlet right ventricle (DORV). Additional cardiac malformations were double upper caval district, atrial communication, subpulmonary interventricular communication, and moderate subvalvular and valvular pulmonary stenosis. Few days after birth, the patient presented low oxygen saturation and the heart team decided for a palliative surgery. We describe a very rare case in a newborn with bronchial-abdominal mirror imagery, AV discordance, and DORV in levocardia.
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A right atrial appendage thrombus mimicking a tumor p. 231
Sajjad Ahmadi-Renani, Mohammad Alidoosti, Abbas Salehi-Omran, Narges Shahbazi, Ali Hosseinsabet
DOI:10.4103/jcecho.jcecho_78_20  
A right atrial (RA) mass was incidentally found by transthoracic echocardiography in a 79-year-old man with atrial fibrillation rhythms but without a history of anticoagulation. Transesophageal echocardiography revealed a pedunculated immobile mass in the RA appendage. In addition, some calcification was detected in computed tomography. The mass was excised, and pathological examinations revealed organized thrombosis. Accordingly, in the presence of predisposing factors, thrombi, which may mimic some imaging features of tumors, should be considered in the differential diagnosis of RA masses.
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