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   Table of Contents - Current issue
Coverpage
September-December 2020
Volume 4 | Issue 3
Page Nos. 227-396

Online since Friday, December 18, 2020

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ORIGINAL RESEARCH  

Effect of General Endotracheal Anesthesia and Mechanical Ventilation on the Echocardiographic Measurements in Severe Aortic Stenosis Highly accessed article p. 227
Muralidhar Kanchi, Rudresh Manjunath, Pooja Natarajan, Kumar Belani
DOI:10.4103/jiae.jiae_17_20  
Introduction: We measured the peak pressure gradient (pPG) and mean pressure gradient (mPG) obtained by transesophageal echocardiography (TEE) after induction of anesthesia and compared it with the preoperative pPG and mPG by transthoracic echocardiography (TTE) in adults with aortic stenosis (AS). We also compared the aortic valve area (AVA) measurements as obtained preoperatively by TTE versus those by TEE following induction of general endotracheal anesthesia (GETA) during the inspiratory phase, expiratory phase of the ventilatory cycle and with incremental increases in tidal volume. Materials and Methods: All patients had preoperative TTE within 1 month of surgery and was reviewed 1 day before the surgery. After anesthetic induction, precardiopulmonary bypass (CPB) TEE evaluation was done to measure mPG and pPG across AV, under steady-state conditions. Three different controlled tidal volumes: 8 ml, 10 ml, and 12 ml per kg body weight were utilized during the TEE measurements. Results: A total of 90 adults underwent aortic valve replacement from 2017 to 2018. The preoperative pPG and mPG across the AV by TTE was 96.7 ± 23.27 mmHg and 60.7 ± 18.1 mmHg, respectively. Compared to preoperative TTE, pre-CPB TEE pressure gradient during both phases of ventilation under GETA was significantly lower. The pPG and mPG were higher during inspiration as compared to those in the expiratory cycle during mechanical ventilation under GETA (pPG during inspiration = 66.63 ± 22.15 mmHg; mPG during inspiration = 38.24 ± 13.65 mmHg; pPG during expiration = 52.49 ± 19.10 mmHg; mPG during expiration = 30.76 ± 12.66 mmHg). There were no significant changes in AVA between TTE/TEE and inspiration/expiration. Conclusions: The findings of this study demonstrate that the TEE pre-CPB PGs underestimated the severity of AS; hence, the severity of AS must be interpreted with caution during GETA and mechanical ventilation (MV). In addition, PGs must be done at similar points in the respiratory cycle.
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Impact of Mitral Valve Replacement on the Right Ventricle Function in Mitral Stenosis Highly accessed article p. 232
N Swaminathan, Venkatesan S Sangareddi, G Ravishankar, Justin Paul, L Alen Binny
DOI:10.4103/jiae.jiae_9_20  
Background: In patients with mitral stenosis (MS), right ventricular (RV) function may be altered due to an increase in the left atrial pressure and/or changes in pulmonary arteriolar vasculature or may be affected by rheumatic process directly. Aims: In this study we have evaluated the recovery of RV function upto 3 months in patients undergoing mitral valve replacement (MVR) using two dimensional and tissue Doppler echocardiographic indices (TDI). Materials and Methods: A total of 30 patients who were advised MVR were enrolled prospectively. All patients underwent MVR successfully. RV function was assessed using conventional and TDI pre-operatively, 1 week, and 3 months after surgery. Results: New York Heart Association (NYHA) functional class improved significantly at the end of one week. Mean transmitral gradient reduced postoperatively. Tricuspid regurgitation severity reduced significantly. Significant RV reverse remodelling was noted at the end of 3 months. Global RV function parameters fractional area change and RV Tei index improved significantly at the end of 3 months. In patients with mild to moderate pulmonary hypertension (PH), global RV function improved significantly, RV remodelling was seen. In patients with severe PH, both global and longitudinal functions did not improve at the end of 3 months follow up, though RV remodelling was noticed. Conclusion: In patients with severe rheumatic MS whenever per-cutaneous trans-mitral commissurotomy is not feasible, MVR promotes RV remodelling and improvement in RV function along with significant improvement in NYHA functional status. But this improvement in RV function was noted only in patients with mild to moderate PH rather than in patients with severe PH.
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Left Atrial ReModeling in Disease: Association with Clinical Markers p. 237
Joel Quadros Piedade, Srilakshmi M Adhyapak, Pradyumna Muralidharan, John Michel Raj, Fabio Fantini, Kiron Varghese
DOI:10.4103/jiae.jiae_19_20  
Background: The role of left atrial (LA) enlargement has a significant and independent association with moderate and severe diastolic dysfunction, atrial fibrillation, and left ventricular (LV) end-diastolic volume. Clinical features of heart failure have shown a correlation with LV dilatation and LV ejection fraction (LV). Aims: Correlation of clinical features with substrates of cardiac remodeling, especially left atrial (LA) remodeling, has not been well-documented. We sought to determine the major clinical factors that are associated with LA enlargement in subjects with heart failure. Materials and Methods: We studied 200 patients who presented with breathlessness due to underlying cardiac disease. The association of clinical features of cardiac disease with LA remodeling was studied using three-dimensional echocardiography. Results: This was a cross-sectional study conducted between January 2016 and January 2017. We found that clinical features of heart failure such as breathlessness, elevated jugular venous pressure, dilated LV, diastolic dysfunction, severe mitral regurgitation, pulmonary hypertension, and abnormal tricuspid annular plane systolic excursion were significantly associated with LA enlargement. LA volume was significantly and independently associated with moderate and severe diastolic dysfunction, atrial fibrillation, lower hemoglobin levels, and LV diastolic size on echocardiography. The sensitivity and specificity of breathlessness with LA enlargement were not significant. Conclusions: Clinical features of heart failure, namely breathlessness, were significantly associated with LA enlargement. LA enlargement was not a sensitive or specific marker of breathlessness in heart failure.
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FROM THE GUEST EDITORíS DESK Top

Echo in Congenital Heart Disease p. 243
Munesh Tomar
DOI:10.4103/jiae.jiae_64_20  
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FOCUS ISSUE - CONGENITAL HEART DISEASE Top

Sequential Segmental Approach to Congenital Heart Disease Highly accessed article p. 244
Samir Shakya, Palleti Rajashekar, Saurabh Kumar Gupta
DOI:10.4103/jiae.jiae_60_20  
The sequential segmental approach is essential for better understanding of cardiac anatomy in normal and malformed hearts. It is based on a detailed analysis of the three main cardiac segments, namely atria, ventricles, and great vessels, and the two connecting segments, namely atrioventricular and ventriculoarterial connections. Each segment is systematically defined based purely on its morphological characteristics. In most cases, echocardiography is sufficient, but some cases necessitate the use of other imaging modalities. Systematic identification of different segments, connections, and their abnormalities helps in making an accurate diagnosis of congenital heart disease (CHD). This review provides a brief description of the sequential segmental approach for detecting CHD on echocardiography.
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Echocardiographic Evaluation of Atrial Septal Defect p. 253
Sushil Azad
DOI:10.4103/jiae.jiae_45_20  
Atrial septal defect accounts for 8-10% of all congenital heart defects. Echocardiography is method of choice for assessment of patient with a known or suspected atrial septal defect. A Thorough knowledge and understanding of all echocardiographic view is essential for complete assessment of atrial septal defect , associated physiological status and assessment of neighbouring intracardiac structures. Complete evaluation is crucial for planning the modality of treatment whether it is suitable for catheter intervention or needs surgical intervention.
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Ventricular Septal Defect: Echocardiography Evaluation p. 260
Ravi Ranjan Tripathi
DOI:10.4103/jiae.jiae_42_20  
Ventricular septal defects (VSDs) are among the most common congenital heart defects. These defects may be isolated, associated with other defects, or occur as an intrinsic component of some complex heart defects. There is wide variation in size and location of VSD. Echocardiography plays an important role in evaluation of anatomy, hemodynamic significance, and planning of management of VSDs. With the emerging trends in transcatheter closure of VSD, echocardiography plays a crucial role in decision-making and intra- and postprocedure evaluation. A stepwise approach of echocardiography is necessary for accurate evaluation and management of VSDs.
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Assessment of Atrioventricular Septal Defect on Echocardiography p. 267
Munesh Tomar
DOI:10.4103/jiae.jiae_69_20  
Atrioventricular septal defect comprise of 1.4-2.9% of congenital cardiac defect and is most common congenital cardiac defect in Trisomy 21. This anomaly is characterized by a common atrioventricular junction coexisting with atrial and/or ventricular septal defect , cleft of left atrioventriocular valve along with left ventricular outflow tract abnormality. Due to cleft of left atrioventricular valve ,valve regurgitation is almost invariably present leading to early onset of congestive cardiac failure in these patients. Other associated structural heart defects are pulmonary stenosis,ductal arteriosus,aortic arch anomalies,pulmonary and systemic venous anomalies and unbalaned atrioventricular valve connection leading to univentricular physiology. Echocardiography plays very crucial role in defning the anomaly and planning management In this article, I am going to focus on role of echocardiography in atrioventricular septal defect.
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Echocardiography to Evaluate Pulmonary Stenosis p. 276
Smita Mishra, Praneet Lele
DOI:10.4103/jiae.jiae_47_20  
Congenital pulmonary stenosis (PS) is a common term for lesions causing right ventricular outflow obstruction. It can be further classified as the valvar, supravalvar, and infundibular PS. The PS may often present with other congenital heart diseases. In this article, echo imaging of isolated PS has been discussed. It is imperative to know that the guideline for intervention in isolated PS is totally based on echocardiography. Echocardiographic guidance is required for the selection of procedure, hardwares, evaluation of the outcome of the procedure, and long-term prognosis.
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Left Ventricular Outflow Tract Anomalies: Echocardiographic Evaluation p. 287
Tanuja Karande
DOI:10.4103/jiae.jiae_40_20  
The left ventricular outflow is divided into subvalvar area, the aortic valve and supra valvar region. There can occur a number of anomalies in the outflow tract, most commonly of which are obstructive lesions, which can exist in isolation or as a part of association with other defects such as ventricular septal defects or interrupted arch. The following chapter highlights on echocardiography imaging of the left ventricular outflow tract and its anomalies.
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Double Outlet Ventricle: Echocardiographic Evaluation p. 295
Anil Kumar Singhi, Kothandam Sivakumar
DOI:10.4103/jiae.jiae_35_20  
Double outlet ventricle is a type of conoventricular anomaly. The great arteries arise predominantly (more than 50%) from one of the ventricle. The aortomitral discontinuity varies from minimum discontinuity to complete bilateral conal tissue. Both right and left ventricles can have double outlet though double outlet right ventricle (DORV) is the most common anomaly in this group of abnormalities. Double outlet left ventricle (DOLV) is relatively rare. There are multiple types of DORV based on the site of ventricular septal defect and great artery relationship and presence or absence of ventricular outflow obstruction. The correct anatomical diagnosis requires a detail segmental approach in echocardiography. The echocardiographic features of DORV reviewed in detail followed by a brief discussion on DOLV.
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Echocardiographic Evaluation in Complete Transposition of Great Arteries p. 304
Bharti Sharma, Shreepal Jain
DOI:10.4103/jiae.jiae_41_20  
Complete transposition of great arteries (TGA) is a common and nearly fatal cyanotic congenital cardiac malformation if not treated in time. Without any intervention, nearly 50% succumb in neonatal period and 90% before their first birthday. Advancements in diagnostic and surgical modalities have led to significant improvement in the survival rate of these children. This article discusses comprehensive echocardiographic evaluation in TGA and its variants before and after surgical correction.
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Echocardiographic Approach to Congenitally Corrected Transposition p. 312
Maitri Chaudhuri, Munesh Tomar
DOI:10.4103/jiae.jiae_48_20  
The hallmark of corrected transposition is discordance at atrio-ventricular and ventriculo-arterial level and that is defined as “double discordance”. This can occur as an isolated anomaly but more commonly has associated defects; most common being ventricular septal defect followed by tricuspid valve abnormalities. Other associated defects are pulmonary stenosis, systemic and pulmonary venous anomalies, univentricular physiology, ventricular dysfunction (morphological right ventricle facing systemic circulation) and association of conduction abnormalities. Echocardiography plays a pivotal role in defining the anatomy and planning the management. In this article we are discussing about role of echocardiography in evaluation of corrected transposition, diagnosing the lesion, role in immediate post-operative period and on follow up.
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Aortopulmonary Shunts: Echocardiographic Evaluation p. 325
Neeraj Awasthy, Gaurav Kumar, Romila Chimoriya
DOI:10.4103/jiae.jiae_49_20  
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Pulmonary Venous Anomalies: Evaluation by Echocardiography p. 332
Munesh Tomar
DOI:10.4103/jiae.jiae_53_20  
Congenital anomalies of pulmonary veins vary widely in anatomic spectrum. Depending on anatomic spectrum, clinical presentation varies from being asymptomatic with incidental diagnosis to critical presentation in neonatal period. Echocardiography plays a very crucial role in defining these lesions and planning for surgical intervention. Additional imaging modalities such as cardiac catheterization, computerized tomographic pulmonary angiography, cardiac magnetic resonance imaging, or cardiac catheterization are needed in a very selective group of patients.
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Systemic Venous Anomalies: Echocardiographic Evaluation p. 344
Nandeeswari Subramanian, Anuradha Sridhar
DOI:10.4103/jiae.jiae_51_20  
Systemic venous anomalies can occur in isolation but are more commonly found in association with other structural heart diseases. Echocardiography has become a routine tool in the diagnosis of these anomalies, which although hemodynamically insignificant, can cause significant morbidity in the setting of cardiac catheterisation and surgical intervention in patients with congenital heart disease if not identified correctly.
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Aortic Arch Anomalies and Pulmonary Artery Anomalies : Echocardiographic Evaluation p. 350
Prashant Mahawar
DOI:10.4103/jiae.jiae_54_20  
Congenital variants and anomalies of the aortic arch are important to recognize as they may be associated with vascular rings, congenital heart disease, and chromosomal abnormalities, and can have important implications for prognosis and management. The purpose of this article is to describe the embryology and anatomy of the aortic arch system, discuss aortic arch variants and review other malformations of the aortic arch, including interrupted aortic arch (IAA), hypoplastic aortic arch, and coarctation of aorta. I have also described few anomalies of pulmonary artery (PA) origin and bifurcation like PA sling which has clinical presentation similar to vascular ring and anomalous origin of PA from aorta which present as large aorto-pulmonary communication with congestive heart failure. Aortic arch variants and anomalies will be reviewed in the context of a theoretical double aortic arch system. Arch anomalies can be associated with symptoms, such as dysphagia lusoria in the setting of left aortic arch with aberrant right subclavian artery. Arch variants that form a vascular ring, such as double aortic arch, can result in respiratory distress due to tracheal compression.
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Coronary Artery Anomalies: Echocardiographic Evaluation p. 362
Aditi Gupta, Munesh Tomar
DOI:10.4103/jiae.jiae_59_20  
Congenital coronary artery anomalies occur either in isolation or in association with other congenital heart disease. With the advent of multimodality imaging, the number of incidentally detected anomalies of coronary origin has risen over the last decade. The clinical presentation of these anomalies can range from being asymptomatic to serious morbidity and mortality, including sudden cardiac death in children and adolescents. We review the most common coronary anomalies and various echocardiographic views used to image the coronary arteries origin, size, and flow.
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Complex Congenital Heart Disease: Echocardiographic Evaluation p. 370
Srinivas Lakshmivenkateshiah, Ashutosh Singh, Nilesh Bachhav
DOI:10.4103/jiae.jiae_66_20  
Various combinations of congenital heart defects are included in complex congenital heart disease. Various pathologies of cardiac structures have varied embryological dysmorphology. Lesions described are single ventricle pathologies, hypoplastic left heart syndrome, tricuspid atresia, pulmonary atresia and intact ventricular septum, and crisscross atrioventricular connections. Irrespective of underlying structural abnormalities, most of these lesions will need a unified single ventricle pathway of palliative surgeries for continued survival. A few complex lesions are amenable to corrective surgery. Approach to diagnosis, echocardiography of different lesions, a unified approach toward treatment is discussed.
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DOPPLER QUIZ Top

Doppler Basics p. 378
Satish K Parashar
DOI:10.4103/jiae.jiae_22_20  
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INTERESTING CASE REPORTS Top

Extracorporeal Membrane Oxygenation Cannula Malposition p. 380
Osman Nuri Tuncer, Gökmen Akkaya, Derya Aydin, Yüksel Atay
DOI:10.4103/jiae.jiae_26_20  
Malposition of the extracorporeal membrane oxygenation (ECMO) cannulas is not frequently reported in central cannulation technique: we aimed to present an ECMO cannula malposition in follow-up in a neonate case. The patient was followed up three days on ECMO support with optimum hemodynamics. On the third day swelling occurred in the left face area within hours. Chest radiography showed that the arterial cannula tip was identified upwardly facing, which implied malposition of the cannula in the left carotid artery. After repositioning the cannula, swelling on the left side of the face completely disappeared in 4 hours. Clinicians should be alert for ECMO cannula malposition. Chest radiography which can be accessed quickly and easily can be beneficial for the diagnosis.
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Congenital Mitral Aortic Intervalvular Fibrosa Aneurysm with Submitral Aneurysm p. 383
Rajesh Krishnachandra Shah
DOI:10.4103/jiae.jiae_1_20  
Congenital aneurysm of the mitral aortic intervalvular fibrosa (MAIVF) is a relatively rare condition. It was initially described in the African population and subsequently reported in other racial groups. Many of the subaortic aneurysms arise from the MAIVF; association with submitral aneurysm (SMA) is even rare. They more commonly occur as a pseudoaneurysm of the MAIVF-P, which is usually due to a complication of endocarditis or aortic valve surgery. Diagnosis is usually with echocardiography, and complete confirmation and anatomical assessment are done by computerised tomography and cardiac magnetic resonance imaging, which are useful for surgical evaluation. Surgery is the only treatment when it is large or symptomatic or has related complications, such as rupture, compression of adjacent structures, embolic events, mitral regurgitation, or heart failure. Here, case is presented of a congenital variety of MAIVF aneurysm with congenital SMA, in a 31-year-old female. She presented with breathlessness. She had mitral regurgitation, and had to undergo surgical repair and mitral valve replacement. This may be the first case reported of a congenital MAIVF aneurysm with a congenital SMA.
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Ventricular Septal Defect and Bicuspidity of Both Semilunar Valves with Obstruction Creating Complex Hemodynamics p. 387
Munesh Tomar, Hariraj Singh Tomar
DOI:10.4103/jiae.jiae_6_20  
Aortic and pulmonary valves share a common developmental origin from the embryonic arterial trunk, so there are chances of involvement of both semilunar valves in the process of congenital malformation involving one valve. However, in reported literature, this is not a common association. Here, we report an infant diagnosed to have bicuspid morphology of both semilunar valves with a large perimembranous ventricular septal defect.
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Vanishing Tumor of the Heart: Very Unusual Location of Left Ventricular Thrombus p. 390
Sunil Gurmukhani, Deebanshu Gupta, Samkit Mutha, Aman Patel, Sanjay Shah, Tejas Patel
DOI:10.4103/jiae.jiae_8_20  
Left ventricular (LV) cavity mass is common in clinical practice. Most of the time, it is a thrombus at the LV apex. Nonapical location of mass leads to confusion in the diagnosis with possibilities of tumors or vegetations. Here, we describe a case of LV thrombus in an extremely unusual location. Multimodality images helped us to come to a proper diagnosis. The mass vanished completely from LV cavity with medical management. Our case is unique, as presentation of clot was at very unusual location, only few such cases have been reported in literature. With the help of multimodality imaging, we were able to successfully manage the case conservatively with oral anticoagulation. Left ventricular thrombus is a common complication in patient with ischemic or nonischemic cardiomyopathy. Nonapical location of a thrombus is not only extremely rare but also creates diagnostic confusion. Although echocardiography is a screening imaging modality of choice, magnetic resonance imaging is extremely useful before planning surgical versus nonsurgical treatment option.
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INTERESTING IMAGES Top

Cor Triatriatum or Pseudo Cor Triatriatum in an Elderly Patient: Are We Missing Something? p. 393
Sourabh Agstam, Anunay Gupta, Preeti Gupta, Sandeep Bansal
DOI:10.4103/jiae.jiae_57_19  
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The Triad of Lefts: Left Isomerism, Left-Sided Continuation (Hemiazygos) of Interrupted Inferior Vena Cava Draining into Left Superior Vena Cava p. 395
Pradyot Tiwari, Shradha Runwal, Munish Dev, Bhavin Patel, Tejas Patel, Sanjay Shah, Antara Banerji
DOI:10.4103/jiae.jiae_4_20  
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