Timely-automatic procedure for estimating the endocardial limits of the left ventricle assessed echocardiographically in clinical practice

In this paper, we propose an analytical rapid method to estimate the endocardial borders of the left ventricular walls on echocardiographic images for prospective clinical integration. The procedure was created as a diagnostic support tool for the clinician and it is based on the use of the anisotropic generalized Hough transform. Its application is guided by a Gabor-like filtering for the approximate delimitation of the region of interest without the need for computing further anatomical characteristics. The algorithm is applying directly a deformable template on the predetermined filtered region and therefore it is responsive and straightforward implementable. For accuracy considerations, we have employed a support vector machine classifier to determine the confidence level of the automated marking. The clinical tests were performed at the Cardiology Clinic of the County Emergency Hospital Timisoara and they improved the physicians perception in more than 50% of the cases. The report is concluded with medical discussions.European Union (UE)Ministerio de Economía y Competitividad (MINECO). Españ

Эхокардиография в диагностике инфаркта миокарда у новорожденных

Early and correct diagnostics of myocardial infarction in newborns is impossible without modern instrumental methods, among which echocardiography is the leading one. Hypokinesia, akinesia or dyskinesia of local segments of the heart ventricular wall is determined with echocardiography. We examined a 3-days-old baby with circulatory failure requiring cardiotonic support. On auscultation there was a heart murmur. It was an intracardiac conduction disoder and infarction-like changes on ECG, however, a convincing evidence to interpret the patient’s condition as myocardial infarction has not been received. Therefore, it was decided to conduct echocardiography. According to the results of echocardiography the presence of hyperechogenic diskinetic locus in the apical segment of the right ventricle (post-infarction scar), a local pericardial effusion in the same projection, hyperechogenic movable mass (thrombus) in the apical segment of the right ventricle were determined that together with the results of the ECG allowed us to set diagnosis myocardial infarction. Transthoracic echocardiography is one of highly informative methods; the data obtained allowed to correctly interpret the clinical picture of heart failure and to reveal the cause of the patien’st dependance on cardiotonic support.Своевременная и правильная диагностика инфаркта миокарда у новорожденных невозможна без современных инструментальных высокоинформативных методов исследования, среди которых ведущим является эхокардиография. В статье представлено клиническое наблюдение ребенка в возрасте 3 дней жизни, направленного на обследование в связи с недостаточностью кровообращения, требующего кардиотонической поддержки. При эхокардиографии было установлено наличие гиперэхогенного дискинетичного локуса в апикальном сегменте правого желудочка (постинфарктный рубец), локального перикардиального выпота в той же проекции, гиперэхогенного подвижного образования (тромб) в апикальном сегменте правого желудочка, что вместе с результатами электрокардиографии позволило установить наличие инфаркта миокарда и выраженность нарушения гемодинамики. Данные трансторакальной эхокардиографии позволили правильно интерпретировать клиническую картину сердечной недостаточности и выявить причину зависимости пациента от кардиотонической поддержки

Pulmonary valve balloon valvuloplasty compared across three age groups of children

The aim of this study was to investigate the characteristics and outcomes of treating pulmonary stenosis with percutaneous valvuloplasty, and to compare them among three childhood age groups. All children under 15 years of age who had undergone pulmonary valve balloon valvuloplasty in Madani Heart Center from 2005–2009 were enrolled in this study. Data were analyzed using IBM SPSS software (SPSS, Inc, Chicago, IL). Mean (± standard deviation) age of patients was 55.5 ± 47.4 months. Two-thirds of the subjects had moderate pulmonary valve stenosis. Balloon valvuloplasty failed in nearly one-fifth of the treated patients. There were 17 failures and two cases of mortality, descriptively less frequent among children >5 years; however, the observed difference was not statistically significant. Mild pulmonary valve insufficiency was a common finding

Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 +/- 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 +/- 31 min and cardiopulmonary bypass was 137 +/- 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This off label implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC

Left ventricular myocardial cellular perfusion against the background of cardiac contractility modulation in patients with heart failure and atrial fibrillation

Aim. To assess the effect of cardiac contractility modulation (CCM) in patients with heart failure (HF) and atrial fibrillation (AF) on left ventricular (LV) myocardial cellular perfusion using perfusion single photon emission computed tomography (SPECT).Material and methods. 99mTc-MIBI SPECT gated myocardial perfusion imaging was performed in 60 patients with HF and AF before implantation of CCM device and after 6-months follow-up. All patients received long-term optimal medication therapy for HF. Results. The results obtained indicate a significant positive effect of CCM use in patients with HF and AF on LV ejection fraction (increase from 22 [18;30] to 25,5 [19;38] (p=0,002)), LV volume (decrease in LV end-systolic volume from 187 [114;238] to 154 [100;201] (p=0,001), end-diastolic volume from 229 [174;290] to 209 [159;259] (p=0,007)), as well as myocardial perfusion values. There is a favorable myocardial perfusion dynamics, which was more pronounced in nonischemic HF: increase in SRS from 6 [5;9] to 8,0 [6;11] after 6 months (p=0,01)). The extent of impaired perfusion significantly decreases from 12 [9;17] to 9 [6;16] (p=0,04). An indicator reflecting the total impairment of LV myocardial perfusion significantly decreases: total perfusion deficit decreased from 10 [8;14] to 7 [6;14] after 6 months (p=0,02), compared with ischemia-related HF.Conclusion. Perfusion SPECT makes it possible to assess the myocardial cellular perfusion during CCM therapy in patients with HF of various origin and AF. CCM therapy improves myocardial contractility and perfusion in patients with HF and AF

Возможности эхокардиографии на этапах хирургического лечения пациента с пролапсом задней створки митрального клапана с развитием выраженной митральной недостаточности и фибрилляции предсердий (клиническое наблюдение)

The mitral valve prolapse is characterized by the degeneration of the valve leaflets, accompanied by their thickening, increasing surface area and flexibility. The mitral valves leaflets bulge (prolapse) beyond the plane of the atrioventricular ring into the left atrium during ventricular systole and lose the ability to close tightly, leading to the mitral regurgitation. Acute chord rupture of the mitral valve posterior leaflet is a rare but important cause of severe mitral regurgitation and the development of acute or progressive chronic heart failure. Acute mitral insufficiency, accompanied by hemodynamic disorders, requires an urgent valve plastic surgery or valve prosthetics. The mitral valve plastic surgery gives a number of undeniable advantages over prosthetics, providing the best hemodynamic parameters, saving the patient from lifelong receiving of anticoagulant drugs. Detailed qualified echocardiographic evaluation of all structures of the mitral valve (fibrous ring, MV leaflets by segments, overlapping structures, structure of the chordal apparatus, papillary muscles) provides the necessary information for the mitral valve reconstructive plastic surgery with the choice of the method that is most optimal for a certain patient at the preoperative stage. We report herein a clinical observation of the patient with a diagnosis: acquired heart disease, the mitral valve posterior leaflet prolapse with mitral insufficiency Grade 3. Chronic heart failure IIA. II FC. Atrial fibrillation. The patient underwent multicomponent mitral valve reconstruction with the creation of a neochord and the fibrous ring plastic on the duplicate of a PTFE strip (soft support ring), pairwise isolation of the pulmonary vein entrance and right cavotricuspid isthmus.Пролапс митрального клапана характеризуется дегенерацией створок клапана, сопровождающейся их утолщением, увеличением площади поверхности и гибкости. В систолу створки пролабируют за пределы плоскости кольца в полость левого предсердия и теряют способность плотно смыкаться, в результате чего возникает митральная регургитация. Острый отрыв хорды задней створки митрального клапана – редкая, но важная причина тяжелой митральной регургитации, развития острой или прогрессирующий хронической сердечной недостаточности. При острой митральной недостаточности, сопровождающейся гемодинамическими нарушениями, показана срочная пластика или протезирование клапана. Пластическая реконструкция митрального клапана дает ряд неоспоримых преимуществ перед протезированием, обеспечивая наилучшие гемодинамические параметры, избавляя пациента от пожизненного приема антикоагулянтных препаратов. Детальная квалифицированная эхокардиографическая оценка всех структур митрального клапана (фиброзное кольцо, створки митрального клапана по сегментам, подклапанные структуры, строение хордального аппарата, папиллярных мышц) дает необходимую информацию для реконструктивной пластический коррекции митрального клапана с выбором на дооперационном этапе метода, наиболее оптимального для конкретного пациента. Представлено клиническое наблюдение пациентки с диагнозом: приобретенный порок сердца, пролапс задней створки митрального клапана с недостаточностью митрального клапана III степени. Хроническая сердечная недостаточность IIА стадии. II функциональный класс. Фибрилляция предсердий. Пациентке выполнена многокомпонентная реконструкция митрального клапана c созданием неохорд и пластикой фиброзного кольца на дупликатуре полоски из PTFE (мягкое опорное кольцо), попарная РЧА-изоляция устьев легочных вен и правого кавотрикуспидального истмуса

Patent ductus arteriosus in extremely preterm infants : characteristics, risk factors and treatment decisions

Survival rates in infants born extremely preterm, before 28 weeks of gestation, are increasing and the focus has shifted towards decreasing morbidites after extremely preterm birth and promoting life-long health for the survivors.1-3Approximately 50-60% of extremely preterm infants have the past decade been treated for patent ductus arteriosus (PDA) to induce ductal closure.4,5In the abscence of ductal closure, hemodynamic changes follow which can result in significant systemic hypoperfusion and excessive pulmonary perfusion which has been associated with an increased risk of the neonatal morbidities such as intraventricular hemorrhage (IVH), necrotising enterocolitis (NEC), renal failure and and bronchopulmonary dysplasia (BPD).6 Cyclooxygenase (COX) inhibitors, ibuprofen or indomethacin, are used as first line of treatment to promote ductal closure.7,8 Surgical closure may be indicated if pharmacological therapy fails, or when contraindications to COX inhibitors are present.9 The theoretical rationale for PDA treatment is unquestionable, but trials showing long-term benefits from PDA treatment are scarce.10-12 In this thesis, paper I-III are cohort studies conducted in Sweden and in Europe. The study in paper IV is a hospital-cohort study in Stockholm. The overall aim of the studies is to investigate PDA incidence, neonatal characteristics associated with PDA closure or treatment, variation in treatment strategies, and association with neonatal outcomes. Furthermore, to evaluate the role of cardiac biomarkers in predicting PDA closure. In paper I, the aim was to investigate if timing of pharmacological PDA treatment (at 0-2 days, 2-6 days or ≥7 days of age) was associated with risk of later PDA surgery or death; or risk for BPD at 36 weeks postmenstrual age (PMA). This was investigated in the population-based prospective Extremely Preterm Infants in Sweden (EXPRESS) cohort (infants born at <27 weeks of gestation during 2004-2007).13 Two hundred ninety of 585 children were treated pharmacologically, of whom 102 later underwent PDA surgery. In a model stratified on GA and adjusted for clustering on region, hazard ratios (HR) for late and intermediate vs early start were 1.10 [CI 0.53–2.28] and 0.89 [CI 0.57–1.39] respectively. Compared to early start, the risk of BPD after late start of PDA treatment was associated with a significantly lower risk of BPD odds ratio (OR) 0.29 [CI 0.13-0.61] in a model stratified on gestational age (GA) and adjusted for sex and small for gestational age (SGA). In paper II, the aim was to investigate incidence and variation in PDA treatment and association with BPD at 36 weeks PMA or death; and survival without major neonatal morbidity. This was performed in a large European cohort (the EPICE study) of infants born at 25%, n = 4) proportion of PDA treatment. The difference in PDA treatment could not be explained by differences in perinatal characteristics between these regions. Infants treated for PDA, compared to those not treated, were at higher risk of BPD or death in all regions, with an overall propensity score adjusted risk ratio of 1.33 [95% confidence interval 1.18–1.51]. Survival without major neonatal morbidity was not related to PDA treatment. In paper III, the neurodevelopmental outcome after PDA treatment was studied. In the EXPRESS cohort (see paper I), the survivors at 6.5 years of age had an extensive neurodevelopmental follow-up.15 Four hundred and thirty five of 486 children had available data on both PDA treatment and neurodevelopmental outcome. PDA treatment as an exposure was categorized as no PDA treatment; pharmacological PDA treatment; PDA surgery after prior pharmacological treatment; and primary PDA surgery. The outcomes studied were NDI (by the definition of Moore16) and the full-scale intelligent quotient (FSIQ) as measured by Wechsler Intelligent Scale for Children (WISC-IV17). No increased risks of adverse neurodevelopment were found among children treated pharmacologically for PDA, regardless of whether they later had surgical PDA closure or not. The risk of moderate to severe NDI was higher among children treated with primary PDA surgery in the adjusted model than in extremely preterm children not receiving PDA treatment, IRR 1.62 [95% CI 1.28-2.06] p20 days of age, had increased risk for moderate to severe NDI, IRR 3.26 [95% CI 2.40 to 4.42] p<0.001; and adjusted mean difference of FSIQ -15 [95% CI-19 till -12] p<0.001. In paper IV, the perinatal characteristics associated with spontaneous PDA closure were investigated in a hospital-based cohort of extremely preterm infants in Stockholm. The association of the biomarkers N-Terminal fragment-pro-Brain Natriuretic Peptide (NT-proBNP) and cardiac Troponin T (cTnT) with spontaneous closure and all types of PDA treatment was investigated. Fifty-eight of 98 infants were treated for PDA with a median age at start of treatment of 8 days (interquartile range, IQR 5-11). Six (6%) infants closed their PDA at ≤7 days of age. All infants who closed their duct spontaneously were born at ≥25 weeks of gestation. Higher NT-proBNP values on day 3 were associated with later need of PDA surgery and lower levels were associated with PDA closure without any PDA treatment. In conclusion, there is large variation in PDA treatment across Europe which is not associated with perinatal characteristics. This indicates need of standardization of diagnostics and treatment. In all four studies, the strongest predictor for PDA treatment is GA and the spontaneous closure rate in extremely preterm infants born at ≥25 weeks is relatively high. A more conservative approach with later start of PDA treatment is not associated with increased risks of morbidity and PDA treatment is not associated with decreased risk of survival without major morbidities. PDA pharmacological treatment with or without later surgery is not associated with adverse neurodevelopment. PDA surgery at <10 days of age and primary PDA surgery are associated with increased risk of adverse neurodevelopment. More precise PDA diagnostic criteria and are needed in future studies. NT-proBNP may be useful as an additional parameter in combined scores of clinical and echocardiographic markers of ductal severity. Optimally designed, blinded placebo-controlled studies with a clear definition of the PDA exposure and related outcomes are needed to understand the PDA in extremely preterm populatio

ЧРЕСПИЩЕВОДНАЯ ЭХОКАРДИОГРАФИЯ: МЕТОДИКА, ПОКАЗАНИЯ, ВОЗМОЖНОСТИ

With transthoracic echocardiography, many pathologies can certainly be seen, but in a number of cases, due to the anatomical and physiological characteristics of the patient (thick layer of subcutaneous fat, large breast size in women, lung disease, chest deformation, etc.) hearts can not be fully explored. The use of a transoesophageal sensor can overcome all these difficulties. The review highlights the methodology, indications, and possibilities of transesophageal echocardiogram in the main heart diseases (coronary heart disease, congenital and acquired heart defects, arrhythmias) and acute pathological conditions (acute dissection of the aorta, air embolism).При трансторакальной эхокардиографии можно, несомненно, увидеть многие патологии, однако в ряде случаев из-за анатомических и физиологических особенностей пациента (толстый слой подкожно-жировой клетчатки, большой размер грудных желез у женщин, заболевания легких, деформация грудной клетки и т.д) все интересующие отделы сердца в полной мере исследовать невозможно. Использование чреспищеводного датчика позволяет преодолеть все эти трудности. В обзоре освещены методика, показания и возможности чреспищеводной эхокардиографии при основных заболеваниях сердца (ишемическая болезнь сердца, врожденные и приобретенные пороки сердца, аритмии) и острых патологических состояниях (острая диссекция аорты, воздушная эмболия)

ECHOCARDIOGRAPHIC DIAGNOSTICS OF HEART TUMORS

The article focuses on ultrasound diagnosis of cardiac tumors (CT). In recent time, the frequency of detecting cardiac neoplasm has been growing. Correct diagnosis at an early stage of the process would allow timely treatment. Before the introduction of two-dimensional echocardiography (EchoCG), life-time diagnosis of CT was very rare. This article describes major echocardiographic criteria for most common benign, malignant, and metastatic CTs. The article is illustrated with original echocardiographic images

Echocardiographic Diagnostics of Myocardial Infarction in Newborns

Early and correct diagnostics of myocardial infarction in newborns is impossible without modern instrumental methods, among which echocardiography is the leading one. Hypokinesia, akinesia or dyskinesia of local segments of the heart ventricular wall is determined with echocardiography. We examined a 3-days-old baby with circulatory failure requiring cardiotonic support. On auscultation there was a heart murmur. It was an intracardiac conduction disoder and infarction-like changes on ECG, however, a convincing evidence to interpret the patient’s condition as myocardial infarction has not been received. Therefore, it was decided to conduct echocardiography. According to the results of echocardiography the presence of hyperechogenic diskinetic locus in the apical segment of the right ventricle (post-infarction scar), a local pericardial effusion in the same projection, hyperechogenic movable mass (thrombus) in the apical segment of the right ventricle were determined that together with the results of the ECG allowed us to set diagnosis myocardial infarction. Transthoracic echocardiography is one of highly informative methods; the data obtained allowed to correctly interpret the clinical picture of heart failure and to reveal the cause of the patien’st dependance on cardiotonic support