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   Table of Contents - Current issue
January-April 2021
Volume 5 | Issue 1
Page Nos. 1-83

Online since Wednesday, April 21, 2021

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Can Strain Imaging Predict Left Ventricle Remodeling? A Study from Eastern India p. 1
Rakesh Agarwal, Soumya Kanti Dutta, Rashmi Baid, Dhurjati Prasad Sinha
Background: Even persistently patent infarct-related artery has been shown to be associated with left ventricle (LV) remodeling. The purpose of this study was to evaluate the role of LV strain imaging by echocardiography in predicting LV remodeling in patients undergoing coronary revascularization. Materials and Methods: A total of 104 patients between the ages of 18 and 75 years of age undergoing percutaneous transluminal coronary angioplasty (PTCA) for acute coronary syndrome (ACS) were selected and subsequently followed up for 3 months. Echocardiography was obtained before PTCA and subsequently 3 months later with global longitudinal strain (GLS) measurements. Results: In our study, 24% patients studied developed LV remodeling at 1 month even after clinical, angiographic, and procedural success of percutaneous intervention. A value of LV GLS <−10.8 predicted the development of LV remodeling with 80% sensitivity and 86% specificity with lower values having higher specificity. Conclusions: GLS assessment by echocardiography in the acute setting is feasible and easy to do with no complications and may be used with considerable sensitivity in predicting patients with adverse remodeling after ACSs.
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Correlation of Global Longitudinal Strain with Functional Status of Patients with Left Ventricular Systolic Dysfunction p. 5
Lalit Mohan Rathi, Sanjeev Sanghvi, Rohit Mathur, Anil Baroopal
Background: Two-dimensional (2D) left ventricular ejection fraction (LVEF) is a well-known parameter to assess the functional status of the patients. Recently, global longitudinal strain (GLS) has emerged as a more sensitive tool for assessing left ventricular (LV) systolic function. We aimed to assess the superiority of GLS by 2D speckle-tracking echocardiography over 2D LVEF in patients with moderate-to-severe LV systolic dysfunction (LVSD) calculated using Simpson's biplane method of disks, in predicting the functional status of the patients. Materials and Methods: One hundred patients in age group 18–80 years with moderate-to-severe LVSD (2D LVEF <40%) were included. New York Heart Association class 4 patients and patients of rheumatic heart disease or valvular heart disease were excluded. 2D LVEF was calculated using Simpson's method. 2D GLS was assessed using automated function imaging technique. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used to assess functional status of patients with moderate-to-severe LVSD. Results: Results showed that 2D GLS better correlated with functional status of the patients (P ≤ 0.0001) than 2D LVEF (P = 0.619). Patients who had better 2D GLS had better functional status according to MLHFQ. Conclusion: Correlation of functional status of patients with poor LVSD was superior with 2D GLS when compared to 2D LVEF. Since strain imaging is an inexpensive tool, it can be easily applied to assess functional status in large number of patients without adding any additional cost.
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Strain Reversus: A Diagnostic Regional Myocardial Left Ventricular Longitudinal Strain Pattern in Tuberculous Constrictive Pericarditis on Two-Dimensional Speckle Tracking Echocardiography p. 10
Mrunmayee S Deshpande, Milind S Phadke, Varun P Bhatia, Pooja R Mankame, Nitin J Burkule, Md Talha Abid Khan, Ajay U Mahajan, Pratap J Nathani
Background: Tuberculous constrictive pericarditis (CP) is a chronic inflammatory disease by Mycobacterium tuberculosis affecting the pericardium, occurring mainly in developing nations. The aim of this study was to evaluate left atrial (LA) and left ventricular (LV) myocardial mechanics in tuberculous CP using standard two-dimensional (2D) echocardiography and speckle tracking echocardiography (STE). Methods: A prospective observational echocardiographic study of 30 subjects was performed: 15 patients with tuberculous CP and 15 controls. 2D echocardiography, color Doppler imaging, and tissue Doppler imaging (TDI) were performed along with STE to evaluate the LV and LA mechanics. Results: We found that the global circumferential strain (GCS, P = 0.002) and the global longitudinal strain (P = 0.02) were significantly reduced in patients with CP compared with controls. The longitudinal lateral wall strain was significantly reduced (P = 0.001) in CP patients, whereas longitudinal septal strain was not reduced significantly (P = 0.18) in CP patients compared with controls. The longitudinal lateral strain was significantly reduced as compared to the longitudinal septal strain (P = 0.001) within the CP group (strain reversus). Annulus reversus (medial early diastolic mitral annular velocity [e'] > lateral e') by TDI was observed in 11 cases out of 15 in tuberculous CP group, whereas strain reversus (septal strain > lateral strain) was seen in all cases of CP group. The LA reservoir strain showed a statistically significant reduction in CP patients (P = 0.001) compared to controls. Conclusions: “Strain reversus” and reduced GCS are characteristic imaging findings on STE in patients with tuberculous CP and may provide an additional parameter to conventional echocardiography in the diagnosis of tuberculous CP.
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The Role of Echocardiography in Heart Failure Today p. 16
Jostol Pinto, A George Koshy
Although heart failure (HF) is often defined clinically, it has a large pre-clinical spectrum and its diagnosis, staging, response to therapy, and etiology are often determined by echocardiography. Understanding of pathophysiologic nuances in HF is significantly aided by the novel parameters that modern echocardiography can assess today, especially in the field of diastolic function and imaging of strain. This article attempts to link the understanding of the progression of HF with an applicable echocardiographic approach to patients at any point in this progression, sometimes in special clinical scenarios. It also conveys that how systolic and diastolic dysfunction is not mutually exclusive but can be assessed separately or simultaneously. Early HF can be subclassified based on myocardial deformation being dysfunctional either longitudinally or circumferentially. An insight into right ventricular evaluation is also included here.
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Echocardiographic Evaluation of Postoperative Patient with Tetralogy of Fallot: A Step-Wise Approach p. 24
Sakshi Sachdeva, Sivasubramanian Ramakrishnan
As tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, with the advancements in cardiac surgical techniques, there has been an ever-increasing number of postoperated patients with this condition. TOF repair is denoted as “total correction,” however, many hemodynamic and electrophysiologic sequelae remain or come into picture over time, which need to be tackled for the improvement of quality of life and life expectancy. Therefore, regular life-long follow-up is required after TOF surgery. During follow-up visits, only clinical assessment does not suffice, and various investigations are employed from time to time. These include electrocardiogram, echocardiogram, computed tomogram angiography, perfusion scanning, cardiac catheterization, and cardiac magnetic resonance imaging. Echocardiography nevertheless, is the easiest, quickest, noninvasive and overall, the most informative investigation. In this review, step-by-step echocardiographic evaluation of a postoperated TOF patient is described.
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Proximal Isovelocity Surface Area Method for Assessment of Mitral Regurgitation Severity: Principles, Pitfalls, and Future Directions p. 31
Jesu Krupa
Quantification of mitral regurgitation (MR) is important in clinical practice. As fluid approaches a finite circular orifice, concentric hemispherical shells are formed with gradually decreasing surface area and increasing velocity. Severity of MR by the proximal isovelocity surface area (PISA) can be quantified using this principle. Careful attention to detail needs to be paid in the acquisition and measurement to ensure accuracy and reproducibility of the PISA method. The pitfalls of this method are related to geometric assumptions, the limitations of ultrasound, and the shape of the orifice. Some of these can be overcome with a good understanding of the principles and limitations of PISA and also newer three-dimensional techniques for quantification.
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An Interesting Case of Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm p. 40
Abhay Thakre, JS Arneja, Avinash Sharma
Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIF) usually occurs as a rare complication of aortic valve endocarditis; however, it may also be idiopathic in etiology. We report a 45-year-old male presenting with acute-onset progressive dyspnea of 2 weeks duration. There was no history of fever. Symptoms were secondary to MAIF aneurysm rupturing into the left ventricular outflow tract causing a large shunt which was diagnosed on echocardiography. The MAIF aneurysm that is idiopathic in etiology is a relatively rare entity as compared to that because of infective endocarditis.
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Intermediate Type of Gerbode Defect Associated with Atrial Septal Defect: An Extremely Rare Anomaly p. 43
Pankaj Jariwala, Karthik Jadhav, Marri Ajay Reddy
A young girl was evaluated for the recent onset of dyspnea. She was found to have an intermediate or Type III communication between the left ventricle and the right atrium (a unusual form of Gerbode defect) associated with an atrial septal defect (ASD) on the echocardiography. The combination of the intermediate form of the Gerbode defect with an ASD is rare and not documented in the literature.
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Fatal Mycotic Pulmonary Artery Aneurysms in Patients with Congenital Heart Disease Complicated by Right-sided Infective Endocarditis: A Report of Two Cases p. 47
Raghuram Palaparti, G R. Rohit Raj, Kothandam Sivakumar
Mycotic aneurysms of pulmonary arteries are potentially fatal conditions occurring in patients ith congenital heart disease complicated by infective endocarditis folloing surgery or interventions. Presentation is indolent and symptoms may be nonspecific. Unless suspected and investigated ith computed tomography, they are missed until their advanced stage. Treatment options are limited as shon in to patients presented in this report.
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Cardiac Magnetic Resonance Imaging to Detect Right Atrial Thrombus in Right Ventricular Endomyocardial Fibrosis p. 50
Stigi Joseph, Anwar C Varghese, Sajan Narayanan, G Rajesh
Tropical endomyocardial fibrosis (EMF) is endemic in southern districts of Kerala state in India, and sporadic cases are reported from other parts of Kerala. Transthoracic echocardiogram (TTE) is the initial imaging tool and is diagnostic for this condition. The inherent limitation of TTE is its limited sensitivity in the detection of intracardiac thrombus. Transthoracic echocardiography, contrast-enhanced cardiac computed tomography, and cardiac magnetic resonance imaging (CMR) are the imaging modalities for the detection of intracardiac thrombus. This report describes a 46-year-old male with right ventricular EMF (RVEMF) who presented with right heart failure. The TTE diagnosed RVEMF but failed to demonstrate the right atrial thrombus which was clearly seen on CMR. The merits of different imaging modalities for the detection of intracardiac thrombus are discussed.
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Unusual Cause of Left Ventricular Pseudoaneurysm p. 54
P Krishnakumar, A George Koshy, Mathew Iype, Sunitha Viswanathan
Closed mitral valvotomy (CMV) became an accepted surgical procedure to open a stenotic mitral valve (MV) about 50 years ago. CMV is performed through an incision in the left atrial appendage. Tubbs dilator is passed in to the left ventricle via the apex and then advanced retrogradely through the stenosed MV and is then opened within the orifice to split the commissures. The dilator is then removed and the orifice closed. Incisional left ventricular pseudo aneurysm has been described as a rare complication of this technique. Here we encountered a similar scenario. Percutaneous transmitral commissurotomy has virtually replaced CMV. But with the expanding use of the transapical approach to treat a variety of structural heart diseases, especially transcutaneous aortic valve replacement, one is likely to encounter similar complications in the modern era also.
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Cardiac Magnetic Resonance Depiction of Different Morphological Appearances of Becker Cardiomyopathy in Siblings p. 58
Pudhiavan Arunachalam, Richa Kothari, Saravanan Palaniappan, Vimal Raj
Becker muscular dystrophy (BMD) is an X-linked recessive disorder involving mutation of the dystrophin gene. Cardiac involvement in BMD is frequent and represents the foremost cause of mortality. Two male siblings with severe left ventricular (LV) dysfunction and presence of deletion in the dystrophin gene underwent cardiac magnetic resonance (CMR) imaging, which revealed typical but varying imaging findings. The CMR revealed dilated left ventricle with severe global hypokinesis with preserved right ventricular (RV) function. Few patchy areas of septal edema were seen with typical epicardial enhancement along the LV lateral wall and the RV side of septum in one sibling. Both the siblings revealed an elevated myocardial native T1 values. CMR has the potential to detect cardiac involvement early by identifying and quantifying fibrosis, before wall motion abnormalities set in and determine prognosis in patients with muscular dystrophy and BMD carriers.
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Unusual Combination of Cardiac Anomalies with Absent Pulmonary Valve Syndrome in a Fetus p. 63
Anupama Nair, Savitri Srivastava
Absent pulmonary valve syndrome is a rare anomaly and its combination with a complete atrioventricular septal defect and double-outlet right ventricle is even rarer which has never been reported in the literature as an antenatal diagnosis. We report a case of a 21-week fetus diagnosed having this rare combination of lesions. The main purpose of reporting this case is to highlight the prognostic implications for the fetus with this complex heart defect. There is a high risk of fetal heart failure and a higher risk of associated extracardiac and chromosomal anomalies. Unfortunately, the pregnancy was terminated, and hence, further antenatal course and postnatal details could not be evaluated.
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Complex Congenital Heart Disease with Common Atrium: A Rare Entity p. 66
Navni Garg, Bosky Jain
Common atrium (CA) is a rare congenital cardiac anomaly characterized by complete lack of interatrial septal tissue. It is commonly associated with atrioventricular valve malformations and other extracardiac anomalies. Hereby, we report a case of a term neonate with complex congenital heart disease with CA and panorama of dual-source computed tomography imaging findings in the patient.
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Pulmonary Hypertension - Glimpse from an Upper Window Can Help! p. 70
Pratheesh George Mathen, Jesu Krupa
Pulmonary hypertension (PH) is an increasingly common condition encountered by physicians and cardiologists. PH is a complex, multidisciplinary disorder characterized by elevated mean pulmonary artery pressures, which can be the hemodynamic and pathological culmination of a large variety of distinct underlying disorders. This makes an accurate etiological diagnosis challenging for the clinician. History and physical examination, although nonspecific, can point toward a particular diagnosis, gauge the severity of PH, and assist in identifying associated disorders. However, a well-performed echocardiographic examination can enable a physician to arrive at an accurate diagnosis. Here, we present an interesting case in which a careful systematic transesophageal echocardiographic assessment allowed us to reach an accurate diagnosis for the etiology of PH.
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Unusual Echocardiographic Diagnosis of a Metastatic Thrombus - A Case Report p. 75
Nivedhyaa Srinivasaraghavan, Kalpana Balakrishnan, Meenakshi V Venketeswaran, Punitha Chockalingam
Renal cell carcinoma has high propensity for intravascular and lymphatic spread. In one percent of such cases, tumor can reach up to the right atrium. This case reports the postoperative tumor embolization in a patient with renal cell carcinoma. An elderly female underwent a left radical nephrectomy and inferior vena cava (IVC) thrombectomy. She developed atrial fibrillation on the sixth postoperative day following the surgery in the postoperative unit. A bedside transthoracic echocardiogram detected a migrating echo dense structure moving across the tricuspid valve. Following this, she underwent an urgent right atriotomy and extraction of the tumor thrombus through cardiopulmonary bypass. The occurrence of atrial fibrillation in this patient with renal cell cancer in the postoperative period could have possibly been trigerred by a tumor thrombus in the right atrium.
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Pericardial Effusion Secondary to Dressler's Syndrome Leading to Intractable Ventricular Tachycardia: Pericardio (Centesis) - Cardioversion of an Electrical Tamponade p. 78
Pankaj Jariwala, Karthik Jadhav
Post infarction pericarditis, Dressler's syndrome is a well-recognized condition, but its incidence has decreased in the present interventional era due to early reperfusion strategy. We encountered an unusual association of large pericardial effusion secondary to Dressler's syndrome and intractable ventricular tachycardia that reverted upon pericardiocentesis. We coined a term “electrical tamponade” to describe an electrical storm or high-grade ventricular arrhythmias secondary to pericardial effusion.
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A Giant Left Atrial Myxoma Causing Left Ventricular Inflow Obstruction and Mitral Regurgitation p. 81
Vinayakumar Desabandhu, Jomy Vadasseril Jose
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Erratum: Sequential segmental approach to congenital heart disease p. 83

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