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   Table of Contents - Current issue
September-December 2018
Volume 2 | Issue 3
Page Nos. 147-200

Online since Monday, December 10, 2018

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Estimation of Z-scores of cardiac structures in healthy Indian pediatric population p. 147
Bhadra Trivedi, Manish Chokhandre, Poornima Dhobe, Swati Garekar
Introduction: Nomograms of pediatric cardiac structures are an effective tool to differentiate between normal and abnormal changes in dimensions of the heart. There is impending need for nomograms of Z-Scores of echocardiographic data derived from Indian children. Objective: The main objective of this study is to gather echocardiographic data from the healthy Indian pediatric population visiting the pediatric cardiology outpatient clinic and to derive the Z-Scores for various cardiac structures. Materials and Methods: All the echocardiographic studies from an eligible normal Indian population at a single centre were assessed. All the studies were performed on a single vendor echocardiography machine using weight appropriate neonatal, pediatric, and adult probes. Statistical Analysis: Body surface area (BSA) was used as an independent variable in a nonlinear regression analysis for the predicted mean value of each of the 19 echocardiographically measured structures. Results: The total number of children evaluated during the study period was 596, with age ranging from newborn to 16 years. The total parameters collected in the study were 8102. The correlation with Haycock's BSA and an individual parameter was found to be the most sensitive predictor of normal progression with age. Relationship of individual parameters with BSA was represented in the form of graphs. Conclusion: This study of normal Indian pediatric population is the largest Indian study to date. The regression formulae along with the graphs can be used to acquire the Z score of 19 individual echocardiographic parameters.
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A journey from adult to fetal echocardiography p. 155
UP Singh, Hargunbir Singh, Ladbans Kaur
As a cardiologist in a group practice or hospital settings, many a times you are requested to comment on fetal Echocardiography performed by radiologist or fetal medicine specialist. With overconfidence, we perform or comment on fetal echocardiography without knowing critical differences between adult and fetal echocardiography. First, fetal heart at 20 weeks of gestation is of the size of an almond. Due to the limitation of resolution of ultrasound machines, small size of fetal heart makes it difficult to visualize many direct signs of congenital heart defects such as total anomalous pulmonary venous connection (TAPVC), transposition of the great arteries (TGA), coarctation, and double outlet right ventricle (RV). Hence, in fetal echo, we use indirect signs and clues to diagnose these disorders. Second, there are two physiological shunts in fetal circulation; fossa ovalis and ductus arteriosus which make its very different from adult circulation. A cardiologist needs to know about indirect signs, special views, peculiar fetal cardiac defects, and hemodynamics of fetal circulation before attempting fetal echocardiography. Many of us have an impression that fetal heart is just a miniature form of adult heart. Fetal echocardiography is a lot different from adult or pediatric echocardiography because there are many structural and functional differences in fetal circulation. Moreover, many congenital heart defects such as TGA, TAPVC, and ventricular septal defect, can present with only subtle findings, so we need to be more vigilant while performing fetal echocardiography.
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Evaluation of right ventricle p. 161
Sulagna Banerjee, Soumitra Kumar
Right Ventricle (RV) has been treated as the neglected cardiac chamber for a long time. Advent of cardiac MRI and advancements in echocardiography have facilitated the understanding of RV structure and function and elucidated its role in management and prognosis of various cardiac ailments. Further refinement of three-dimensional (3D) and strain imaging and their application to study of right ventricular structural and functional abnormalities will be helpful in early identification of cardiac pathologies and their timely intervention.
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Double aortic arch presenting with neonatal respiratory distress but not due to airway obstruction: Anatomic and embryologic explanation p. 167
Vinoth Duraiswamy, Rajeshkumar Ramasamy, Kothandam Sivakumar
Double aortic arch resulting from embryonic persistence of bilateral fourth branchial arches often leads to neonatal stridor due to tracheal compression. Two neonates presented with dyspnea without evidence of tracheal compression. An aneurysmal ductal aneurysm from the left-sided arch in the first neonate led to symptoms. Spontaneous duct closure and regression of ductal aneurysm led to relief of symptoms. Second neonate had severe neonatal pulmonary hypertension due to aortic origin of left pulmonary artery (LPA) that was disconnected from main PA. Surgical reanastomosis of the LPA and division of the smaller right arch corrected the anatomy. These two associations show that airway obstruction alone is not the cause of respiratory symptoms in neonates with double aortic arch.
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Serendipitous continuous murmur in an octogenarian turned out to be an asymptomatic ruptured sinus of Valsalva p. 170
Iragavarapu Tammiraju, S Akhil, A Aswini Kumar
Sinus of Valsalva aneurysm is a rare cardiac anomaly which is more often congenital than acquired. Rupture of the aneurysm can present as plain as an asymptomatic murmur to as dramatic as a myocardial infarction or cardiogenic shock or even death. Ruptured sinus of Valsalva (RSOV) is very rare in the elderly, and an asymptomatic rupture in an octogenarian is rarer still. An octogenarian, accompanying his wife for her diabetic follow-up, was found to have a continuous murmur by chance examination. Echocardiography unmasked a RSOV; surprisingly, the elderly man was completely asymptomatic. The patient was referred to a cardiothoracic center for further management. A RSOV is a precarious disposition needing prompt recognition and urgent intervention even though asymptomatic. This case report highlights the importance of recognizing such entities even among the elderly despite its rarity. This case also highlights the cardiovascular auscultation as one of the most important, simple, and inexpensive clinical investigations.
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Tachycardia-induced cardiomyopathy in a teenage boy p. 174
Rajesh Krishnachandra Shah
Tachycardiomyopathy or tachycardia-induced cardiomyopathy (TIC) is a relatively rare but completely or partially treatable condition, where there is an impairment of left ventricular (LV) function secondary to chronic, continuous, or intermittent tachycardia, which presents as heart failure. It has been shown that the rate control by means such as cardioversion, negative chronotropic agents, and surgical- or catheter-based atrioventricular nodal ablation, depending on the etiology, resulted in significant improvement of systolic function. The diagnosis of TIC is entertained following the observation of improvement in LV systolic function, after necessary therapy to control the arrhythmia or heart rate. It is necessary that the clinicians should have a high index of suspicion while dealing with LV systolic dysfunction or dilated cardiomyopathy and should control the arrhythmia stringently. This case report describes a 14-year-old boy presenting with breathlessness of 18–24-month duration who had features of dilated cardiomyopathy on echocardiography. Impaired LV systolic function was due to fascicular ventricular tachycardia and he recovered completely after catheter-based ablation within a period of 5–6 months.
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Submitral aneurysm: A rare cause of complete heart block p. 179
Jaywant M Nawale, Rajendra V Chavan, Meghav M Shah, Ajay S Chaurasia, Digvijay Nalawade
Subvalvular left ventricular (LV) aneurysms are rare and are of two types – subaortic and submitral. More commonly, they are submitral in position. Submitral aneurysms (SMAs) are most commonly located below posterior mitral leaflet (PML), whereas subaortic aneurysms are present below intermediate portion of the left aortic sinus. SMA was first described by Corvisart in 1812, and since then, only about 100–120 cases have been described worldwide. Aneurysmal dilatation in submitral position behind PML that communicates with left ventricle helps in making the diagnosis. Color Doppler echocardiography reveals the severity of mitral regurgitation. Transesophageal echocardiography and contrast-enhanced computed tomography (CT) are helpful in diagnosis in cases of acute rupture of SMA, and contrast-enhanced CT helps in evaluation of coronaries. Surgical resection is the definitive treatment for these aneurysms. Our special case presented with complaints of giddiness and presyncope and was diagnosed as complete heart block on electrocardiogram and was then diagnosed as having a large SMA on two-dimensional echocardiogram with LV dysfunction. Usually, SMAs present with dyspnea, pansystolic murmurs due to mitral regurgitation, fever secondary to infective endocarditis, or as thromboembolism. However, this patient presented symptoms of complete heart block. To conclude, SMA should be considered in differential diagnosis of mitral regurgitation with LV dysfunction and heart failure in young patients. Although complete heart block is uncommon in these patients, it should be kept in mind.
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An unusual case of right atrial mass p. 182
Chetana Krishnegowda, Rangaraj Ramalingam, K Subramanyam, Anand Palakshachar, Manjunath Nanjappa Cholenahally, Nagraj Moorthy
Imaging modalities are invaluable noninvasive tools in identifying and diagnosing intracardiac masses. However, it is not always easy to differentiate one from the other. Here, we report an unusual case of right atrial mass in a 54-year-old man presenting with atypical chest pain, in whom despite the multimodal approach, the histopathology study was the one that gave us the definitive diagnosis.
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Effect of arrhythmias on tissue Doppler velocities p. 185
Sita Ram Mittal
Sa wave of tissue Doppler imaging correlates with ventricular systole (QRS-T of electrocardiogram). Ea wave correlates with ventricular filling in early diastole. Aa wave correlates with ventricular filling during atrial contraction and correlates with P wave of electrocardiogram. Therefore, a careful analysis of the relation between Ea and Aa waves gives a correct impression about the underlying cardiac arrhythmia. In sinus bradycardia, all waves are normal, but the distance between Ea and Aa wave is increased. In sinus tachycardia, Aa wave comes closer to Ea wave and may even fuse with Ea wave due to shortened diastole. Prematurely occurring Aa wave suggests atrial premature beat. The absence of Aa wave suggests atrial fibrillation. More than one Aa wave per cardiac cycle suggests atrial flutter. Premature Sa wave suggests ventricular premature beat. Increased distance between Aa wave and Sa wave suggests first-degree atrioventricular (AV) block. Progressive decrease of the distance between Ea and Aa waves till one Aa wave fuses with preceding Ea wave followed by a pause suggests Wenckebach phenomenon. In 2:1 AV block, one Aa wave is fused with Ea wave and the next Aa wave is followed by Sa and Ea waves. Sa and Ea waves occur regularly at a slow rate and Aa wave occurs regularly at a fast rate; thus, total dissociation between Ea and Aa waves suggests complete AV block. Usually, the person performing echocardiography is not aware of electrocardiography (ECG) findings. Clinicians may not be aware of the ECG findings when they are interpreting the tissue Doppler images. Further, arrhythmia recorded during tissue Doppler imaging need not necessarily be present in the 10 s ECG recorded routinely. Knowledge of the effect of arrhythmia on tissue Doppler findings helps in correct interpretation of the tissue Doppler findings.
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Immediate and delayed distal stent migration in congenital coarctation of the aorta: Sliding over an elephant trunk! p. 191
Pankaj Jariwala, Satya Sridhar Kale, Lakshmana Sepur, Ragam Chenna Kesava Rao
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Novel demographic capture employing electronic and social media: Preliminary report from the national cardiac sonographer survey Highly accessed article p. 193
K Praveen Kumar, Raju Rambothu, Rupali Shah, Aparna Sacchit Thakur, Sandya Nandakumar, PS Kumarvel, Vidyasagar Reddy Meesala, Aswini Umashankar, Prashanth Gunasekar, Ashwin Venkateshvaran
Background: While cardiac sonography is recognized as a skilled allied health profession in the developed world, sonographers are relatively unorganized in India. This survey aimed to capture basic demographic data of this organically growing community employing electronic and social media platforms. Materials and Methods: A predominantly multiple-choice-based questionnaire was created using a free, open-access survey platform and circulated on available sonographer social media forums, messenger groups, and E-mail lists. Information distribution, data collection, and response analysis were entirely paperless. Results: Between July 2017 and April 2018, 290 sonographers from 19 states participated in this survey. Forty-six allied health courses offering echocardiography were identified across India. A majority of respondents and identified courses were based in the South and West India. About 62% of the sonographers were women, and approximately 60% were <30 years old. Multiple training pathways were displayed, and >30% held university-level degrees in echocardiography. More than 50% were early to mid-career sonographers and scanned more than 20 patients a day. All sonographer scanned under authorized supervision. A minority were credentialed after training. Less than 1 in 3 were members of the National Indian Academy of Echocardiography. Conclusions: Preliminary analysis in this ongoing survey suggests that the Indian sonographer community is young, predominantly female, and generally work in hospital-based clinical environments. Sonographer credentialing, enhanced society engagement and continuous medical education may support career development and contribute to the society's goals to promote echocardiography practice and education in India.
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Modified parameter of two-dimensional echocardiographic Wilkins score for assessment of rheumatic mitral valve stenosis p. 197
Wassam El Din Hadad El Shafey
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Update from the editor of the journal American society of echocardiography p. 199
Michael H Picard
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