An unexpected cause of right ventricular failure – an intruder in the right ventricular outflow tract

Case report: 56-year-old male patient was admitted due to fever of unknown origin. Upon admission, the patient was in bad general condition with high values of inflammatory markers in laboratory results and signs of right side heart failure. 12-lead ECG showed nonspecific conduction disorders. No signs of systemic disease have been found with extensive internal and diagnostic treatment. Scintigraphy with labeled leukocytes, as attempt to find origin of infection did not show any pathological accumulation. Coronarography excludes atherosclerotic changes in epicardial vessels. Transthoracic (TTE) and transesophageal (TEE) echocardiography described a visible hyperechogenic formation in a right ventricular outflow tract (RVOT), oriented towards pulmonic valve, 1.6 cm long and 0.3 cm wide (Figure 1). Right ventricle (RV) showed milder reduced systolic function, with signs of right-side congestion. There was moderate pulmonary valve regurgitation (PR 2+), and mild tricuspid regurgitation with estimation of right ventricular systolic pressure of 27 mmHg. Preserved left ventricular fraction of 58% was observed. MSCT of thorax identified a strange metal body, resembling to sewing needle in the RV area. The patient initially refused the surgical procedure of foreign body extraction, until the clinical condition deteriorated. He was hospitalized again with fever, hem culture positive on Escherichia coli. Transthoracic echocardiography now showed a formation of 8 mm, possibly vegetation, on the ventricular surface of the pulmonary valve with severe pulmonary insufficiency, severe tricuspid regurgitation and moderate right-side heart failure. Diagnosis of pulmonary valve endocarditis has been established. The patient was successfully operated, the bioprosthetic pulmonary valve was implanted combined with tricuspid valve repair and the foreign body was removed from the right ventricle. Postoperative recovery went well, and control echocardiography showed a good function of the bioprosthetic pulmonary valve and tricuspid valve repair. Foreign body was a sewing needle, but the patient could not remember how did it get there. Conclusion: Isolated right ventricular heart failure can be caused by pulmonary valve insufficiency1,2, as in our case by foreign body in RVOT finally complicated by endocarditis of pulmonary valve

Careful preoperative planning of aortic valve surgery – impact of echocardiography and CT parameters

Objective: We can observe an increase in incidence and prevalence of patients with aortic valve stenosis in the general population. The gold standard in aortic valve therapy is aortic valve replacement. Preoperative planning is essential for good outcomes, as the severity of stenosis and calcifications can sometimes be extremely progressive and even involve the aortic root and ascending aorta. There is not enough research on comparation of CT scan analysis of aortic valve stenosis and echocardiography which is the golden standard of disease diagnosis.1-3 Patients and Methods: We have analyzed 88 patients [age: 70.01±9.066 (mean±SD); female: n=45, 51.1%]. Among the patients, 12 had bicuspid aortic valve leaflet structure while the rest of the patients (n=76, 86.4%) exhibited TAV stenosis. Degree of aortic stenosis was assessed according to mean pressure gradient (MPG), peak pressure gradient (PPG), aortic valve area (AVA) indexed aortic valve area (AVAi) and maximum speed through aortic valve (Vmax). These were compared with calcium score (AVCS) calculated from CT scan. All of these patients were observed in the operating room during surgery and valves analyzed after explantation. All of the patients underwent aortic valve replacement. Results: Average AVCS values (median + IQ range) were 3306.3 (1995.4 – 4820.6) [female: 2215 (1463.35 – 3372.85); male: 4093.5 (3133.3 – 5274.4). Average AVCS values for BAV patients were 3063.5 (3323.125 – 4868.9) and 3106.55 (1965.375) – 4780.125) for TAV patients. There were significant correlations between AVCS and AVAi (Spearman’s ρ=−0.24, P=0.025), PPG (ρ= 0.38, P< 0.001), MPG (ρ= 0.36, P= 0.001) V max (ρ= 0.37, P < 0.001) and gender (ρ= 0.485, P < 0.001) while AVA values showed no significant correlation with AVCS (ρ= -0.066, P = 0.540). Overall survival was similar not depending of severity of calcifications and stenosis, however clamp time and surgery time were longer for patients with severely calcified valves which means calcium scoring as a parameter should also be taken in consideration during preoperative planning. Conclusion: Careful preoperative planning is essential for good outcome of surgery, here we have proven the connection between echocardiography parameters of aortic stenosis and calcium score calculated by CT scan

The role of multimodality imaging in clinical decision-making of the heart team in complex aortic root reconstruction due to endocarditis

Case report: 29-year-old m ale u nderwent aortic root reconstruction w ith root remodeling technique and external ring annuloplasty (Corneo Extra Aortic Ring A 29, Gelweave graft 30 mm) in 2015 due to bicuspid aortic valve with significant aortic regurgitation and aortic root dilatation. In 2017 due to pseudoaneurysm of aortic root and severe aortic regurgitation, the patient was reoperated and mechanical aortic valve was implanted (Carbomedics Mechanical A 25) with patch plastic of the pseudoaneurysm. A year later he was admitted again, now due to fever and high inflammatory markers. Multimodality imaging, transthoracic echocardiography, transesophageal echocardiography, MSCT aortography and abdominal CT described aortic /perivalvular root abscess with significant paravalvular leak in terms of hemodynamically significant regurgitation with high flow velocity over the mechanical valve, peak velocity > 4 m/s. TEE (2D+3D) showed the septate hyperechogenic formation with hypoechogenic cavities which seemed to touch a part of trigonum, approximately 15 mm thick, extending from annulus ascending to the entire visible part of the aortic root, ascending more than 4 cm. It appeared to affect > 50% of the annulus, with visible paraannular leak and massive aortic regurgitation. Previously implanted patch plastic on aortic root was hypermobile depending on heart cycle. Left ventricle showed normal contractility. MSCT of thorax and aortography confirmed the finding (Figure 1). The patient was diagnosed with endocarditis of the mechanical aortic valve and aortic root abscess, thus the antimicrobial therapy was started. Patient had to undergo urgent surgical reoperation. Aortic root replacement with coronary artery reimplantation was performed (sec Bentall, BioIntegral Surgical A 23). There were no signs of paravalvular leak on the control MSCT aortography, with proper flow through graft, coronary artery and supra-aortal branches. Control echocardiography showed a good function of the mechanical valve. Patient recovered successfully and was sent home after antimicrobial therapy protocol was finished. Conclusion: Cooperation of the heart team (cardiologist, heart surgeon, radiologist) and multimodality imaging is a paramount for accurate diagnosis and management of patients with complex aortic pathology1,2