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   Table of Contents - Current issue
Coverpage
September-December 2021
Volume 5 | Issue 3
Page Nos. 183-249

Online since Wednesday, December 1, 2021

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ORIGINAL RESEARCH  

Stress Echocardiography Audit: Experience of a Tertiary Care Center p. 183
Harin Kamleshbhai Vyas, Mitul Abhaykumar Shah, Neha Vijay More
DOI:10.4103/jiae.jiae_63_20  
Background: Stress echocardiography is a very useful diagnostic and prognostic test in the evaluation of significant coronary artery disease (CAD) causing inducible myocardial ischemia. Stress echocardiography has higher sensitivity and specificity as compared to exercise stress electrocardiography, and therefore, the guidelines recommend opting for the former modality over the latter. There are data suggesting that the incidence of major cardiac events is <1% within 12 months of a negative stress echocardiogram showing no reversible ischemia. The present audit was performed to assess the predictive accuracy of stress echocardiography at our center for major cardiac events during the first year of the test. Methods: Data for all patients referred for stress echocardiography between March 10, 2015 and December 31, 2018 were captured. All patients were contacted after 1 year to evaluate for any cardiac event (cardiac death, nonfatal myocardial infarction, need for revascularization or hospital admission related to acute coronary syndrome, and/or heart failure). Analysis was performed using the standard statistical definitions. Results: Baseline information was available for 1205 patients (mean age 59 years, 60% males). Of these, 416 (34.4%) had documented CAD; 223 (18.4%) underwent stress echocardiography for chest pain evaluation, whereas 273 (22.6%) underwent the test for preoperative assessment before a noncardiac surgery. Dobutamine stress echocardiography was the modality in 1145 (95.0%) patients; ultrasound contrast was used in 1154 (95.8%) patients. One-year event rates were available for 1024 patients. Stress echocardiography was normal in 1009 (98.5%) of these patients, eight of whom had a cardiac event during the subsequent year, yielding a negative predictive value (NPV) of 99.2%. The test was abnormal in 15 (1.5%) patients, but two of them were later found to have normal coronary arteries, yielding a positive predictive value (PPV) of 86.7%. The NPV and PPV were thus both at par or even higher than most other centers. The incidence of complications during stress echocardiography was extremely low. Conclusions: This audit shows that stress echocardiography at our center has an excellent safety as well as accuracy for predicting major adverse cardiac events during the subsequent year. Stress echocardiography could thus obviate the need for coronary angiogram and even revascularization in many patients. Our findings also reinforce the value of stress echocardiography as a greatly useful preoperative test for cardiac fitness in patients undergoing a major noncardiac surgery.
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Early Assessment of Left Atrial Appendicular Velocities in Patients Undergoing Balloon Mitral Valvuloplasty p. 190
Subramanyam Kasamsetty, Manohar J. Suranagi, Rangaraj Ramalingam, K. S. Subramani
DOI:10.4103/jiae.jiae_65_20  
Introduction: Peripheral embolism is a major complication in patients with mitral stenosis. Several studies have suggested a relation between a decrease in left atrial appendage (LAA) function and more frequent thromboembolic events of cardiac origin. This study was conducted to assess LAA function before and after percutaneous transvenous mitral commissurotomy (PTMC) using transesophageal echocardiography and to determine factors related to improvement in LAA function. Methods: Fifty consecutively admitted patients with significant mitral stenosis undergoing PTMC were included in the study. All patients underwent transthoracic and transesophageal echocardiographic examination, including the study of LAA velocities, before and 48 h after PTMC. Results: PTMC resulted in a twofold increase in the mitral valve area and no severe mitral regurgitation occurred. The mean mitral valve orifice area increased from 0.9 ± 0.3 cm2 to 1.84 ± 0.22 cm2. There was a decrease in the mean left atrial pressure from 26 ± 8.6 to 12 ± 2.8 mmHg. PTMC also resulted in a significant improvement in the LAA flow velocities, with the anterograde component of the flow increasing from 19.56 ± 9.48 cm/s to 33.10 ± 14.01 cm/s. There was also a significant resolution of the spontaneous echo contrast in the left atrium. Conclusion: There is a significant improvement in the LAA velocities following PTMC and a significant decrease in the spontaneous echo contrast, potentially leading to a lower risk of embolism.
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A Study on Fetal Intracardiac Echogenic Foci: Pondering Possible Etiology of Echogenicity with Histopathology Correlation p. 195
Saji Philip, Shalom Elsy Philip, Pradeep Vaideeswar, UP Singh
DOI:10.4103/jiae.jiae_70_20  
Objective: The objective of this study is to determine the frequency, location, and delineation of the echogenicity of intracardiac echogenic foci (ICEF) and to ponder the possible etiology of ICEF. Materials and Methods: Retrospective study of 2445 referred cases in second and third trimester for fetal cardiac ultrasound scan from 2010 to 2020, targeted for ruling out congenital heart disease were evaluated and analyzed in detail for ICEF. Further postnatal follow-up was done in 64 cases of ICEF till 7 years of age to see the natural course. Histopathology was performed from one case of fetal autopsy at 19 weeks of gestation for further correlation. Results: Among the fetal cardiac ultrasound cases, 323 (13.2%) showed ICEF (95% confidence interval 11.9–14.6). Majority of these ICEF (96%) were in the left ventricular cavity, and then both ventricles (3%) and remaining in right ventricle and all were located within the papillary muscles. On follow-up of 66 postnatal cases, ICEF had resolved in 97% by 5 years of age. Only two cases reported to have congenital heart disease. No chromosomal anomalies was associated in any case. Histopathology of fetal heart specimen in one case revealed myxomatous degeneration at the apices of the papillary muscle. Conclusion: Frequency of single ICEF is much higher in the left ventricle, and it is invariably located within the upper third of the anterior papillary muscle in such cases. As the gestational age advances, ICEF can resolve in utero, and further complete resolution is seen by 1–7 years of postnatal life. Variability in the echogenicity could be part of transformation of myxomatous tissues to fibrosis or microcalcification. In this study, ICEF have no particular association with congenital heart disease or chromosomal association.
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Echocardiography Study of Hypertrophic Cardiomyopathy Phenotypes: An Indian Perspective p. 201
Rohit Tandon, Shivam Dutt, Namita Bansal, Gurbhej Singh, Bhupinder Singh, Abhishek Goyal, Sheeba Takkar Chabbra, Naved Aslam, Bishav Mohan, Gurpreet Singh Wander
DOI:10.4103/jiae.jiae_71_20  
Background: Hypertrophic cardiomyopathy (HCM) is a genetic disorder with a heterogeneous phenotype. Historically, only obstructive and nonobstructive forms have been described. Improvements in imaging techniques have led to elaborative description of various new phenotypes, although there are limited epidemiological data regarding these phenotypes from within our population. Aims and Objectives: •To identify HCM patients from a cohort of cardiomyopathy patients. •To describe their demographic profile and mode of presentation based on the presenting symptoms. •To subclassify the selected HCM population into various phenotypes based on echocardiography. Results: There were 233 patients of HCM in this study. The mean age of the patients was 53 ± 14.5 years with male preponderance (70%). Thirty-six percent patients were asymptomatic, 37% mildly symptomatic (in class I-II), and 27% severely symptomatic (in class III-IV). Patients were classified into six phenotypes consisting of five classically described phenotypes and one atypical phenotype. Reverse curvature phenotype was most prevalent (49%) and symptomatic phenotype with 19.3% having significant resting left ventricular outflow tract (LVOT) obstruction. Other phenotypes were 19% apical mid, 11% neutral, 6% sigmoid, and 4% atypical. Male: female ratio for reverse curvature phenotype was 3:1, apical (mid) phenotype 2.4:1, and both apical and neutral phenotypes 2:1. Sigmoid phenotype had female-to-male ratio of 2.5:1. Conclusion: HCM patients require phenotype specific approach for complete assessment. Transthoracic echocardiography with myocardial contrast plays a pivotal role in identifying morphological phenotypes, effects on cardiac remodeling and hemodynamics which consequently influence mode of presentation. Reverse curvature, apical mid, and sigmoid phenotypes are comparatively more symptomatic, have larger left atrial size and segment thickness compared to less symptomatic apical and neutral phenotypes. Symptom status of the patient seems to be dependent on age, septal contour, severity of LVOT obstruction, left atrial volume, and maximal segment thickness.
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REVIEW ARTICLES Top

Crossed Pulmonary Arteries: A Literature Review p. 207
Abhinav Agarwal, Vimalarani Arulselvam, Suad Rashid Al Amer, Neale Nicola Kalis
DOI:10.4103/jiae.jiae_2_21  
Crossed pulmonary artery (CPA) is a rare congenital malformation with only about 100 cases reported worldwide. It is often an incidental finding on cardiac imaging with symptoms rarely attributed to this anomaly. Sometimes, it can result in difficulties during catheterization and surgical procedures. Thus, it is necessary to diagnose CPA preoperatively to reduce misadventures. CPA is primarily diagnosed by computerized tomography angiography (CT angio) and missing it during echocardiography is common, even when an accurate diagnosis is possible by echocardiography alone. Echocardiography can also differentiate it from other causes of nonvisualization of pulmonary artery bifurcation. Recent studies suggest that CPA is not as rare as previously described. With increased utilization of CT angio, more cases of CPA are being picked up, which were not noted earlier on echocardiography. Missing CPA on echocardiography is attributed mainly to the lack of awareness regarding this condition among echocardiographers. Raising awareness can avoid missed diagnoses and aid in planning the interventional and surgical procedures.
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Role of Strain Imaging for Guiding Management of Valvular Heart Disease: Current Status p. 211
Atul Karande
DOI:10.4103/jiae.jiae_6_21  
Echocardiographic strain imaging allows more precise evaluation of cardiac function and provides new insights into the complex cardiac mechanics. Global longitudinal strain is found to be clinically useful in various valvular heart diseases. It provides additional diagnostic and prognostic information besides standard echocardiographic and clinical parameters. In this review, a summary of current clinical applications, limitations, and future of strain echocardiography in patients with valvular heart diseases is discussed.
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INTERESTING CASE REPORTS Top

A Case of Ebstein Anomaly with Left Ventricular Noncompaction and Anomalous Mitral Chordae to the Septum p. 218
Biswaranjan Mishra
DOI:10.4103/jiae.jiae_76_20  
Left-sided involvement is increasingly recognized in cases of Ebstein anomaly (EA) of tricuspid valve, thus making it not an exclusive right-sided disease, rather a global form of heart disease, a type of cardiomyopathy. Left-sided involvement commonly occurs in the form of noncompaction. Mitral valve prolapse and other forms of mitral and aortic valve abnormalities are also associated with EA that contribute to the patient's symptoms and prognosis. Here is a case report of EA in a 25-year-old female presenting with dyspnea. Echocardiography revealed left ventricular (LV) noncompaction fulfilling Jenni criteria. In addition, there was an abnormal chordal attachment from the anterolateral papillary muscle to the ventricular septum. There was no LV outflow obstruction, ventricular functions were normal. The combined involvement of LV myocardium and mitral apparatus in EA made this case unique in its category.
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Assessment of Right Ventricle Function in Children with Pulmonary Arterial Hypertension - Moving Beyond Longitudinal Motion p. 222
Mani Ram Krishna
DOI:10.4103/jiae.jiae_80_20  
Right ventricular (RV) systolic function is an important determinant of clinical outcomes in patients with pulmonary arterial hypertension (PAH). However, RV function assessment is less well defined than left ventricle function and requires the use of multiple echocardiographic indices. We report a child with severe PAH and RV dysfunction in whom traditional measures of RV systolic function were deceptive.
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Role of Imaging in the Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy in Presence of Congenital Heart Disease p. 225
Anil Kumar Singhi, Anup Bhargava, Sanjeev S. Mukherjee, Soumya Kanti Mohapatra, Rabin Chakraborty
DOI:10.4103/jiae.jiae_82_20  
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an underdiagnosed entity manifesting with arrhythmia, heart failure and sometimes with sudden cardiac death. Rarely, congenital heart disease (CHD) can co-exist with ARVC which creates a diagnostic challenge. The presence of ARVC in a known case of CHD changes the management plan. We describe three patients with CHD having additional features of ARVC based on proposed criteria in the last 5 years in our institution. The mean age of the patients was 43 years. Two patients had atrial septal defect and one had Ebsteins's anomaly. Cardiac magnetic resonance imaging was done in two patients which showed characteristic features of ARVC and fulfilled the criteria of diagnosis. One patient was labeled as probable ARVC. Medical therapy helped the patients with symptoms of arrhythmia and heart failure. On short-term follow-up, they were doing well. Diagnosis of ARVC in a known case of CHD requires a high index of suspicion. The proposed imaging criteria and holistic approach may help with early diagnosis and appropriate management.
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Double-Outlet Right Atrium – A Rare and Easily Misdiagnosed Entity p. 233
Kothandam Sivakumar, Sandeep Mohanty, Roy Varghese
DOI:10.4103/jiae.jiae_7_21  
Double-outlet right atrium (DORA) is a rare clinical entity associated with atrioventricular septal defects. Although it is easily correctable by surgery, it may be misdiagnosed during echocardiographic evaluation. Awareness and a thorough knowledge of this entity, its associations, echocardiographic appearances, surgical techniques, and its embryogenesis can alert the clinician to identify this rare but correctable condition. A young patient with DORA is described in this clinical report.
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Spontaneous Aortic Thrombosis in a Neonate: A Rare Differential Diagnosis for Aortic Coarctation p. 236
Kothandam Sivakumar, Sandeep Mohanty, Suba Karthikeyan, Krishnamoorthy Sankaranarayanan
DOI:10.4103/jiae.jiae_12_21  
Spontaneous aortic thrombosis is a serious clinical entity with clinical features that mimic neonatal coarctation of aorta. While both conditions manifest with weak femoral pulses, pallor and poikilothermia of lower limbs are unique to spontaneous aortic thrombosis. Proper imaging helps in precise diagnosis. A combination of thrombolysis and anticoagulation is used for resolution of thrombus. We present images of a neonate with spontaneous aortic thrombosis and its clinical management strategies.
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Paradoxical Infective Endocarditis of the Right Coronary Aortic Cusp in a Restrictive Ventricular Septal Defect: Bernoulli's Phenomenon Revisited p. 239
Debasish Das, Debasis Acharya, Tutan Das, Subhas Pramanik
DOI:10.4103/jiae.jiae_13_21  
We present the case of a 35-year-old female with small restrictive ventricular septal defect (VSD) presenting with prolonged fever for the last 1 month with vegetation on the right coronary cusp (RCC) of the aortic valve with flail aortic leaflet causing severe aortic regurgitation (AR). Her echocardiography done 1 year back had revealed the presence of small restrictive VSD with a gradient of 80 mm Hg without any prolapse of RCC or presence of AR. She did not have any early diastolic murmur of AR during 3 monthly routine follow-up in the cardiology outpatient department suggestive of previous aortic valve prolapse with AR in the aforesaid period before the infective endocarditis episode. Common sites of the vegetation in small restrictive VSD are right ventricular side of the interventricular septum, undersurface of the tricuspid valve, free wall of the right ventricle, and rarely the pulmonary valve on the low-pressure site of the shunt where the turbulent jet containing the bacteria slows down, and bacteria adhere the underlying endocardium. Normally, vegetation across any turbulent jet does not occur on the high-pressure site due to the reason that bacteria can not adhere to the wall across the turbulent jet in high-pressure zone, which sweeps away all the bacteria from the high-pressure zone to low-pressure zone. Paradoxical finding in our case was that vegetation was noted on the RCC of the aortic valve which was a high-pressure zone, which may be explained by only Bernoulli's phenomenon. Our case illustrates paradoxical vegetation on the RCC of the aortic leaflet in a patient with small restrictive VSD and is also a unique demonstration of left-sided endocarditis in a patient with left-to-right shunt.
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INTERESTING IMAGES Top

Rugby Ball Cardiac Calcification p. 243
Shreetal Rajan Nair, Asishkumar Mandalay, Jayesh Bhaskaran, Ali Faizal
DOI:10.4103/jiae.jiae_9_21  
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Acute Lower-Limb Ischemia Due to Embolism of a Giant Left Ventricular Thrombus p. 245
Kapil Dev Mohindra, Manoj Kumar
DOI:10.4103/jiae.jiae_23_21  
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LETTER TO THE EDITOR Top

An Unusually Aggressive Idiopathic Annuloaortic Ectasia p. 247
Debasish Das, Debasish Acharya, Tutan Das, Subhas Pramanik
DOI:10.4103/jiae.jiae_11_21  
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