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   Table of Contents - Current issue
January-April 2020
Volume 4 | Issue 1
Page Nos. 1-143

Online since Saturday, April 11, 2020

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Comparison of Traditional and Novel Markers of Subclinical Atherosclerosis for Evaluating Cardiovascular Risk in Asymptomatic Population p. 1
Rohit Tandon, Mamta Bansal, Namita Bansal, Abhishek Goyal, Bhupinder Singh, Shibba Takkar Chabbra, Naved Aslam, Bishav Mohan, Gurpreet S. Wander
Background: There is a definite need to identify markers that could offer greater discrimination of high- and low-risk patients within the general population at risk of cardiovascular disease (CVD). We tried to estimate the cardiovascular (CV) risk using novel imaging markers and compared them with traditional risk scores and biochemical markers. The study aimed at (1) evaluating the estimation of anthropometric, biochemical measurements (body surface area, body mass index, and lipid profile) along with novel imaging markers carotid intima-media thickness test (CIMT) and epicardial adipose tissue (EAT) for subclinical atherosclerosis carotid-femoral pulse wave velocity (CFPWV) for vascular stiffness; (2) comparing anthropometric markers, biochemical markers, and imaging markers in the study population with clinical risk prediction algorithms (American College of Cardiology/American Heart Association [ACC/AHA] atherosclerotic CVD [ASCVD] Risk Calculator). Materials and Methods: This was a prospective cross-sectional study done at a tertiary-level cardiac facility for a duration of 3 months. The study population consisted of apparently healthy individuals between the age group of 40 and 65 years. Persons with established ASCVD, chronic liver disease, chronic kidney disease, history of diabetes mellitus, or hypertension >7 years were excluded from the study. Results: Two hundred and seventy-seven individuals were included and divided into two groups based on the ACC/AHA ASCVD Risk Calculator. Individuals with <5% risk of ASCVD death/myocardial infarction/stroke over 10 years were included in low-risk group while individuals with 5%–15% risk of ASCVD death/myocardial infarction/stroke over 10 years were included in moderate-risk group. The relationship of these imaging parameters with ACC/AHA risk score was 8%, 16%, and 30% for CIMT, EAT, and CFPWV, respectively, whereas for total cholesterol/high-density lipoprotein (TC/HDL) ratio, it was 13% meaning that CIMT and TC/HDL ratio have weak correlation as compared to EAT and CFPWV. Inter-marker correlation with ACC/AHA Risk Calculator was 30% (P < 0.0001) for CFPWV, 16% (P = 0.008) for EAT, 13% (P = 0.026) for TC/HDL ratio, and 8% (P = 0.181) for CIMT. Multivariate regression showed that age, mean arterial blood pressure, history of diabetes mellitus, and EAT remain statistically significant parameters. Conclusion: Our study results suggested that both EAT and CFPWV measurements add incremental value over traditional methods for ASCVD risk stratification and should be of additional value over traditional methods for estimating ASCVD risk of an individual.
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Effect of Off-pump Coronary Artery Bypass Graft Surgery on Transthoracic Echocardiographic Right Ventricular Function in Indian Patients p. 7
Veenu John, Anju Thomas, Madhuprakash Sorekaidoddi Chikkamadegowda, Rajagopal Jambunathan
Background: The importance of the right ventricle as a determinant of exercise capacity and its significant prognostic value in the evaluation of surgical outcomes has been largely proven. In this study, we sought to explore the effect of off-pump coronary artery bypass surgery (OPCAB) on right ventricular (RV) function by the different methods of RV functional assessment on transthoracic echocardiography. Materials and Methods: This is a prospective cohort study. All patients undergoing elective OPCAB were included in the study from July 1, 2016, to October 1, 2016 after an informed consent. Their preoperative, postoperative day 4, and postoperative 2-month transthoracic echocardiographic RV and left ventricular functions were evaluated and analyzed. Results: A total of 48 patients undergoing OPCAB were included in this study. The mean age of the cohort was 57.2 ± 8 years. About 85.4% (41) were males. Overall, there is a significant time effect observed in RV ejection fraction (RVEF), with a significant decline from preoperative to postoperative value and a significant increase from postoperative day 4 to postoperative 2-month value. Although RVEF was lower throughout the study in patients with events than those without events, this difference was not statistically significant. Conclusion: In this Indian cohort of patients undergoing OPCAB, there is a significant drop in RVEF, RV tissue Doppler, tricuspid annular peak systolic excursion on postoperative day 4, and also a significant increase in these values over the next 2 months though not reaching the basal value. Hence, suggesting that the drop in RV function is temporary and recovers over time in patients undergoing OPCAB. Patients with events had a lower RVEF when compared to those without events suggesting prognostication.
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Role of Flow Propagation Velocity Across Mitral Valve in the Assessment of Diastolic Dysfunction and Prognostication in Acute Myocardial Infarction p. 11
Ravi Vishnu Prasad, Kumar Vikram Singh, K. K. Sethi, Sukhvinder Singh
Background: The importance of left ventricular (LV) systolic dysfunction as a predictor of mortality and morbidity after acute myocardial infarction (MI) is well known. In MI, Doppler echocardiography can be used to determine the LV diastolic function, and a restrictive transmitral flow pattern has been related to the development of congestive heart failure and increased mortality. In patients with various etiologies of LV systolic dysfunction, restrictive filling has also proven to be an independent predictor of adverse outcome. Materials and Methods: 130 patients who presented with diagnosis of acute MI were included. Echocardiography was performed within 24 hours of arrival to the coronary care unit. Most widely used approach for measuring mitral-to-apical flow was used for velocity propagation. Based on the ratio E/Vp, patients divided into two groups with E/Vp <1.5 and E/Vp >1.5. Patients were followed up subsequently. Results: In the study population, the average age of patients was 59 ± 11.6 years. There were 105 male (80.77%) and 25 female patients (19.23%). On evaluation of risk factors, 69 patients (53.08%) were hypertensive, 71 patients (54.62%) were diabetic, 7 patients (5.38%) were smokers, and 43 patients (33.08%) had dyslipidemia. In patients with E/Vp <1.5, 31 patients (73.81%) had Grade I diastolic dysfunction (DD) and 10 patients (23.81%) had Grade II DD. One patient (2.38%) had Grade III DD. In patients with E/Vp >1.5, 20 patients (22.73%) had Grade I DD, 52 patients (59.09%) had Grade II DD and 16 patients (18.18%) had Grade III DD. Conclusion: In this echocardiographic study of 130 patients with MI E/Vp measured with color M mode is easily obtainable and this E/Vp is a strong predictor of heart failure and mortality. The ratio of peak E wave velocity to flow propagation velocity can be used with other diastolic function variables in predicting outcome. Furthermore, these Doppler variables may be used as simple tools to rapidly risk stratify patients with acute MI.
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Global Longitudinal Strain in Patients with ST-Elevation Myocardial Infarction Post-percutaneous Coronary Intervention Using Speckle Tracking Echocardiography p. 18
Swati Mahajan, Sanjeev Sanghvi, Pawan Sarda, Pal Singh Yadav
Background: Routinely, two-dimensional (2D) left ventricular ejection fraction (LVEF) is used to assess the left ventricular (LV) systolic function. Lately, global longitudinal peak systolic strain (GLPSS) has emerged to be a more sensitive tool for assessing LV systolic function. We aimed to assess the superiority of GLPSS by 2D speckle-tracking echocardiography in patients with ST-elevation myocardial infarction (STEMI) before and within 48 h after percutaneous coronary intervention (PCI) over 2D-LVEF calculated using the Simpson's biplane method of disks. Materials and Methods: A total of 70 patients with STEMI who underwent PCI were included in this study, which was conducted in the Department of Cardiology, MDM hospital, Jodhpur, Rajasthan, India, between November 2018 and February 2019. Patients having preexisting cardiomyopathy, moderate-to-severe valvular heart disease, morbid obesity, and poor echocardiographic window were excluded from the study. Echocardiography before and within 48 h of PCI was done. 2D-LVEF was calculated using Simpson's method. GLPSS was assessed using the automated function imaging technique. Results: Post-PCI GLPSS increased significantly compared to pre-PCI value (−17.68 vs. −16.65;P < 0.002). 2D-LVEF, on the contrary, did not show any significant increase post-PCI (40.1 vs. 40.57;P = 0.98). Furthermore, the improvement in the average GLPSS was significantly higher when the target vessel revascularized was nonleft anterior descending (LAD) than LAD (−18.32 vs. −17.46;P < 0.001) . Conclusion: The assessment of LV systolic function after PCI in patients with STEMI was superior with GLPSS when compared to 2D LVEF. As strain imaging is an inexpensive tool, it can be applied easily to assess LV function in the large subset of population.
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Global Longitudinal Strain: A practical Step-by-Step Approach to Longitudinal Strain Imaging Highly accessed article p. 22
Govindan Vijayaraghavan, Sivasubramonian Sivasankaran
Global longitudinal strain imaging of the left ventricle is a simple bedside modality for objectively assessing the global and regional function of the major pumping chamber of the heart, the left ventricle. Currently available echo machines provide good quality speckle-tracking methods with good computational facilities providing standard, comparable bull's eye maps and parametric plots. This introductory chapter provides a step-by-step approach for the beginner to utilize this additional facility in day-to-day practice to precisely understand the left ventricular regional and global function for serial follow-up and prognostication. Pattern recognition is illustrated in the following article. Essentially, this article illustrates what the pictures mean and how to generate these meaningful echo pictures.
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Role of Chest X-ray for the Detection of Pulmonary Thromboembolism: A Critical Evaluation p. 29
Rishabh Khurana, Poonam Khurana, Parveen Kumar, Dhairya Shrivastava, Sameer Shrivastava
Pulmonary thromboembolism is a common prevalent problem leading to various kinds of morbidities and can be the potential cause of deaths directly or indirectly in approximately onethird of the cases. Early diagnosis accompanied by early treatment has shown to reduce the morbidity. Due to variable clinical presentation and non-specific symptoms, early diagnosis can be challenging at times. Suspecting this entity on plain radiograph can play important role in early detection and use of subsequent image modalities, i.e. CT angiography and/or echocardiography to establish the diagnosis, leading to improved outcomes. This review highlights the role of chest X ray and CT in diagnosis of pulmonary thromboembolism.
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Hypereosinophilic Syndrome: What to Expect in Echo p. 33
Ashok Garg, Deepak Agrawal, G. L. Sharma
Hypereosinophilic syndrome is characterized by eosinophilic tissue damage. The clinical presentation is variable. When there is cardiac involvement, which occurs in 40%–60% of cases, it is referred commonly as Loeffler's endocarditis. Recently, a unique case report was published by Dr. Garg et al., in which they described pulmonary valve involvement with thickening and stenosis detected by two-dimensional transthoracic echocardiography in an adult presenting with Loeffler's endocarditis. Based on this case report, we review this topic to elucidate various manifestations of hypereosinophilic syndrome, which we should expect during echocardiography.
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Very Early and Unusual Aortic Bioprosthetic Valve Deterioration 9 Months after Implantation p. 36
Madhu Shukla, Vishwas Mohan, Jagdish C. Mohan
Every component of valvular bioprostheses is prone to variable structural deterioration secondary to multifactorial etiopathogenesis. Calcific degeneration is the most common phenomenon. However, it is a slow process in the elderly and typically starts after several years of implantation. We herein report a very early bioprosthesis deterioration of unknown etiology due to inward bending of the stent posts (“stent creep”) causing severe aortic stenosis. Nine months after aortic valve replacement with a 21-mm Epic Supra bioprosthesis (St. Jude Medical, St. Paul, MN, USA) with concomitant coronary artery bypass grafting and carotid endarterectomy, valve orifice narrowing with leaflet restriction and markedly reduced geometric orifice of the outflow causing severe valvular stenosis was documented in a 72-year-old man. A possible reason for this extremely early deterioration was circumferential compression of the bioprosthesis stent causing inward bending of the stent posts. The patient refused redo surgery and continued to be symptomatic with dyspnea for the next 2 years till his demise.
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Embolic ST-segment elevation myocardial infarction following aortic prosthetic valve replacement: Diagnosis and management issues p. 39
Deepak R. Nenwani, M. Nanda Kumaran, S. Venkatesan, C. Elangovan, P. M. Nageshwaran, J Cecilly Mary Majella
Acute thromboembolism resulting in ST-segment elevation myocardial infarction years after aortic valve replacement (AVR) is an uncommon occurrence. 38 years old female admitted with chest pain of 8 hours duration. Patient had history of Aortic valve replacement 3 years. Patient on evaluation found to have infero-lateral wall myocardial infarction. Coronary angiography (CAG) was done, which showed occlusive thrombus in the left coronary artery. The left circumflex artery after second obtuse marginal branch had total occlusion, and distal left anterior descending had total occlusion with thrombus containing lesion, whereas the right coronary artery was normal. The patient was thrombolyzed with intravenous streptokinase 1.5 mIU over 30 min infusion with door-to-needle time of 75 min. Pre- and postprocedure echocardiogram showed no evidence of thrombus. Gradient across the aortic valve and mobility was within the normal limits. Check CAG after 7 days showed resolution of thrombus burden in coronaries.
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Left Atrial Myxoma: A Great Masquerader with Multiple Clinical Faces – A Case Series p. 42
Mohamed Iliyas, N. Swaminathan, Gnanavelu Ganesan, Venkatesan Sangareddi
While syphilis and pulmonary embolism are well known with the eponym of “The Great Masquerader,” atrial myxoma should also be given the eponym due to its variable presentations and frequent misdiagnosis. Myxoma is the most common primary tumor of the adult heart, which is silent and is discovered incidentally. We would like to present three consecutive patients who attended our department with different symptomatologies over a time frame of 2 months. Later, all the three patients were found to be having the same lesion in the left atrium.
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Cor Triatriatum Sinister p. 45
Ishita Banerji
A 10-year-old boy presented with complaints of poor weight gain, progressively increasing dyspnea since early childhood, and orthopnea. Echocardiogram was suggestive of cor triatriatum. Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium (cor triatriatum sinister) or the right atrium (cor triatriatum dextrum) is divided into two compartments by an abnormal fibromuscular septum usually with an opening between the two chambers associated with varying degrees of obstruction of the pulmonary veins. The pulmonary venous return is followed by pulmonary arterial hypertension. Cor triatriatum literally means a heart with three atria (triatrial heart), namely, the superior chamber, the inferior chamber or the true atrium, and the atrial appendage. This anomaly occurs in 0.4% of patients with congenital heart defects, with a slight male predominance. The present case of cor triatriatum sinister is being reported in view of the fact that the child remained undiagnosed till the age of 10 years, despite being “sick since a little boy” requiring multiple hospital admissions for chest infections. He had been receiving treatment for “chest problem” and had been on bronchodilators. The classical echocardiographic findings would be of academic interest as well.
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A Rare Case of Coexisting Subaortic and Submitral Left Ventricular Aneurysms p. 49
Biswaranjan Mishra
Subvalvar left ventricular aneurysm is a rare disorder. Commonly it occurs below the posterior annulus of the mitral valve. Rarely the aneurysm may be found below the aortic annulus. Coexistence of both aortic and submitral aneurysms is still rarer. Here is a 58-year-male who presented with heart failure. Echo revealed an aneurysm below the aortic annulus adjacent to right coronary cusp collapsing in diastole and enlarging in systole. Doppler interrogation showed flow into and out of aneurysm from left ventricle and mild aortic regurgitation. In addition there was a submitral aneurysm below the posterior mitral leaflet with a single localised neck and mild mitral regurgitation. There was evidence of moderate left ventricular systolic dysfunction and grade II diastolic dysfunction with features of right heart failure. He was given diuretics and referred for surgery.
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Pericardial Constriction with Severe Mitral Regurgitation: An Uncommon Association p. 53
Saurabh Ajit Deshpande, A. George Koshy, Mathew Iype, K. Sunitha Viswanathan
Pericardial constriction is a condition, in which there is a lack of transmission of changes in intrathoracic pressures to the structures encased in pericardium due to thickened, fibrosed, and most of the cases, calcified pericardium. A 24-year-old male presented to us in right heart failure. There was a history of diagnosis of acute rheumatic fever with carditis in childhood. X-ray and echocardiogram gave us a probable diagnosis of rheumatic constrictive pericarditis (CP) with mitral regurgitation (MR). The diagnosis of CP was confirmed with computed tomography chest and invasive hemodynamic assessment. He had significantly elevated pulmonary artery (PA) pressures and elevated left ventricular dip diastolic pressures, which were unexpected findings. We have discussed the probable causes of associated MR and elevated PA pressures in this case report. We have also tried to differentiate CP from restrictive cardiomyopathy, specifically endomyocardial fibrosis, which is common in the state of Kerala.
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Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance p. 58
William A. Zoghbi, David Adams, Robert O. Bonow, Maurice Enriquez-Sarano, Elyse Foster, Paul A. Grayburn, Rebecca T. Hahn, Yuchi Han, Judy Hung, Roberto M. Lang, Stephen H. Little, Dipan J. Shah, Stanton Shernan, Paaladinesh Thavendiranathan, James D. Thomas, Neil J. Weissman
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Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in Adults: A Report from the American Society of Echocardiography p. 122
Thomas R. Porter, Sasha K. Shillcutt, Mark S. Adams, Georges Desjardins, Kathryn E. Glas, Joan J. Olson, Richard W. Troughton
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ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak p. 137
Contributors: James Kirkpatrick, Carol Mitchell, Cynthia Taub, Smadar Kort, Judy Hung, Madhav Swaminathan
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