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   Table of Contents - Current issue
Coverpage
May-August 2019
Volume 3 | Issue 2
Page Nos. 45-122

Online since Thursday, August 29, 2019

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ORIGINAL RESEARCH  

Recovery of left ventricular twist and left ventricular untwist rate in patients with ST-segment elevation acute myocardial infarction p. 45
Krasimira Hristova
DOI:10.4103/jiae.jiae_34_19  
Background: Left ventricular (LV) functional recovery and morphological remodeling after acute myocardial infarction (AMI) followed by reperfusion remain incompletely understood. The aim of the study was to describe the recovery of LV twist (LVT) and LV untwist rate (LVUR) upon revascularization after AMI using two-dimensional (2D) speckle tracking. Methods: We evaluated 88 subjects: 22 normal volunteers (mean age 31 ± 5 years), and 66 patients with AMI (mean age 65 ± 12 years), of which 40 had an inferior AMI and 26 an anterior one. All AMI patients had ST-segment elevation. Echocardiography was performed in all subjects. Patients were scanned within 36 h (baseline) after revascularization (percutaneous coronary intervention) and after 4 months (4 mFU). Apical and basal short-axis images were acquired (frame rate 67 ± 5 frames/s) and analyzed offline to extract the rotation (rate) curves. From these, maximal systolic LVT and peak LVUR were derived. Finally, the infarct size (IS) was estimated based on magnetic resonance imaging delayed enhancement and expressed as a percentage of the total LV volume. Results: At 36 h, LVT and LVUR were significantly reduced in both AMI groups when compared to normals. At 4 mFU, both AMI groups showed recovery in ejection fraction (EF) and reduction in IS (7.24 ± 10.07 vs. 20.13 ± 13.9, P < 0.0001 for inferior AMI and 13.13 ± 10.3 vs. 24.40 ± 15, P < 0.0001 for anterior AMI). LVT and LVUR increased significantly but remained below normal levels. Correlation of LVT and LVUR with IS was significant, but weak (r = 0.34 and r = 0.34, respectively). In addition, a fair correlation of LVT with EF (r = 0.64) and a weak correlation of LVUR with end-diastolic volume (r = 0.43) were found. Conclusion: LVT and LVUR are reduced in AMI patients early after reperfusion and recover incompletely upon follow-up. Interestingly, recovery of LVT characteristics as measured with this 2D speckle tracking-based method showed to be independent of infarct location or extent. LVT and LVUR might be good parameters to monitor the recovery of global LV function after treatment.
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Transesophageal echocardiography in patients of acute ischemic stroke p. 53
Rahul Mehrotra, Raj Kumar, Showkat Hussain Bhat, Bharat Bansal, Mohit Bhagwati
DOI:10.4103/jiae.jiae_46_18  
Background: Approximtely one third of cases of acute ischemic stroke are of undetermined etiology (cryptogenic). Among these cases, cardio embolic tend to be more severe than other causes. Transthoracic echocardiography is used as a standard imaging modality to study structural aspects of heart, however, transesophageal echocardiography (TEE) is a better and much more yielding modality. The present study was carried out in a tertiary care multispecialty hospital to enumerate the findings on TEE in the patients undergoing TEE for “cryptogenic stroke.” Methods: This retrospective observational study was done at our echo lab based on the TEE data of the last 10 years. Sixty-one consecutive adult patients admitted under department of neurology with a diagnosis of acute ischemic stroke and referred for TEE were included in the study. Results: Sixty one consecutive patients of cryptogenic acute ischemic stroke undergoing TEE were studied. Overall, 33% patients had grossly normal TEE findings. Patent foramen ovale (PFO) was the commonest abnormal finding present in 36%, atrial septal aneurysm (ASA) in 18% and both PFO and ASA were present in 18%. No statistical difference was noted between young (0-50 years) and elderly patients (>50 years) with respect to inter atrial septum abnormalities.Twenty eight percent had atheroma in descending aorta. Left atrial appendage clot or spontaneous echo contrast was present in 5% and vegetation was present in 5%. Conclusion: Dilated left atrium was present in 16% and left ventricular dysfunction was present in 18% of the patients. Our results reinforce the idea of a TEE examination in all patients of ischemic stroke which are not explained by routine clinical evaluation and transthoracic echo.
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Reproducibility of echocardiography in assessing left atrial reservoir function in rheumatic mitral valve disease p. 57
Mona A Elsaidy, Mohamed A Abdalaal, Ayman A Elsheikh, Sarah Elsharkawi
DOI:10.4103/jiae.jiae_13_19  
Background: Although abnormal left atrial (LA) reservoir function had been associated with clinical events in patients with mitral valve disease, its routine assessment is not performed due to inaccuracies and difficult time-consuming measurements. Aim: The aim was to study the feasibility and reproducibility of different echocardiographic parameters for LA assessment in patients with rheumatic mitral valve disease. Methods: Two hundred and fifty-nine patients with mitral valve disease underwent full echocardiographic examination. LA reservoir function was measured by two-dimensional (2D) volumes, 3D volumes, and global longitudinal strain (LA GLS). LA GLS, volumes, and total left atrial emptying fraction values were repeated to obtain the intra- and interobserver variabilities. The latter was performed between a nonexpert and two expert examiners. Results: 3D echocardiography was highly feasible in assessing LA function, feasibility was 94%, and was performed in the shortest time (1.3 ± 0.4, ANOVA, P < 0.0001). All LA 3D measurements showed excellent intraobserver and interobserver reproducibility between the two expert readers; coefficient of variation (CV) was 7% and 8%, respectively, for LA maximal volume index (LAVImax). Although CV for interobserver variability between the expert and nonexpert readers was 12% for 3D minimal LAVI (LAVImin), assessment of 2D LA volumes had the lowest reproducibility; CV was 15% for LAVImin. Conclusion: 3-d echocardiography assessment of LA volumes and function in patients with rheumatic heart disease is highly feasible and reproducible; it is easy to learn and can be easily performed by nonexperts.
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CONTEMPORARY TOPICS Top

Myocardial contrast echocardiography – Use in viability assessment and acute myocardial infarction p. 63
Jiwan Pradhan, Roxy Senior
DOI:10.4103/jiae.jiae_36_19  
Myocardial contrast echocardiography (MCE) is now guideline-directed tool to assess myocardial perfusion both at rest and during stress. Its prognostic value has been established in the scenario of stable and unstable coronary artery disease and heart failure through assessment of myocardial ischemia, myocardial viability, coronary flow reserve, and microvascular dysfunction. We will discuss the pathophysiologic basis of MCE and its role in myocardial viability assessment both in the setting of chronic ischemic left ventricular dysfunction and acute myocardial infarction.
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Intraoperative assessment of mitral regurgitation p. 66
Angela L Pollak, Madhav Swaminathan
DOI:10.4103/jiae.jiae_35_19  
Since its advent, transesophageal echocardiography (TEE) has played an important role in the surgical management of patients undergoing mitral valve (MV) surgery. Mitral regurgitation (MR) assessment and surgical decision making remains one of the most challenging situations, especially when considered in the context of ischemic heart disease or when associated with another dominant lesions. Techniques for MV repair are becoming more and more intricate with outcome studies strongly supporting repair in contrast to replacement in patients with primary MV pathology. It is in these scenarios that a comprehensive intraoperative TEE is invaluable. Once MR is detected, it is vital to assess the valve for both qualitative and quantitative features. The following text discusses the approach, challenges and value of intraoperative TEE in the assessment of MR.
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REVIEW ARTICLES Top

Stress echocardiography in aortic stenosis p. 71
Nitin Burkule
DOI:10.4103/jiae.jiae_41_19  
In apparently asymptomatic severe aortic stenosis (AS) group, stress echocardiography objectively identifies symptomatic, high-risk AS patients requiring early aortic valve replacement (AVR). The low-flow, low-gradient AS is well-characterized clinical entity with distinct diagnostic, management, and clinical outcome challenges. A comprehensive two-dimensional transthoracic echocardiography (2D echo) and Doppler and low-dose dobutamine stress echocardiography are of paramount importance for accurate diagnosis and timely decision of AVR. However, clinicians and imaging experts should be aware of the pitfalls and inaccuracies inherent in 2D echo/Doppler measurements and the effects of pathophysiological factors which impact the stroke volume and transvalvular gradient measurements. In appropriate clinical situations, clinicians should take additional help of cardiac computational tomography, cardiac magnetic resonance imaging, and biomarkers.
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Cardiac magnetic resonance imaging in infiltrative cardiomyopathy p. 78
A Pudhiavan, Richa Kothari, Vimal Raj
DOI:10.4103/jiae.jiae_2_19  
Infiltrative cardiomyopathies are a wide spectrum of disorders characterized by deposition of abnormal substances in the myocardium. These have a varied etiology and can be idiopathic, familial, or secondary to systemic disorders. The infiltrative process primarily causes a diastolic dysfunction resulting in heart failure with preserved ejection fraction. Common infiltrative cardiomyopathies encountered are cardiac amyloidosis, sarcoidosis, Fabry disease, iron overload cardiomyopathy, endomyocardial fibrosis, and idiopathic restrictive cardiomyopathy. Early and accurate detection of cause of infiltration is very important to improve outcomes through disease-specific therapies. Cardiac magnetic resonance (CMR) plays an important role in the diagnosis, avoiding the need of invasive endomyocardial biopsy in many cases. The use of postcontrast late gadolinium enhancement and T1 and T2 mapping sequences in CMR is improving diagnosis of infiltrative cardiomyopathy. In this review, we highlight the role of CMR in detection of different types of infiltrative cardiomyopathy.
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INTERESTING CASE REPORTS Top

Arrhythmogenic isolated left atrial cardiomyopathy p. 85
Madhu Shukla, Vishwas Mohan, Jagdish Chander Mohan
DOI:10.4103/jiae.jiae_14_19  
The atrial structure or substrate of patients with atrial arrhythmias can present very differently, and also, the “phenotype” of the arrhythmia cannot explain these differences. Idiopathic isolated atrial cardiomyopathy is a novel subtype of cardiomyopathy characterized possibly by atrial fibrosis that does not involve the ventricular myocardium and is associated with significant atrial tachyarrhythmia and no systemic, inflammatory, or infiltrative disease. We report a 57-year-old female doctor who presented with recurrent palpitations of 2-week duration and was shown to have normal left ventricular size, function, longitudinal strain, and filling pressures as judged by E/e' ratio and mitral early diastolic Doppler tissue velocities. The study of atria revealed markedly enlarged left atrium (LA), significantly reduced left atrial reservoir strain, and increased LA stiffness index. Frequent atrial ectopy may be manifestation of a structural atrial disease which could be termed arrhythmogenic isolated LA cardiomyopathy.
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Prenatal diagnosis of Ebstein's anomaly: An autopsy correlation predicting poor prognosis p. 88
Saji Philip, Shalom Elsy Philip, Linta Thampi, Sarasa Bharati
DOI:10.4103/jiae.jiae_22_19  
Ebstein's anomaly (EA) is rare but not an uncommon congenital heart disease in the fetus. Fetal echocardiogram has progressed to detect many forms of congenital heart diseases, especially to assess the prognosis of EA based on their anatomy and presentation in utero causing nonimmune hydrops. Fetal echocardiographic findings of cardiomegaly, apical displacement of tricuspid valve with severe regurgitation, can confirm the diagnosis of EA in utero. Severe cardiomegaly and nonimmune hydrops further contribute poor prognosis leading to fetal demise. Identifying fetal risk factors for predicting perinatal mortality is important, including the lack of antegrade flow across the pulmonary valve and retrograde duct flow. Here, we describe fetal echocardiographic findings of a case of EA causing severe cardiomegaly, restricted growth of the lungs, and hydrops in a 26-year-old primigravida at 20 weeks of gestation. The diagnosis was further correlated with the autopsy, characterized by severe cardiomegaly, huge right atrium, apical displacement, and tethering of septal and posterior leaflet, with markedly reduced lung volumes. Autopsy findings of dilated ductus further suggestive of possible reversed ductal flow causing circular shunt in EA raising the possibility of the poor postnatal outcome, even intrauterine death, and warranted for safe termination. Poor prognostic factors in EA have also been discussed with autopsy findings.
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A rare combination of anomalous origin of right pulmonary artery from the ascending aorta with congenital tricuspid valve anomaly and severe tricuspid regurgitation p. 93
Rakesh Koranchery, Gopalan Nair Rajesh
DOI:10.4103/jiae.jiae_43_18  
Anomalous origin of a pulmonary artery (PA) from the aorta is a rare presentation in adulthood. As these patients invariably develop severe pulmonary hypertension in infancy itself, prognosis is poor. Here, we present a patient with anomalous origin of right PA from the aorta and congenital tricuspid valve anomaly with severe tricuspid regurgitation, a very rare combination surviving to adult life.
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Quadrivalvular rheumatic heart disease p. 97
Deepak Ramchand Nenwani, Gnanavelu Ganesan, S Venkatesan, S Saravana Babu
DOI:10.4103/jiae.jiae_45_18  
Rarely, rheumatic heart disease (RHD) involves all the four valves and causes could be rheumatic, congenital, infective, or degenerative. Here, we report a case of a 42-year-old female known case RHD for 30 years and underwent closed mitral commissurotomy 25 years back presented with progressive exertional dyspnea for the past 1 year. On clinical examination, she was in atrial fibrillation with evidence of the involvement of the mitral, aortic, and tricuspid valves. Transthoracic echocardiography showed the quadrivalvular involvement including pulmonary valves. Only few case reports are available describing rheumatic quadrivalvular damage.
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Type 9 dual left anterior descending artery or triple left anterior descending artery anomaly: A rare anomaly p. 99
Pankaj Jariwala, Rajani S Sunnadkal
DOI:10.4103/jiae.jiae_5_19  
A middle aged patient presented with acute coronary syndrome. Echocardiography showed regional wall abnormality in the left anterior descending artery territory with reduced left ventricular dysfunction. Coronary angiogram showed early division, suggestive of a rare case of dual LAD.
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Pericardial tamponade due to main pulmonary artery dissection in a young patient with eisenmenger's syndrome p. 101
Rohit Tandon, Hitesh Gupta, Gurpreet Singh Wander, Abhishek Goyal
DOI:10.4103/jiae.jiae_8_19  
Spontaneous pulmonary artery dissection is a rare catastrophic emergency. Its clinical course and natural history is not well studied due to paucity of available cases in the literature, so optimal management guidelines are lacking. Easy availability of bedside echocardiography has made early diagnosis of these near-miss cases possible. We describe a case of a 36-year-old male, a known case of Eisenmenger's syndrome (secondary to unoperated large ventricular septal defect), who presented to us in cardiogenic shock due to spontaneous main pulmonary artery dissection readily diagnosed and confirmed by bedside three-dimensional echocardiography.
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Aortic intimo-intimal intussusception: A rare variant of aortic dissection p. 104
MN Dilip, A George Koshy, Mathew Iype, K Sunitha Viswanathan
DOI:10.4103/jiae.jiae_40_18  
This report describes a very rare and life-threatening form of Stanford Type A circumferential aortic dissection causing intimo-intimal intussusception. Rapid and accurate diagnosis is possible by transesophageal echocardiography for which the features have been described in this article.
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A large undulating left ventricular apical thrombus encroaching up to aortic valve p. 107
Sanjeev Sanghvi, Swati Mahajan
DOI:10.4103/jiae.jiae_1_19  
Left ventricular (LV) thrombus is a serious complication of acute myocardial infarction (MI) with the risk of systemic thromboembolism. Two-dimensional echocardiography (2D-Echo) allows detection and is an important tool for the follow-up of such cases. Our patient had suffered from an acute ischemic stroke and was referred by the treating neurologist for changes in the electrocardiogram. The patient had anterior wall MI, and 2D-echo showed a large LV thrombus. He was started on anticoagulants to prevent future thromboembolic events.
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MESSAGE FROM THE ASE PRESIDENT Top

Building a global and diverse community of echo enthusiasts p. 109
Madhav Swaminathan
DOI:10.4103/jiae.jiae_23_19  
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FROM THE EDITORS DESK Top

History behind development of echocardiography in India p. 110
Satish K Parashar
DOI:10.4103/jiae.jiae_39_19  
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