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   Table of Contents - Current issue
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January-March 2022
Volume 32 | Issue 1
Page Nos. 1-64

Online since Thursday, April 21, 2022

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ORIGINAL ARTICLES  

Focused transesophageal echocardiography in critical care: The COVID-19 pandemic p. 1
Edgar García-Cruz, Daniel Manzur-Sandova, Daniel Sierra-Lara Martínez, Rodrigo Gopar-Nieto, Antonio Jordán-Ríos, Arturo Díaz-Méndez, Emmanuel Lazcano-Díaz, Gustavo Rojas-Velasco, Francisco Baranda-Tovar
DOI:10.4103/jcecho.jcecho_9_21  
Background: The use of transesophageal echocardiography (TEE) is controversial in patients with COVID-19. The aim of this case series was to demonstrate the usefulness of transesophageal echocardiography in acute cardiovascular care settings in patients with COVID-19 infection. Materials and Methods: We enrolled 13 patients with confirmed SARS-CoV-2 infection admitted to the critical care unit of our center from April 1, 2020, to July 30, 2020, in which transesophageal echocardiography was performed. TOE was performed by three cardiologists with training in echocardiography. Results: The main indication was suspected infective endocarditis in four cases, venovenous extracorporeal membrane oxygenation cannulation in four cases, suspected prosthetic mitral valve dysfunction in two patients, suspected pulmonary embolism in two patients, and acute right ventricular dysfunction and prone position ventilation in one patient. The final diagnosis was confirmed in 11 patients and discarded in 2 patients. None of the operators result infected. Conclusions: TOE is safe in the context of COVID-19 infection; it must be performed in well-selected cases and in a targeted manner.
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Sensitivity and reproducibility of inferior vena cava diameter and superior vena cava flow velocity measurements to changes in cardiac preload in subjects with hypertension Highly accessed article p. 6
Ryan John Mcnally, Bushra Farukh, Phil J Chowienczyk, Luca Faconti
DOI:10.4103/jcecho.jcecho_56_21  
Objectives: We investigated the sensitivity and reproducibility of inferior vena cava (IVC) diameters and superior vena cava (SVC) flow velocities in detecting changes in cardiac preload in clinically euvolemic subjects with hypertension. Methods: Measurements were obtained during passive leg raising (PLR) and lower limb venous occlusion (LVO), interventions which respectively transiently increase and decrease cardiac preload. Measurements were made in 36 subjects and repeated on two separate occasions to examine reproducibility. Results: During PLR, there was no significant change in IVC diameters, but peak flow velocity of the SVC S wave increased by 6.5 (95% confidence interval 1.6–11.3) cm/s (P = 0.01). During LVO, IVC diameter in expiration decreased by 3.2 (1.7–4.7) mm and the SVC S wave decreased by 9.7 (4.4–14.7) cm/s (P < 0.001). Venae cavae-derived indices can be used to assess changes in preload within the physiological range in euvolemia. Conclusions: Despite suboptimal reproducibility of baseline measurements, high agreeability between the changes in IVC diameter and SVC flow after LVO suggests that these indices can be used to monitor changes in cardiac preload.
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Left ventricular functional remodeling after primary percutaneous coronary intervention p. 12
Mahesh Kumar Batra, Muhammad Atif Malik, Kamran Ahmed Khan, Lajpat Rai, Rajesh Kumar, Jehangir Ali Shah, Jawaid Akbar Sial, Tahir Saghir, Naveedullah Khan, Musa Karim
DOI:10.4103/jcecho.jcecho_64_21  
Background: Improvement in left ventricular (LV) function after revascularization is an important determinant of long-term prognosis in a patient with acute myocardial infarction (AMI). However, data on the changes of LV function after revascularization are scarce in our population. Hence, this study was conducted to evaluate the changes in LV function and dimensions by echocardiography at 3 and 6 months after primary percutaneous coronary intervention (PCI). Materials and Methods: A total of 188 patients were recruited in this study who had undergone primary PCI. Patients with preexistent LV dysfunction, prior PCI, or with congenital heart disease were excluded. Echocardiography was performed at baseline (within 24 h of intervention), 3 months, and 6 months of intervention. Remodeling in terms of change in LV ejection fraction (LVEF), LV end-diastolic dimension (LVEDD), LV end-systolic dimension, and wall motion score index (WMSI) was evaluated. Results: Out of the 188 patients, 90.4% were male, and mean age was 53.94 ± 9.12 years. Baseline mean LVEF was 39.79 ± 6.2% with mean improvement of 5.11 ± 3.87 (P < 0.001) at 3 months and 6.38 ± 4.29 (P < 0.001) at 6 months. Baseline LVEDD was 46.23 ± 3.86 mm which improved to 44.68 ± 2.81 mm at 6 months. Basal WMSI decreased by -0.09 ± 0.08 and -0.13 ± 0.09 at 3 and 6 months, respectively, after revascularization. Conclusions: Primary PCI is the recommended mode of reperfusion in patients with AMI. It reduces infarct size, maintains microvascular integrity and preserves LV systolic function hence improving LV function.
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Correlation between myocardial iron overload detected by CMRT2* and left ventricular function assessed by tissue doppler imaging in patients with thalassemia major p. 17
Mehdi Najimi, Yazdan Ghandi, Sarvenaz Mehrabi, Aziz Eghbali, Danial Habibi
DOI:10.4103/jcecho.jcecho_29_21  
Background: Iron overload and cardiac dysfunctions are common complications in patients with thalassemia major (TM). Different imaging methods can be used to detect ventricular dysfunction in these patients. In this study, we aim to understand the value of tissue Doppler imaging (TDI) in the detection of myocardial dysfunction in patients with TM who have been diagnosed with iron overload using cardiovascular magnetic resonance CMRT2*. Methods: In this cross-sectional study, fifty patients with TM diagnosed with iron overload who had no clinical signs and symptoms of cardiac dysfunction were chosen as a case group. The control group included fifty sex- and age-matched healthy participants without a history of cardiac and hematological diseases. TDI, pulsed wave Doppler (PWD), and standard echocardiography were performed to study the left ventricular function, and cardiac iron overload assessed by CMRT2*. Then, the patients with TM were divided into two subgroups and compared with each other. Group 1a includes individuals with T2* value <20 ms and group 1b T2* value >20 ms. Results: There was no significant difference between the standard echocardiography results and PWD parameters of the case and control groups; however, CMRT2* findings and TDI parameters were different between the case and control groups. CMRT2* findings also were not correlated with PWD parameters. In group 1a, CMRT2* findings were negatively correlated with age, E', A', early deceleration time, and isovolumetric relaxation time and positively correlated with E/E' ratio. Finally, PWD and TDI parameters were significantly different between the two subgroups. Conclusion: TDI can detect ventricular systolic and diastolic dysfunctions in earlier stages among patients with iron overload. It seems that TDI could detect abnormalities more accurately, and it is better to consider subclinical cardiac dysfunction in patients with even CMRT2* value of more than 20 ms and reevaluate them in future.
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Assessment of aortic stiffness by transthoracic echocardiographic in young COVID-19 patients p. 23
Asli Kurtar Mansiroglu, Tuba Disikirik, Hande Seymen, Mehmet Cosgun, Isa Sincer
DOI:10.4103/jcecho.jcecho_65_21  
Background: Deteriorated aortic elasticity is part of the atherosclerotic process. Inflammation is an underlying factor in both COVID-19 and atherosclerosis. Aims and Objectives: Using aortic elastic properties, we aimed to assess the subclinical indicators of susceptibility to inflammatory atherosclerosis in patients with COVID-19. Materials and Methods: Out of 194 participants included in this study, 100 were diagnosed with COVID-19 in the last 6 months (60 women and 40 men with a mean age of 34.13 ± 6.45 years) and 94 were healthy controls (55 women and 39 men with a mean age of 30.39 ± 7.21 years). We analyzed transthoracic echocardiographic and aortic stiffness parameters in all participants. Results: Values of systolic blood pressure (110 [85–140] vs. 110 [80–140], P = 0.037) and pulse pressure (PP) (37 [25–55] vs. 40 [25–55], P < 0.01) were significantly different between the groups. As for laboratory parameters, levels of glucose (97.89 ± 20.23 vs. 92.00 ± 9.95, P = 0.003) and creatinine (0.80 ± 0.13 vs. 0.75 ± 0.09, P = 0.003) were significantly higher in the COVID-19 group. Echocardiographic parameters showed that both groups differed significantly in diastolic aortic diameter (2.42 ± 0.28 vs. 2.31 ± 0.35, P = 0.017), aortic strain (9.66 [1.20–31.82] vs. 12.82 [2.41–40.11], P = 0.025), aortic distensibility (0.502 [0.049–2.545] vs. 0.780 [0.120–2.674], P < 0.01), and aortic stiffness (16.67 [4.19–139.43] vs. 11.71 [3.43–65.21], P = 0.006). Conclusion: Measurement of aortic stiffness is a simple, practical yet inexpensive method in COVID-19 patients, and therefore, may be used as an early marker for COVID-19-induced subclinical atherosclerosis.
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Impact of chest wall conformation on the outcome of primary mitral regurgitation due to mitral valve prolapse p. 29
Andrea Sonaglioni, Gian Luigi Nicolosi, Elisabetta Rigamonti, Michele Lombardo
DOI:10.4103/jcecho.jcecho_71_21  
Background: The possible influence of chest wall conformation on cardiovascular (CV) outcome of patients with mitral regurgitation (MR) due to mitral valve prolapse (MVP) has never been previously investigated. Methods: This retrospective study included all consecutive symptomatic patients with MVP and moderate MR who underwent exercise stress echocardiography at our institution between February 2014 and February 2021. Modified Haller Index (MHI; chest transverse diameter over the distance between sternum and spine) was noninvasively assessed. During the follow-up, we evaluated the occurrence of any of the following: (1) CV hospitalization, (2) mitral valve (MV) surgery, and (3) cardiac death or sudden death. Results: Four hundred and twenty-four consecutive patients (66.8 ± 11.5 years, 48.3% men) were retrospectively analyzed. Overall, MVP patients had concave-shaped chest wall (MHI = 2.55 ± 0.34) and were found with small cardiac chamber dimensions. During a mean follow-up time of 3.2 ± 1.7 years, no patients died, 55 patients were hospitalized due to CV events, and 20 patients underwent MV surgery. On multivariate Cox analysis, age (heart rate [HR] 1.05, 95% confidence interval [CI] 1.03–1.06), diabetes mellitus (HR 3.26, 95% CI 2.04–5.20), peak exercise-E/e' ratio (HR 1.07, 95%CI 1.05–1.09), and peak exercise-effective regurgitant orifice area (HR 2.53, 95% CI 1.83–3.51) were directly associated to outcome, whereas MHI (HR 0.15, 95%CI 0.07-0.33) and beta-blocker therapy (HR 0.26, 95% CI 0.19–0.36) showed strong inverse correlation. An MHI ≥2.7 showed 80% sensitivity and 100% specificity for predicting event-free survival (area under the curve = 0.98). Conclusions: Symptomatic patients with moderate MR due to MVP and MHI ≥2.7 have an excellent prognosis over a medium-term follow-up. Noninvasive chest wall shape assessment should be encouraged in clinical practice.
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Severe rheumatic mitral stenosis, worse left atrial mechanics is closely associated with echo criteria for intervention p. 38
Olga Vriz, Khaliel Feras, Mohammed Alamri, Benny Blassy, Anwar Almozel, Matthew Smith, Abdulhalim Jamal Kinsara, Domenico Galzerano, Afrah Alsomali, Gruschen R Veldtman
DOI:10.4103/jcecho.jcecho_80_21  
Background: Rheumatic mitral valve (MV) stenosis is associated with progressive left atrial (LA) fibrosis and functional impairment, Pulmonary artery systolic pressure (PASP) and right ventricular (RV) dysfunction. The aims of the study were to determine in those patients with severe MV stenosis if LA mechanical function as assessed by speckle tracking echocardiography could identify those with increased PASP, atrial fibrillation (AFib), and RV dysfunction. Subjects and Methods: Patients with severe MV stenosis were identified from the institutional echo database. Echocardiograms were read off line and measurements included atrial and ventricular strain. Patients were divided into tertiles of LA reservoir strain (LASr) values and data compared between the groups. Results: Ninety-seven patients, 67 females, mean age 47.4 ± 11.9 years, had MV mean gradient of 8.3 ± 5.1 mmHg, MV area by pressure half time of 1.3 ± 0.3 cm2 and LASr of 11.18% ± 6.4%. Those patients in the lowest LASr tertile had more AFib (72%, P = 0.0001), PASP >50 mm Hg (39%, P = 0.005), and worst RV impairment. In multivariable logistic regression analysis, LASr, age, and mean MV gradient were the independent predictors of AFib and PASP >50 mm Hg. Cutoffs, determined by receiver operating characteristic curve analysis had high specificity for the composite outcome of Afib and PASP >50 mmHg (85% for LASr <7.7%). Conclusion: In severe MV stenosis LASr, age and mean MV gradient, are independent predictors of Afib and PASP >50 mmHg. LASr <7.7% has high sensitivity and specificity in identifying those who meet ESC guideline 2017 criteria for valve intervention, suggesting its potentially helpful addendum to the surveillance of patients with MV stenosis.
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Importance of coronary to pulmonary artery fistulae incidentally detected on echocardiography: Can we ignore it during childhood? p. 47
Savas Dedeoglu, Helen Bornaun
DOI:10.4103/jcecho.jcecho_73_21  
Backround: Coronary artery fistula (CAF) is an abnormal precapillary connection between a coronary artery and an adjacent structure. The incidence of CAF in children as estimated from echocardiography is 0.06-0.2%. We aimed to establish the follow up results of clinically silent CAF found incidentally by colour Doppler echocardiography. Methods: The study included patients with abnormal fistulous flow in the pulmonary artery who had been studied between 2008 and 2020. Patient demographics, clinical findings, indication for echocardiography, electrocardiographic findings at presentation, follow-up times and any fistula progress were obtained from the recorded files. Results: Among the 78,000 patients who had had an echocardiographic examination, 118 had been found by colour Doppler flow mapping to have a clinically silent CAF. The exit point of CAF was clearly visualized with colour Doppler in all patients. In most patients the CAF was located around the pulmonary valve and the bifurcation; in 76 patients, it was on the aortic side of the main pulmonary artery, 26 patients had fistulous flow through the anterior wall of the main pulmonary artery, two had the right ventricular outflow tract (RVOT) as the exit site, for 12, it was the right pulmonary artery, and for another two, the left pulmonary artery. The 118 patients had ongoing follow-up to mean 41 months. There was no spontaneous resolution of fistula. The patients were asymptomatic without intervention and with ongoing echocardiographic evidence of small CAF at the last follow-up. Conclusion: We recommend the treatment strategy for paediatric patients should be individualized according to fistula origin, size, chamber enlargement, draining site, age of the patient and cost of imaging during follow up.
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CASE REPORTS Top

Heart and lung fibrosis in a patient with COVID-19-related myocarditis p. 52
Giovanni Camastra, Federica Ciolina, Luca Arcari, Luca Cacciotti, Mariateresa Pucci
DOI:10.4103/jcecho.jcecho_43_21  
A COVID-19 patient, in whom pneumonia lesions were first detected by chest computed tomography, was further evaluated by cardiac magnetic resonance (CMR) due to a suspected myocarditis. Beyond heart alterations, CMR revealed peculiar features of affected pulmonary areas in T1 mapping sequences and showed a particular distribution of late gadolinium enhancement in the same regions. The noninvasive assessment of the cellular, fluid, or fibrotic content of lung lesions may provide key information about the underlying pathophysiological pathways in the search of a tailored medical therapy and ventilatory support for COVID-19 patients.
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Isolated tricuspid regurgitation alternans in acute myocardial infarction: A rare entity p. 54
Rakesh Agarwal
DOI:10.4103/jcecho.jcecho_46_21  
Pulsus alternans is characterized by alternating strong and weak beats, and occurs with failing hearts. Left ventricular pulsus alternans is known to occur with ischemic heart disease, valvular heart disease, and outflow tract obstructions. Isolated right ventricular (RV) pulsus alternans is a rare entity. We report the case of a 51-year-old male patient who presented with inferior wall myocardial infarction and cardiogenic shock. He was diagnosed to have an isolated tricuspid regurgitation alternans signifying severe RV dysfunction. The patient was resuscitated and treated with primary percutaneous intervention to the right coronary artery. We also review the literature associated with RV pulsus alternans and its mechanisms.
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A case of dyspnea in a patient with a previous coronavirus disease infection: Pulmonary is not always the cause p. 57
Vincenzo Francesco Tripodi, Luca Bellieni, Fabio Scigliano, Michele Rossi, Pasquale Fratto, Frank Antonio Benedetto, AnnaTeresa Mazzeo
DOI:10.4103/jcecho.jcecho_39_21  
Myxoma is the most common benign primary tumor of the heart. Diagnosis of cardiac myxoma is difficult as it presents itself with varying nonspecific symptoms, and an echocardiography can easily diagnose it. Sometimes, it can cause cardiac syncope and thromboembolic events. A woman with a recent infection by severe acute respiratory syndrome coronavirus-2 was admitted to our hospital with respiratory symptoms: dyspnea and tachypnea; cardiac symptoms: atrial fibrillation; and neurological symptoms: syncope. Initially, she performed brain computed tomography (CT) and CT angiography value. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Chest X-ray did not show any interstitial lesions. Therefore, urgent cardiac surgery was performed to remove the mass. The histological examination confirmed the presence of a cardiac myxoma. Our experience could show the importance of early diagnosis and prompt surgical treatment to prevent stroke.
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Anterolateral papillary muscle rupture revealing infective endocarditis p. 60
Salma Charfeddine, Syrine Triki, Majdi Gueldiche, Tarek Ellouze, Amine Bahloul, Faten Triki, Leila Abid
DOI:10.4103/jcecho.jcecho_57_21  
The rupture of mitral papillary muscles is a very rare complication of infective endocarditis (IE). We report a case of anterolateral papillary muscle rupture resulting in severe mitral regurgitation due to IE in a young man without previous heart disease. The patient underwent urgent mitral valve replacement. The isolated rupture of the mitral papillary muscle complicating IE is rare. Urgent surgery should be performed is such cases.
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LETTER TO EDITOR Top

Heart in the mirror: Artifacts as a violation of ultrasonography assumptions p. 63
Natalia Aleksandra Dulak, Rafal Trzcinski, Pawel Miekus
DOI:10.4103/jcecho.jcecho_76_21  
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