A comparison of clinical paediatric murmur assessment with echocardiography

Objective: To compare the clinical acumen of paediatric cardiovascular examination between various hospital paediatrician grades. Design: Prospective data collection of clinical and echocardiography findings on paediatric echocardiography referrals. Setting and patients: All paediatric patients (birth - 14 years) referred for echocardiography, in a regional hospital catering for the island population of Malta. Echocardiography was carried out by three paediatricians with tertiary training in this technique. Main outcome measures: Pre-echocardiography clinical diagnoses were compared with echocardiography results according to grade of referring hospital doctor (ranging from houseman to consultant). Both normal and abnormal hearts at echocardiography were included. Results: Echocardiographers had the highest clinical accuracy and the highest attempts at reaching a clinical diagnosis. Accuracy and attempts at diagnosis decreased as doctor's hospital grade decreased, from consultant to houseman. Ventricular septal defect was the most easily diagnosed lesion. Atrial septal defect was often misdiagnosed as pulmonary stenosis.peer-reviewe

Early diagnosis of cardiovascular diseases in workers: role of standard and advanced echocardiography

Cardiovascular disease (CVD) still remains the main cause of morbidity and mortality and consequently early diagnosis is of paramount importance. Working conditions can be regarded as an additional risk factor for CVD. Since different aspects of the job may affect vascular health differently, it is important to consider occupation from multiple perspectives to better assess occupational impacts on health. Standard echocardiography has several targets in the cardiac population, as the assessment of myocardial performance, valvular and/or congenital heart disease, and hemodynamics. Three-dimensional echocardiography gained attention recently as a viable clinical tool in assessing left ventricular (LV) and right ventricular (RV), volume, and shape. Two-dimensional (2DSTE) and, more recently, three-dimensional speckle tracking echocardiography (3DSTE) have also emerged as methods for detection of global and regional myocardial dysfunction in various cardiovascular diseases, and applied to the diagnosis of subtle LV and RV dysfunction. Although these novel echocardiographic imaging modalities have advanced our understanding of LV and RV mechanics, overlapping patterns often show challenges that limit their clinical utility. This review will describe the current state of standard and advanced echocardiography in early detection (secondary prevention) of CVD and address future directions for this potentially important diagnostic strategy

The failing heart under stress: echocardiography is an essential monitoring tool in the Intensive Care Unit

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Transthoracic three-dimensional echocardiography for the assessment of straddling tricuspid or mitral valves

Background The advent of 3D echocardiography has provided a technique which, potentially, could afford significant additional information over conventional cross-sectional echocardiography in the assessment of patients with straddling atrioventricular valves prior to surgical correction. Methods Eight patients, aged from 1 month to 9˙2 years, were examined with 3D echocardiography. All but three had discordant ventriculoarterial connections or double outlet right ventricle. Data suitable for reconstruction was acquired with transthoracic scanning. Right and left ventricular volumes were calculated in the 3D dataset. Results 3D echocardiography proved capable of defining the exact degree of straddling by imaging theproportion of tension apparatus attached to either side of the ventricular septum. It was able also to display the atrioventricular junction “en face”, thus permitting identification of the precise site of insertion of the muscular ventricular septum relative to the atrioventricular junction. This made it possiblefirst, to calculate the degree of valvar override, and second, to predict the location of the penetrating atrioventricular bundle. End-diastolic volume of the right ventricle in those with straddling tricuspid valves was 73 (61–83)% of normal, and, of the left ventricle in those with mitral valvar straddling 71 (40‐97)% of normal. Conclusions 3D echocardiography can aid in planning the optimal surgical procedure in patients with straddling or overrriding atrioventricular valves, as it provides diagnostic information superiorto standard crosssectional techniques. It also allows for exact measurement of the volumes of the respective ventricles

Assessment of biventricular function by three-dimensional speckle tracking echocardiography in adolescents and young adults with human immunodeficiency virus infection. a pilot study.

Background. The purpose of the study was to assess biventricular parameters of wall deformation with three-dimensional speckle tracking echocardiography (3DSTE) in adolescents and young adults with human immunodeficiency virus infection (HIV) on antiretroviral therapy in order to detect a possible subclinical myocardial dysfunction. Methods. Twenty-one patients aged 12 to 39years with HIV, 21 normal controls of the same age and sex, and 21 patients with idiopathic non-ischemic dilated cardiomyopathy (DCM) were studied with 3DSTE. All HIV patients were stable in terms of HIV infection, with no history of heart disease or other chronic systemic disease except HIV infection, and were on highly active antiretroviral therapy (HAART) with good immunological control. Standard echocardiographic measures of LV-RV function were assessed. 3D LV global longitudinal strain (GLS), circumferential strain, radial strain and LV twist (TW) were calculated. Global area strain (GAS) was calculated by 3DSTE as percentage variation in surface area defined by the longitudinal and circumferential strain vectors. 3D right ventricular (RV) global and free-wall longitudinal strain were obtained. Results. LV GLS and GAS were lower in HIV patients compared to normal controls (p=0.002, and p=0.01, respectively). There were no significant differences in LV ejection fractions between the groups. There was a weak positive correlation between LV GLS and age (r=0.215, p=0.034) and a weak negative correlation between LV GLS and nadir-CD4 T-cells count (r=0.198, p=0.043). DCM patients had more marked and widespread reduction in LV GLS and GAS compared to controls (p<0.001), whereas in HIV patients LV strain impairment (p<0.05) was more localized in basal and apical regions. RV free-wall longitudinal strain was significantly reduced in HIV patients when compared with the control group (p=0.03). No patient had pulmonary systolic pressure higher than 35mmHg. Conclusions. Three-dimensional speckle tracking echocardiography may help to identify HIV patients at high cardiovascular risk allowing early detection of biventricular dysfunction in the presence of normal LV ejection fraction and in the absence of pulmonary hypertension. LV strain impairment in HIV patients is less prominent and widespread compared to DCM patients

Systolic ejection murmurs and the left ventricular outflow tract in boxer dogs

Turbulence of various genesis in the left ventricular outflow tract (LVOT) causes systolic ejection murmurs. The prevalence of murmurs in adult boxer dogs is 50-80%, the majority of which are of low intensity. Some of the murmurs are caused by aortic stenosis (AS), while the origin of the others is unclear. The aim of this thesis was to study the physiology and clinical evaluation of systolic ejection murmurs and their relation to the development of the LVOT in boxers with and without AS. Growing and adult boxer dogs were examined by the standard methods cardiac auscultation, ECG, phonocardiography and echocardiography. Additionally, the complementary methods time-frequency and complexity analyses of heart murmurs and contrast echocardiography were evaluated. Studies on inter-observer variation in cardiac auscultation proved the importance of experience in detection and grading of low intensity ejection murmurs. Excitement of the dogs by exercise or noise stimulation (barking dog and squeaky toy) caused higher murmur grades, longer murmur duration and increased aortic flow velocities. No differences were found between diameters measured at different levels of the LVOT in growing boxers. Contrast echocardiography enhanced Doppler signals, but did not allow evaluation of myocardial blood flow. Using time-frequency analysis, duration of murmur frequency >200 Hz proved useful for differentiation between dogs with mild AS and dogs without. Combining assessment of murmur duration >200 Hz and complexity analysis using the correlation dimension (T2), a sensitivity of 94% and a specificity of 82% for differentiation between dogs with and without AS was achieved. The variability in presence and intensity of low intensity murmurs during growth was high. None of the young dogs developed AS, whereas 3 out of 16 individuals developed mild-moderate aortic insufficiency. Aortic or pulmonic flow velocities did not differ significantly between growing dogs with or without low intensity murmurs. In conclusion, the variability in presence and intensity of low intensity ejection murmurs in boxers is high during growth with no obvious progression. Both in young and adult boxers the murmur grade increased during excitement, which may be due to rapid flow in a comparatively small LVOT that has been suggested for the boxer breed. Experience is important in cardiac auscultation of low intensity murmurs. Therefore, assessment of murmur duration > 200 Hz combined with T2 analysis may be a useful complementary method for diagnosis of cardiovascular function in dogs

A Case Report of Acute Heart Failure Due to Infective Aortic Endocarditis Diagnosed by Point-of-care Ultrasound

Introduction: Infective endocarditis (IE) is a life-threatening condition with significant morbidity and mortality, and can require surgical repair.Case Report: A 36-year-old man presented to the emergency department for worsening dyspnea and chest pain. Point-of-care echocardiography demonstrated a mobile oscillating mass on the aortic valve with poor approximation of the valve leaflets, suggesting aortic valve insufficiency secondary to IE as the cause of acute heart failure. The patient underwent emergent aortic valve replacement within 24 hours.Discussion: While point-of-care echocardiography has been well documented in identifying tricuspid vegetations, aorticvalve involvement and subsequent heart failure is less well described. Earlier recognition of aortic valve vegetations and insufficiency can expedite surgical intervention, with decreased complication rates linked to earlier antimicrobial therapy.Conclusion: This case report highlights the ability of point-of-care ultrasound to identify aortic vegetations, allowing for the earlier diagnosis and therapy

Cardiac papillary fibroelastomas: A 10-year single-center surgical experience and long-term echocardiographic follow-up study

Aims. Limited contemporary data are available on the clinical and echocardiographic outcomes after surgery for cardiac papillary fibroelastoma (CPF). The aim of this study was to review the clinical manifestations, pathological characteristics, surgical management, and prognoses of patients with histologically verified CPF, who underwent surgery at our cardiac surgery center from 2008 to 2018. Methods and Results. Twelve patients of median age 62 years (28 to 77 years) were treated. Embolic stroke or transient ischemic attack (five patients, 42%) were the only CPF clinical manifestations. Eleven (92%) tumors were localized on the valves, with the aortic valve being the most common tumor site (seven patients; 58%). Multiple factor analysis revealed no independent predictor of CPF-related embolization. Simple shave tumor excision was sufficient in most patients (10 patients, 83%). No operative or tumor-related late mortality during the median follow-up period of 4.7 years (1.1 to 10.2 years) was recorded. Asymptomatic metachronous valve tumor recurrence (in a location different from that of the original tumor) was revealed in two patients (17%) by transesophageal echocardiography (TEE), not detected by transthoracic echocardiography (TTE). One of these two patients underwent repeated surgery for CPF but later suffered a recurrent embolic stroke, due to another tumor recurrence. Conclusion. CPF can be safely and effectively treated surgically. TEE is superior to the TTE option in CPF post-operative recurrence detection. There is a clear need for a prospective study to determine criteria for embolization risk stratification and optimum management in patients with CPF.Web of Science1641918

Mixed Valvular Disease Following Transcatheter Aortic Valve Replacement: Quantification and Systematic Differentiation Using Clinical Measurements and Image-Based Patient‐Specific In Silico Modeling

Background: Mixed valvular disease (MVD), mitral regurgitation (MR) from pre‐existing disease in conjunction with paravalvular leak (PVL) following transcatheter aortic valve replacement (TAVR), is one of the most important stimuli for left ventricle (LV) dysfunction, associated with cardiac mortality. Despite the prevalence of MVD, the quantitative understanding of the interplay between pre‐existing MVD, PVL, LV, and post‐TAVR recovery is meager. Methods and Results: We quantified the effects of MVD on valvular‐ventricular hemodynamics using an image‐based patient‐specific computational framework in 72 MVD patients. Doppler pressure was reduced by TAVR (mean, 77%; N=72; P<0.05), but it was not always accompanied by improvements in LV workload. TAVR had no effect on LV workload in 22 patients, and LV workload post‐TAVR significantly rose in 32 other patients. TAVR reduced LV workload in only 18 patients (25%). PVL significantly alters LV flow and increases shear stress on transcatheter aortic valve leaflets. It interacts with mitral inflow and elevates shear stresses on mitral valve and is one of the main contributors in worsening of MR post‐TAVR. MR worsened in 32 patients post‐TAVR and did not improve in 18 other patients. Conclusions: PVL limits the benefit of TAVR by increasing LV load and worsening of MR and heart failure. Post‐TAVR, most MVD patients (75% of N=72; P<0.05) showed no improvements or even worsening of LV workload, whereas the majority of patients with PVL, but without that pre‐existing MR condition (60% of N=48; P<0.05), showed improvements in LV workload. MR and its exacerbation by PVL may hinder the success of TAVR

Clinical Utility of Echocardiography in Former Preterm Infants with Bronchopulmonary Dysplasia.

BackgroundThe clinical utility of echocardiography for the diagnosis of pulmonary vascular disease (PVD) in former preterm infants with bronchopulmonary dysplasia (BPD) is not established. Elevated pulmonary vascular resistance (PVR) rather than pulmonary artery pressure (PAP) is the hallmark of PVD. We evaluated the utility of echocardiography in infants with BPD in diagnosing pulmonary hypertension and PVD (PVR &gt;3 Wood units&nbsp;×&nbsp;m2) assessed by cardiac catheterization.MethodsA retrospective single center study of 29 infants born ≤29&nbsp;weeks of gestational age with BPD who underwent cardiac catheterization and echocardiography was performed. PVD was considered present by echocardiography if the tricuspid valve regurgitation jet peak velocity was &gt;2.9&nbsp;m/sec, post-tricuspid valve shunt systolic flow velocity estimated a right ventricular systolic pressure &gt;35&nbsp;mm Hg, or systolic septal flattening was present. The utility (accuracy, sensitivity, and positive predictive value [PPV]) of echocardiography in the diagnosis of PVD was tested. Subgroup analysis in patients without post-tricuspid valve shunts was performed. Echocardiographic estimations of right ventricular pressure, dimensions, function, and pulmonary flow measurements were evaluated for correlation with PVR.ResultsThe duration between echocardiography and cardiac catheterization was a median of 1&nbsp;day (interquartile range, 1-4&nbsp;days). Accuracy, sensitivity, and PPV of echocardiography in diagnosing PVD were 72%, 90.5%, and 76%, respectively. Accuracy, sensitivity, and PPV increased to 93%, 91.7%, and 100%, respectively, when infants with post-tricuspid valve shunts were excluded. Echocardiography had poor accuracy in estimating the degree of PAP elevation by cardiac catheterization. In infants without post-tricuspid valve shunts, there was moderate to good correlation between indexed PVR and right ventricular myocardial performance index (rho&nbsp;=&nbsp;0.89, P&nbsp;=&nbsp;.005), systolic to diastolic time index (0.84, P&nbsp;&lt;&nbsp;.001), right to left ventricular diameter ratio at end systole (0.66, P&nbsp;=&nbsp;.003), and pulmonary artery acceleration time (0.48, P&nbsp;=&nbsp;.05).ConclusionsEchocardiography performs well in screening for PVD in infants with BPD and may be diagnostic in the absence of a post-tricuspid valve shunt. However, cardiac catheterization is needed to assess the degree of PAP elevation and PVR. The diagnostic utility of echocardiographic measurements that correlate with PVR should be evaluated prospectively in this patient population