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   Table of Contents - Current issue
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July-September 2021
Volume 31 | Issue 3
Page Nos. 125-188

Online since Tuesday, October 26, 2021

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ORIGINAL ARTICLES  

Left atrial ejection force as a marker for the diagnosis of heart failure with preserved ejection fraction p. 125
Mohamed Saber Hafez, Ahmed Mohamed El Missiri
DOI:10.4103/jcecho.jcecho_142_20  
Introduction: Several echocardiographic techniques are used to diagnose heart failure with preserved ejection fraction (HFPEF). Left atrial ejection force (LAEF) is a measure of left atrial (LA) systolic function. The aim of this study was to examine the use of LAEF as a measure for the diagnosis of HFPEF. Methods: A prospective study including 100 patients with HFPEF and 100 healthy controls. Heart failure association algorithm score for the diagnosis of HFPEF (HFA–PEFF score) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) were assessed. Transthoracic echocardiography measured indexed left ventricular mass index (LVMI), left ventricular (LV) ejection fraction, LA volume index (LAVI), global longitudinal strain (GLS), trans-mitral Doppler velocities, E/A ratio, E/e' ratio, and estimation of LAEF. Results: Patients in the HFPEF group were more frequently hypertensive, diabetic, and had a history of ischemic heart disease. NT-pro-BNP was higher in the HFPEF group (P < 0.0001). LVMI, relative wall thickness, and LAVI were all significantly higher in the HFpEF group (P < 0.0001 for all). LV-GLS was significantly lower in the HFPEF (P < 0.0001). LAEF was significantly higher in the study group 142.14 ± 24.27 versus 92.18% ±13.99% (P < 0.0001). A sub-group of 18 patients in the study group with a borderline HFA-PEF score of 4 had a LAEF that was significantly higher than the control group (P < 0.0001) but did not differ from the rest of the HFPEFF group patients. Conclusion: LAEF was significantly higher in patients with HFPEF compared to healthy controls. Patients with a borderline HFA-PEFF score of 4 had a significantly higher LAEF as compared to controls.
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Regional strain pattern and correlation with cardiac magnetic resonance imaging in fabry disease p. 131
Stephani C Wang, Daisy Tapia, Virginia E Kimonis, Dawn M Lombardo
DOI:10.4103/jcecho.jcecho_119_20  
Background: Cardiovascular disease is the most common cause of death among Fabry disease patients, who carry significantly increased risk for heart failure and sudden cardiac death. Echocardiographic strain imaging and cardiac MRI are important clinical tools for early detection of cardiomyopathy before onset of systolic or diastolic dysfunction. However, studies on these imaging modalities are limited among Fabry patients. Aim and Objective: To evaluate echocardiographic strain pattern and correlation with cardiac MRI in Fabry disease. Materials and Methods: We performed a detailed analysis of global longitudinal strain and correlation with cardiac MRI finding in 9 patients diagnosed with Fabry disease. Results: Despite normal left ventricular ejection fraction, basal and mid inferior segments are more likely to demonstrate strain abnormalities compared to other regions. Additionally, increased interventricular septal and left ventricular posterior wall thickness are correlated with greater strain abnormalities. Finally, MRI evidence of fibrosis and infiltration are detected among most patients with strain abnormalities, but in some cases, strain imaging were able to detect early evidence of cardiomyopathy even before MRI was fully able to detect the change. Basal and mid inferoseptal segment strain abnormalities are early signs of developing cardiomyopathy among patients with Fabry disease. Conclusion: Though cardiac MRIs are critical tools for detection of myocardial infiltration and scarring, these findings may not always be detectable in early phases of the disease. Multiple imaging modalities maybe considered in monitoring and evaluation of cardiomyopathy in Fabry disease.
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Left ventricular twist and untwist in patients undergoing elective percutaneous coronary intervention Highly accessed article p. 137
Ali A Elzieny, Said S Montaser, Ahmed M Emara, Mahmoud K Ahmed
DOI:10.4103/jcecho.jcecho_121_20  
Background: Left ventricular (LV) twist and untwist plays important roles in physiological adaptation and development of clinically relevant cardiac diseases. Aims: To assess LV twist and untwist in patients undergoing elective percutaneous coronary intervention (PCI) by two-dimensional (2D) speckle tracking echocardiography (STE). Subjects and Methods: Fifty patients who had stable angina pectoris and/or abnormal result from noninvasive stress tests were enrolled after undergoing elective PCI. Conventional and 2D STE were performed before elective PCI and after 3 months. Results: There was no significant systolic improvement in conventional echocardiography. However, there was a significant diastolic improvement after elective PCI as higher E, E/A, e' and lower E/e' (P < 0.034, <0.042, 0.015, and 0.033, respectively). In addition, there was a statistically significant improvement of STE-derived systolic parameters as regard higher global longitudinal strain, peak twist, and torsion (P value 0.009, 0.009, and < 0.001, respectively). Furthermore, there was significant improvement of STE-derived diastolic parameters as higher peak untwist, recoil, and lower time to peak untwist (P value 0.013, 0.001, and 0.004, respectively). Conclusions: LV and untwist parameters were improved before most of conventional echocardiographic parameters in postrevascularization of stable coronary artery disease.
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Comparison of myocardial deformation by speckle-tracking echocardiography and cardiac magnetic resonance in patients with fontan circulation: Diagnostic algorithm p. 144
Elena Sanz Pascual, Montserrat Bret Zurita, Jesus Diez Sebastián, Luis García-Guereta Silva, Angel Aroca Peinado, Federico Gutiérrez-Larraya Aguado
DOI:10.4103/jcecho.jcecho_126_20  
Background: While the short- and median-term survival has improved considerably in patients with Fontan circulation, cardiac function and exercise capacity are still reduced and may deteriorate over time. Cardiac magnetic resonance (CMR) is the gold standard for the assessment of ventricular volume and function. Speckle-tracking echocardiography (STE) is a myocardial deformation technique to assess ventricular function, with promising results. The aim of our study is to validate STE and conventional echocardiography parameters and to compare them with CMR. Furthermore, we aimed to design a diagnostic algorithm applying some parameters in series for early detection of myocardial dysfunction. Materials and Methods: We performed a cross-sectional single-center study in 64 patients with Fontan circulation. Longitudinal and circumferential strain, strain rates, and conventional echocardiographic measurements were registered. Ventricular volumes and ejection fraction (EF) were obtained by CMR. Results: Seven patients presented ventricular dysfunction (EF <45% by CMR), without showing a significant correlation between STE parameters or conventional measures by echocardiography and CMR. After the application of the diagnostic algorithm with the optimal cutoff points (global longitudinal strain – 24.5%, global circumferential strain – 20%, and annular plane systolic excursion – 16.5 mm), we got a sensitivity rate and a negative predictive value of 100%. In 19 patients (40.1%), the absence of ventricular dysfunction was demonstrated without no false-negative cases. Conclusions: STE should be considered a complementary diagnostic tool in Fontan patients. These suggested parameters applied in series are a useful tool for identifying early ventricular dysfunction and for diagnostic tests improvement with a fewer CMRs in the follow-up of these patients.
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The role of the left atrial strain parameters on grading of aortic regurgitation p. 151
Sedat Kalkan, Süleyman Cagan Efe, Onur Tasar, Atilla Koyuncu, Fatih Mehmet Yilmaz, Ulaankhuu Batgerel, Zeki Simsek, Can Yucel Karabay
DOI:10.4103/jcecho.jcecho_13_21  
Background: Grading the severity of aortic regurgitation (AR) is very important for clinical follow-up. In AR, left atrial (LA) mechanics can be affected in time and LA strain variations can be illuminating for the grading of AR. The purpose of this study is to determine whether the LA strain parameters are associated with the severity of AR or not. Methodology: Sixty-four consecutive patients with AR were included in this study. Patients divided into three groups as mild (n: 22), moderate (n: 15), or severe (n: 27). All patients' LA strain measurements were performed and results were compared between groups. Results: Between the groups, LA reservoir (LA-Res) in the mild, moderate, and severe AR groups was 42.0 ± 18.0, 41.4 ± 14.8, and 29.2 ± 6.0, respectively (P: 0.002) and LA pump in the mild, moderate, and severe AR groups was 21.2 ± 8.7, 19.3 ± 7.4, and 13.1 ± 4.4, respectively (P < 0.001), different, while no difference was noticed on LA SRs, LA SRe, and LA SRa. Conclusion: This study showed that LA-Res and LA pump parameters of the patients with severe AR significantly decreased compared to those of the mild and moderate AR group. The grading of the LA mechanics in patients with chronic AR might provide a supplementary contribution to the present parameters in the grading of AR.
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Global left ventricular myocardial work efficiency in heart failure patients with cardiac amyloidosis: Pathophysiological implications and role in differential diagnosis p. 157
Giuseppe Palmiero, Marta Rubino, Emanuele Monda, Martina Caiazza, Lucia D'Urso, Guido Carlomagno, Federica Verrillo, Raffaele Ascione, Fiore Manganelli, Giuseppe Cerciello, Maria Luisa De Rimini, Eduardo Bossone, Giuseppe Pacileo, Paolo Calabrò, Paolo Golino, Luigi Ascione, Pio Caso, Giuseppe Limongelli
DOI:10.4103/jcecho.jcecho_16_21  
Introduction: Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy and a common cause of heart failure with preserved and mid-range ejection fraction (HFpEF and HFmrEF). Left ventricular (LV) systolic assessment is pivotal in differential diagnostic and prognostic stratification in CA. However, nondeformation and deformation-based parameters classically implied had many limitations. Myocardial work (MW) has been recently introduced for the evaluation of myocardial performance, in a load-independent fashion, in patients with cardiomyopathies. Aims: This study aimed to evaluate MW parameters in LV performance assessment in CA and their possible role in differential diagnosis between AL and ATTR forms, compared with other echocardiographic parameters, also exploring the possible association between MW parameters and blood biomarkers. Materials and Methods: The study population consisted of 25 patients with CA (10 with AL amyloidosis and 15 with wild-type ATTR [ATTRwt] form) and HFpEF or HFmrHF, enrolled between March 2018 and December 2019, undergoing a comprehensive clinical, biochemical, and imaging evaluation. Ten healthy individuals were studied as controls. ATTR patients had a noninvasive diagnosis of wtATTR-CA (positive 99mTc-hydroxy methylene-diphosphonate scintigraphy with a negative hematological screening), while AL patients underwent endomyocardial biopsy. All patients underwent standard transthoracic echocardiography. MW and related indices were estimated using a vendor-specific module. Results: Compared to the ATTRwt group, patients in the AL group showed a more pronounced myocardial performance impairment assessed by Global Word Efficiency (GWE: 83.5% ± 6.3% vs. 88.2% ± 3.6%; P = 0.026). In multiple linear regression analysis, cardiac troponin I (B = −0.55; P < 0.0001), global longitudinal strain (B =0.35; P < 0.008), and regional relative strain ratio (B = −0.30; P < 0.016) were significant predictors of GWE reduction in CA patients. At receiver operating characteristics curve analysis, among all other deformation-based and nondeformation-based echocardiographic parameters, GWE showed the highest area under the curve (AUC) (AUC 0.74; 95% CI: 0.55–0.96; P < 0.04). The optimal cutoff was determined by sensitivity/specificity analysis: a GWE < 86.5% identified patients with AL amyloidosis with a sensitivity and specificity, respectively, of 80.0% and 66.7%. Conclusions: The results of our pivotal study seem to highlight the importance of new deformation parameters to study myocardial performance in patients with CA, and to differentiate between AL CA and ATTR CA.
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Uncovering cardiac involvement in childhood diabetes: Is it time to move toward speckle tracking echocardiography in childhood diabetes management? p. 165
Maryam Motamedi, Gholamhosein Ajami, Hamid Mohammadi, Gholamhosein Amirhakimi, Zahra Mehdipour Namdar, Homa Ilkhani, Hossein Moravej, Amir Aslani, Anis Amirhakimi
DOI:10.4103/jcecho.jcecho_21_21  
Context: One of the most common endocrine disorders in children is diabetes which is the leading cause of premature cardiovascular disease in adulthood. Aims: This study is aimed to investigate the extend of cardiac involvement in diabetic children by speckle tracking echocardiography (STE) in comparison to two-dimensional (2D) echocardiography and routine laboratory data. Settings and Design: A cross-sectional study conducted on patients under 18 years of age who deal with type one diabetes mellitus for more than 5 years. Subjects and Methods: To compare the STE results, we included the STE data of 25 normal age-matched children. All patients underwent laboratory analysis for lipid profile, blood sugar, and 2D echocardiography plus STE. Statistical Analysis Used: Two-sample independent t-test, Chi-square test, logistic regression test, Spearman's rank correlation coefficient, and the Pearson correlation coefficient. Results: From March 2018 to 2019, we included 53 patients, mean age 15.8 ± 0.39 years and 52.8% female, and 25 nondiabetic control in this study. STE revealed global longitudinal strain (LS) −18.4 versus − 24.2 for patient (44 valid cases) versus control group, respectively, with significant statistical difference. Diabetic patients had lower LS in all segments compared to the control group. Conclusions: STE has very high sensitivity to detect cardiac involvement far earlier than 2D echocardiography. None of the routine biomarkers or demographic features can predict cardiac involvement based on segmental abnormalities of STE. Active investigation to clear the remote impact of STE abnormalities and its practical role in childhood diabetes management is highly recommended.
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Prenatal delineation of coronary anatomy in dextro-transposition of great arteries p. 171
Geetha Haligheri, Chandrakant R Patel, Rukmini Komarlu
DOI:10.4103/jcecho.jcecho_34_21  
Background: Dextro-transposition of the great arteries (D-TGA) is the second-most common cyanotic congenital heart disease with variable coronary artery anatomy. The arterial switch procedure has revolutionized outcomes for this defect, with coronary anatomy being a key determinant of both short- and long-term outcomes following surgical repair. The assessment of coronary anatomy is usually undertaken in the postnatal period by transthoracic echocardiography, with assessment prenatally not being well studied. We sought to assess the feasibility of delineating the coronary arteries on fetal echocardiograms in a small cohort of patients followed prenatally. Methods: This was a retrospective review of fetuses with D-TGA from 2008 to 2018. Patients with prenatal diagnosis of D-TGA were reviewed for the assessment of coronary artery anatomy. Details of coronary artery anatomy diagnosed prenatally were compared with postnatal transthoracic echocardiograms and intraoperative findings. Results: Thirty-four fetuses with findings of D-TGA on prenatal echocardiograms were reviewed. 14/34 fetuses had attempted delineation of coronary artery anatomy, with average gestational age of 28 weeks (range 23–31 weeks) at the time of diagnosis. Two-dimensional and color Doppler imaging of the coronary arteries on both short and long axis images were performed, with complete delineation being possible in ~ 86% of fetuses. These findings were confirmed postnatally. Conclusions: Fetuses with D-TGA can have variable coronary artery anatomy which drives postnatal outcomes. Our study describes a cohort of patients with D-TGA wherein coronary artery anatomy was assessed. We demonstrate that coronary artery evaluation is feasible prenatally with optimal imaging techniques, being more successful after 25 weeks' gestation. The potential knowledge of dangerous variants can help with referral to centers of excellence for appropriate postnatal management and facilitate prenatal care accordingly.
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CASE REPORTS Top

Atretic Coronary sinus orifice and a diverticulum of coronary sinus associated with persistent left superior vena cava and accessory pathway p. 175
Mohammad Tayyebi, Hedieh Alimi
DOI:10.4103/jcecho.jcecho_55_20  
Coronary orifice atresia and diverticula are considered rare congenital conditions. Our understanding of the coronary sinus (CS) and venous drainage anatomy plays a crucial role in performing interventions and surgical procedures required to improve treatment options and related prognosis for these patients. The case study described herein involves a 29-year-old female patient who was diagnosed with coronary orifice atresia and diverticula. The patient's electrocardiography revealed normal sinus rhythm, short PR interval, and delta wave. Transthoracic echocardiography results showed the subject also suffered from mild CS dilation associated with coronary orifice atresia and diverticula. Our clinical intervention included the use of agitated saline injection which was administered intravenously into the patient's left arm. Our clinical observations during the administration of agitated saline solution did not indicate the presence of any detectable air bubbles entering into the CS. The results of two-dimensional and color flow Doppler study showed that CS connection to the right atrium appeared to be atretic. During our examination, we were also successful in detecting a pulsatile free echo space which was connected through an isthmus to the CS. Electrophysiology study and coronary angiogram performed on the subject confirmed our clinical diagnosis and findings of CS atresia, diverticula, and left superior vena cava.
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Retroaortic anomalous coronary artery visualization on transthoracic echocardiogram p. 179
Vladimir Cárdenas López, Pablo Blanco
DOI:10.4103/jcecho.jcecho_6_21  
Incidental findings are not uncommon in echocardiography. A transthoracic echocardiogram (TTE) of an adult woman with arterial hypertension showed a tubular structure with hyperechoic walls in the atrial side of the atrioventricular groove in apical views. Coronary computed tomography angiography correlated this finding with a retroaortic course of the anomalous circumflex artery (retroaortic anomalous coronary artery [RAC], benign coronary artery variant). Recently described as the RAC sign on TTE, practitioners should be aware of this finding to avoid mistaken it as artifacts, catheters/leads, or calcified mitral annulus.
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Plaque prolapse after stent implantation in ectasiant coronary artery atherosclerotic disease and large plaque burden p. 181
Nicola Porchetta, Debora Russo, Daniela Benedetto, Giuseppe Massimo Sangiorgi
DOI:10.4103/jcecho.jcecho_35_21  
Plaque prolapse (PP) is commonly defined as tissue extrusion through the stent strut. It is not a rare event, frequently detected by intravascular ultrasound, and it is associated with stent thrombosis and adverse outcomes. We present a case of PP after stenting of the left anterior descending coronary artery.
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Angiotensin-converting enzyme inhibitor-induced oropharyngeal edema with subsequent stress-cardiomyopathy p. 184
Michael Cronin, Dena Moradi, Paul Cotter
DOI:10.4103/jcecho.jcecho_40_21  
Intramuscular adrenaline is a standard treatment approach for the symptomatic patient presenting with distress and oropharyngeal edema, requiring subsequent doses if oedema persists. This case demonstrates a delayed side-effect of stress-induced cardiomyopathy after adrenaline administration. A 62-year-old suffered acute oropharyngeal angioedema secondary to angiotensin-converting-enzyme inhibitor use. Two standard doses of intramuscular adrenaline 2 hours apart were administered, and she was monitored for 2 days. On day three post discharge, she represented with acute hypervolaemia. Transthoracic echocardiogram showed a globally dilated, poorly functioning left ventricle. Cardiac magnetic resonance imaging described takotsubo cardiomyopathy. One month later, left ventricular function had normalised with optimal medical treatment. Cardiomyopathy with a temporal relationship to a hypersensitivity reaction is thought to occur due to one of three mechanisms: Stress (takotsubo) cardiomyopathy, allergic acute coronary (Kounis) Syndrome, and hypersensitive myocarditis. If a clinical presentation of hypersensitivity is such that it requires treatment with epinephrine, it is particularly challenging to determine the exact cause of cardiomyopathy.
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LETTER TO EDITOR Top

Echocardiography-guided arrhythmic risk prediction in the long qt syndrome p. 187
Rakesh Agarwal, Anunay Gupta
DOI:10.4103/jcecho.jcecho_20_21  
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