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   Table of Contents - Current issue
Coverpage
May-August 2020
Volume 4 | Issue 2
Page Nos. 145-225

Online since Wednesday, August 19, 2020

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EXPERT DOCUMENT  

Joint Consensus Statement – Safety Precautions for Doing Echocardiography and Image Acquisition during COVID-19: Indian Academy of Echocardiography, Bangladesh Cardiac Society, Cardiac Society of Nepal, and Sri Lanka College of Cardiology Highly accessed article p. 145
Rakesh Gupta, SK Parashar, HK Chopra, Sameer Shrivastava, Satish C Govind, Abdullah Al Shafi Majumder, A. K. M. Monwarul Islam, Mohsin Ahmed, A. K. M. Mohibullah, Yadav Kumar Deo Bhatt, Deewakar Sharma, Chandra Mani Adhikari, Dipanker Prajapati, MR Mubarak, Stanley Amarasekara, G Vijayraghavan, P Krisham Raju, AV Anjaneyulu, R Alagesan, RR Kasliwal, Rajan J Manjuran, S Shanmugasundrum, V Amuthan, SK Kaushik, ST Yavagal, Debika Chatterjee, K Raghu, CK Ponde, Manish Bansal, G Gnanavelu, Rahul Mehrotra, Sunil Bohra, S Veermani, UP Singh, G Rajesh, KM Krishnamoorti, Rishikesh Shah
DOI:10.4103/jiae.jiae_38_20  
An echocardiographic investigation is one of the key modalities of diagnosis in patients suffering from COVID-19, especially if they are elderly, have associated comorbid conditions, and pregnant. Hence, it is becoming extremely essential to look into the correct safety precautions, health-care professionals must take while conducting an echo investigation. At the same time, a focused echo examination aimed at correct imaging view acquisition in the shortest possible time is the need of the hour. The decision matrix formulated for conducting an echocardiographic evaluation is based on the presence or absence of cardiological comorbidity vis-a-vis positive or suspected for COVID-19. The safety measures and image acquisition have been constructed keeping in mind the current safety precautions by the World Health Organization, the Centers for Disease Control and Prevention, and the Ministry of Health and Family Welfare, India.
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ORIGINAL RESEARCH Top

Atrioventricular Plane Displacement on Echocardiography in Patients with Left Ventricular Systolic Dysfunction p. 149
Sagar Divekar, Vikrant Khese, Madhusudan Asawa, Deepak S Phalgune, Chandrakant Chavan
DOI:10.4103/jiae.jiae_46_19  
Background: Atrioventricular plane displacement (AVPD) reflects global left ventricular function despite left ventricular asymmetry as it is determined in four different regions of left ventricle. The limitations of agreement between left ventricular ejection fraction (LVEF) and AVPD are not close enough for these two measurements to be interchangeable. There is reason to question whether AVPD provides the same information as LVEF. Aim: The aim of this study was to assess relations of AVPD with LVEF and clinical findings in patients left ventricular failure (LVF). Materials and Methods: One hundred patients aged ≥18 years with coronary artery disease admitted with LVF were included in this cross sectional study. Echocardiographic examination was performed. Left ventricular AVPD was evaluated by M mode, in the four and two chamber views. Primary aim was to compare AVPD with LVEF by echocardiography. Secondary outcome measures were comparison of AVPD with traditional risk factors, clinical features, and pro-B-type natriuretic peptide (BNP) levels. Comparison of qualitative and quantitative variables was done by using Chi-square test/Fisher's exact test and unpaired t-test. Pearson's correlation was used to study correlation. Results: Mean AVPD was significantly lower in patients with severe LVEF as compared to mild, and moderate LVEF. Correlation of AVPD with LVEF, pro BNP, septum, anterior, lateral and posterior wall hypokinesia was 0.895. 0.841, 0.898, 0.911, 0.893 and 0.907 respectively. Conclusions: Mean AVPD was significantly lower in patients with severe LVEF. Mean AVPD positively correlated with LVEF, pro BNP, septum, anterior, lateral and posterior wall hypokinesia.
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Significance of Tissue Doppler Echocardiography-Based Dispersion Index of Myocardial Velocities in the Differentiation of Ischemic and Nonischemic Cardiomyopathy: A Novel Echocardiographic Parameter Highly accessed article p. 154
Narra Sandeep, Otikunta Adikesava Naidu, Ravi Srinivas, Nagula Praveen, Parvathareddy Krishna Malakonda Reddy
DOI:10.4103/jiae.jiae_47_19  
Background: Tissue Doppler imaging (TDI) echocardiography, an objective method for the quantification of left ventricular (LV) function, can detect subtle alterations in contractility both in rest and stress echocardiography. Aim: The study aims were to (1) compare TDI parameters in patients with heart failure (HF) of ischemic and nonischemic etiology, (2) to differentiate both subsets based on velocity dispersion index (VDI) at mitral valve, and (3) to identify parameters that help in identifying the ischemic etiology of HF. Materials and Methods: Patients with symptomatic HF (NYHA class ≥II; LV ejection fraction <40%) were included in the study. Patients with aortic and mitral valve diseases, prosthetic valves, and cor pulmonale were excluded from the study. All patients underwent coronary angiography after stabilization. A total of 100 patients admitted between May 2017 and October 2018 were enrolled. Results: The mean age of presentation was earlier in nonischemic group compared to that of ischemic group of HF (43.4 ± 10.91 vs. 54.06 ± 10.40; P= 0.001). No significant differences in the mitral inflow velocities by conventional Doppler were found. The mean mitral TDI velocities were lower in the nonischemic group compared to those of the ischemic group. Systolic VDI, V s' >25.40 (sensitivity 91.7% and specificity 100%), and diastolic VDI, V e' >17.35 (sensitivity 86.7% and specificity 87.5%), were associated with the probability of diagnosing the ischemic cause of HF. Conclusions: VDIs help in the differentiation of ischemic and nonischemic etiologies of HF compared to the conventional echocardiography.
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Immediate- and Short-Term Effect of Percutaneous Patent Ductus Arteriosus Closure on Left Ventricular Function: A Speckle Tracking Echocardiographic Study p. 161
Dina Adel Ezzeldin, Sherif Lotfy Wahba, Maiy Hamdy El Sayed, Alaa Mahmoud Roushdy
DOI:10.4103/jiae.jiae_2_20  
Background: Patent ductus arteriosus (PDA) closure results in a sudden drop in left ventricular (LV) preload, and this may affect the LV functions. Aim: The aim was to evaluate the immediate- and short-term changes in LV functions by speckle tracking echocardiography (STE) post percutaneous PDA closure. Materials and Methods: The study included 45 patients with PDA who were referred for PDA trans-catheter closure. All the patients included in the study underwent full echocardiographic examination and speckle tracking analysis before PDA closure, immediately after closure, and 1 month after the PDA closure. Results: There was no statistically significant change in LV functions by two-dimensional transthoracic echocardiography; the LV end-diastolic volume (EDV) decreased significantly in the immediate follow-up from 41.608 ± 25.8846 ml before duct closure to 36.317 ± 21.6945 ml. The drop in the LV EDV continued in the 1-month follow-up. The LV end-systolic volume decreased as well, however it took 1 month for this drop to be statistically significant. The LV end-diastolic dimension also decreased significantly after duct closure. Regarding STE results, the global LV strain and strain rate values did not significantly change. The global strain values had a mean of −22.944% ± 3.5128% before duct closure and decreased to a mean −22.028% ± 2.8932% immediately after duct closure. Conclusion: The study concluded that STE could be used to detect subtle changes in LV deformation. Time to peak systolic strain is an understudied parameter that needs further evaluation to provide a better understanding regarding its role in myocardial function assessment.
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Measurement of Aortic Root Dimensions by Transthoracic Echocardiogram in Normal Indian Population p. 168
S Venkatesan, G Prathap Kumar, Deepak Nenwani, N Swaminathan, G Ravi Shankar, G Justin Paul
DOI:10.4103/jiae.jiae_7_20  
Background: Aortic root dimension varies on the basis of age, body surface area, ethnicity, and in pathological states such as bicuspid aortic valve and connective tissue disorders. Aim: This observational study has been done to determine aortic root dimension in normal Indian population. In this study, aortic root dimensions were measured by two-dimensional (2D) echocardiography in parasternal long axis (PLAX) view by inner edge to inner edge method. Materials and Methods: Clinically normal Indian population was prospectively recruited. All participants were asymptomatic. All echocardiographic measurements were done twice and image acquired by single observer on the same machine. Aortic root dimensions measurements were done with 2D echo in PLAX view at 4-level aortic annulus, sinus of Valsalva, sinotubular junction, and proximal ascending aorta. Results: Aortic annulus does not show any significant correlation with age. Age parameter shows a significant correlation with the ascending aorta and sinus, sino-tubular (ST) junction. Weight parameter shows a significant correlation with annulus, sinus, and ST junction. Height parameter shows a significant correlation with all aortic dimensions. Conclusion: Indian patient has different body surface area than the Western population; therefore, there is a need of standard normal aortogram dimension for normal Indian population.
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Value of Speckle Tracking Echocardiography as a Predictor of the Deleterious Effect of Right Ventricular Pacing on Left Ventricular Function Highly accessed article p. 171
Samir Rafla, Amr Zaki, Aly Aboelhoda, Moustafa Sappaq, Gehan Magdy
DOI:10.4103/jiae.jiae_11_20  
Background: Pacemaker-induced cardiomyopathy (PICM) is reported in different articles but with variable incidence. Aim: The aim of the study is to determine the validity of speckle tracking echocardiography as a predictor of the deleterious effect of right ventricular (RV) pacing on left ventricular (LV) function, using two-dimensional guided global and segmental longitudinal strain. Materials and Methods: Fifty patients with conventional indications for permanent pacemaker implantation were studied; they were classified to Group A (37 = 74%) patients who didn't show a significant reduction of ejection fraction (EF) (>10%) and Group B (13 = 26%) represent patients who showed a significant reduction of EF. Group C constituted 25 healthy persons (control group). We defined PICM when EF is reduced >10%. Results: The incidence of pacemaker-induced ventricular dysfunction was 26%. Statistical analysis revealed that left atrial volume index (LAVI), global longitudinal strain (GLS), native-QRS duration, and ischemic heart disease were significant predictors of reduction of LV function, however, on multivariate regression analysis, only the LAVI and GLS were independent predictors of reduction of LVEF after permanent pacing. Conclusions: Speckle tracking echocardiography is a new, unique and evolving tool to assess the myocardial deformation which can detect LV systolic dysfunction much earlier than can be reflected in LVEF. The importance of defining predictors is to predict whom patient will be at risk for the deleterious effect of RV pacing on LV function, and who will need observation with possible upgrading to biventricular pacing.
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Left Atrial and Renal Functional Status as Drivers of Adverse Outcome in Heart Failure with Reduced Ejection Fraction: A Four-Chamber Deformation Study in a Small Cohort of Northern Sweden p. 176
Samir Kanti Saha, Anatoli Kiotsekoglou, Satish C Govind, Krister Lindmark
DOI:10.4103/jiae.jiae_37_20  
In a small cohort of patients (58 ± 12 years) with heart failure and reduced ejection fraction (HFREF), we have analyzed myocardial mechanics in all the four principal cardiac chambers to investigate the prognostic value of left atrial (LA) remodeling. We have also studied to investigate a possible prognostic role of the biochemical markers, such as estimated glomerular filtration rate (eGFR, mL/min/1.73 m2) and N-terminal pro-brain natriuretic peptide (NT-proBNP). We used two-dimensional speckle tracking echocardiography to compute cardiac deformation in addition to measuring LA reservoir strain using two algorithms based on the type of electrocardiogram gating protocol chosen. The data have shown that not only four-chamber strain was significantly lower in HFREF compared with the controls but also LA strain predicted an adverse outcome. In addition, in the subgroup analysis, eGFR was significantly lower in patients with adverse outcome (death or cardiac transplantation). Interestingly, the contribution of the renal biomarker was as significant as NT-proBNP in this regard.
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REVIEW ARTICLE Top

Fetal Echo: Application of Four Chamber View and Additional Views in Obstetrics Anomaly Scan and Third Trimester Low-Risk Pregnancy p. 184
Rajendra Kumar Diwakar, Mahendra Kumar Dwivedi, Vikrant Bhende
DOI:10.4103/jiae.jiae_51_19  
This article presents a step-wise process to evaluate fetal cardiac anatomy by the radiologist and the pediatric cardiologist, to become more familiar while assessing the four chamber view including the views for the outflow tracts. The additional views include bicaval view, three-vessel view (3VV), three- vessel trachea view (3VT), and aortic arch view. M-mode, color flow mapping and pulse Doppler ultrasound are useful to evaluate cardiac anatomy and function. If the heart does not look normal, the patient should be referred to dedicated fetal echo centre for detailed evaluation. Ductus venosus Doppler, cardiovascular profile score and visualization of thymus in 3-vessel view have also been described in brief.
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CONTEMPORARY TOPIC Top

Echocardiography Imaging as a Fast-track Tool to Identify High-risk Population in COVID-19 Pandemic Era p. 193
Keyur Vora
DOI:10.4103/jiae.jiae_16_20  
Degenerative valvular changes are not uncommon findings in echocardiography studies of elderly population. Clinical significance becomes very important during noncardiac morbidities. Our case report identifies the importance of studying valvular changes in elderly population resulting in secondary pulmonary hypertension, in order to categorize them for appropriate preventive measures, to prevent escalation of low risk comorbid conditions to life-threatening clinical outcomes during ongoing coronavirus disease 2019 pandemic.
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INTERESTING CASE REPORTS Top

Cardiac Hydatid Cyst p. 196
Ishita Banerji
DOI:10.4103/jiae.jiae_24_19  
A 52-year-old female presented with features suggestive of acute coronary syndrome. A transthoracic echocardiogram done to assess the cardiac function and regional wall motion abnormality revealed a large cardiac cystic lesion instead, in the apical part of the interventricular septum, suggestive of a hydatid cyst. Cystic hydatid disease results from infection with the larval or adult form of the Echinococcus granulosus tapeworm. Cardiac hydatid cyst is a rare condition seen in 0.5%–2% of patients with hydatid disease, and the location of a hydatid cyst in the interventricular septum is exceptional. Cardiac hydatid cysts can rupture and cause cardiac tamponade, fatal arrhythmias, or systemic infection. The atypical location of a large hydatid cyst in the apical interventricular septum encroaching into the right ventricular cavity filling almost half of it, was an interesting finding, found worth reporting. Also, further investigations that unraveled two more hydatid cysts in the liver, made the case more interesting to report.
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Cardiac Diverticulum p. 200
Neelesh Pandey, Rakesh Aseri, Rohit Tandon, Bishav Mohan, Gurpreet Singh Wander
DOI:10.4103/jiae.jiae_25_19  
Left ventricular diverticulum (LVD) is a rare clinical entity which contains endocardium, myocardium, and pericardium with normal contractility. Contrary to LV aneurysm, which has thin and fibrotic LV wall with paradoxical movement compared to normal left ventricle contraction. LVD are two types, that is, congenital or acquired. Congenital is more common than acquired form. Classification according to the location is either apical or nonapical. Apical diverticula usually associated with midline thoracoabdominal defects and other cardiac malformations, but nonapical diverticula were isolated. Nonapical diverticula can arise from the anterior-free wall, the subaortic region, or, rarely, from both ventricles. A diagnosis can be usually done by echocardiography, whereas computed tomography angiography, magnetic resonance imaging, and invasive ventriculography also help. A major problem with LVD is thrombosis, embolism, rupture, ventricular arrhythmias, congestive heart failure, and valvular abnormalities. The management of LVD depends on the clinical condition and associated abnormalities. In most asymptomatic person can be managed conservatively. Treatment for high-risk cases includes surgery, anticoagulants, and treatment of arrhythmias.
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Diffuse Constrictive Pericarditis with Focal Sparing Resulting in Multiple Ventricular Free Wall Outpouchings Mimicking Aneurysm p. 203
Archit Gupta, Deepak Varshney
DOI:10.4103/jiae.jiae_48_19  
We present a case of diffuse constrictive pericarditis (CP) with multiple right and left ventricular wall outpouchings, simulating ventricular free wall aneurysm. Few cases have been reported till date of multiple ventricular free wall aneurysm-like outpouching adjacent to surrounding regions of thickened pericardium in a patient with CP.
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Right Juxtaposition of the Atrial Appendages p. 206
Shweta Bakhru, Palak Gupta, Sujata Patil, Nageswara Rao Koneti
DOI:10.4103/jiae.jiae_49_19  
Right juxtaposition of atrial appendages are rare and associated with congenital heart defects. We report 3 cases of right juxtaposition of atrial appendages (RJAA) diagnosed by transthoracic echocardiography. The sub-xiphoid sagittal view, parasternal short axis and apical four chambered views demonstrated RJAA. All 3 cases with RJAA were associated with congenital heart disease. Diagnosis was confirmed by CT angiogram and intra-operative findings in two children who underwent surgical correction. Right juxtaposition of atrial appendages is a rare association with congenital heart defects. Transthoracic echocardiographic assessment may give clues to the diagnosis.
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An Unusual Association of Unicuspid Aortic Valve p. 209
Rockey Katheria, Prabhavathi Bhat, BS Arun, Manjunath C Nanjappa, Prasanna Simha Mohan Rao
DOI:10.4103/jiae.jiae_52_19  
Unicuspid aortic valve (UAV) is a rare congenital abnormality of the aortic valve. It usually presents with severe aortic stenosis (AS), necessitating surgical intervention. The diagnosis can be made with echocardiography. Hereby, we are reporting a case of a 23-year-old male who presented with exertional breathlessness and fatigue, due to severe AS, secondary to a unicommissural UAV, associated with mitral valve prolapse with severe mitral regurgitation.
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Right Ventricular Free Wall Rupture: A Catastrophic Sequela of Myocardial Ischemia p. 213
Bharat Rathi, Ravi Inaniya, Rajesh Agarwal
DOI:10.4103/jiae.jiae_53_19  
The case describes a rare mechanical complication of myocardial infarction in the form of right ventricular free wall rupture leading to cardiogenic shock and death. The patient had no cardiac high-risk factors and had short-lasting symptoms of the chest pain but presented in the emergency department in a semi-conscious state. The condition was diagnosed on transthoracic echocardiography and during the course of investigation, the patient instantaneously deteriorated and succumbed to the condition.
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A Rare Case of the Dilated Right Atrium in a Newborn p. 217
S Balasubramanian
DOI:10.4103/jiae.jiae_54_19  
Aneurysms of the right atrium are extremely rare. These aneurysms can be associated with tachyarrhythmia, intracardiac thrombus formation, thromboembolism, and right ventricular compression precipitating heart failure. We report a case of a right atrial aneurysm in a newborn presenting with cardiac failure and multisystem dysfunction.
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Role of Point-of-care Ultrasonography in Cardiac Surgical Emergencies Like Left Ventricular Puncture p. 220
Mangesh Sudhakar Choudhari, Pankaj Haridas Pohekar
DOI:10.4103/jiae.jiae_56_19  
Point-of-care ultrasonography (POCUS) is the application of emergency ultrasonography at the place of patient care to make immediate patient care decisions. POCUS has an important role to play in emergency medical departments because POCUS can shorten time between the onset of symptoms and definitive treatment. Chest tube drain insertion is a simple procedure and routinely practiced. Left ventricular (LV) puncture due to chest drain is a lethal complication of chest tube placement. Early diagnosis and management is essential to save the patient. This case highlights the role of emergency echocardiography in managing LV puncture due to misplaced chest drain and its advantages over contrast-enhanced computerized tomographic scanning. In this case, POCUS helped in finding quick answers to clinical doubts and helped in the management of emergent conditions.
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INTERESTING IMAGES Top

Supravalvular Aortic Stenosis with Extensive Atherosclerosis and Fatal Premature Coronary Artery Disease Secondary to Homozygous Familial Hypercholesterolemia – So Early But Too Late!! p. 223
Pankaj Jariwala, Suresh Giragani
DOI:10.4103/jiae.jiae_45_19  
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An Unexpected Regression of the Ascending Aorta Dilatation in a Young Adult Patient p. 225
Tufan Cinar, Mert Ilker Hayiroğlu, Vedat Çiçek, Ahmet Lütfullah Orhan
DOI:10.4103/jiae.jiae_50_19  
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