Value of contrast echocardiography in patient with advanced heart failure

Introduction: Transthoracic echocardiography is still the diagnostic standard procedure in pre heart transplant and advanced heart failure diagnostics. Despite continued improvements in non-contrast echocardiography, image quality is sometimes suboptimal for assessing regional and segmental wall.1,2 Case report: 22-year-old patient suffering from dilative cardiomyopathy and diabetes mellitus type I presented with signs of severe dyspnoea and was admitted to intensive coronary unit due to acute heart failure. Dilative cardiomyopathy was verified with severely reduced ejection fraction to 15% of the left ventricle, with apical left ventricular thrombus, clinically NYHA IV stage, initially INTERMACS 3. The hypertrabeculation of left ventricular wall was indicating that the aetiology could be non-compaction cardiomyopathy. He was referred to our transplant centre, where complete pre-transplant work-up was conducted. Despite optimal medical therapy, clinical condition deteriorated, NT pro-BNP measured up to 13122.9-pg/mL and he was on inotropic support, heart failure medication and anticoagulation therapy due to left ventricular apical thrombus. Right heart catheterization showed a moderate increase of pressures in pulmonary circulation due to congestion and his cardiac index calculated from right heart catheter was 1.48 L/min/m2. Coronary artery disease was excluded by coronary angiogram. Due to deterioration, the patient needed ECMO support, and finally the multidisciplinary heart transplant team decided to implant extracorporeal left ventricular assist device (LVAD). As it is paramount to be aver of left ventricular thrombus in case of LVAD implantation, the contrast echocardiography for opacification of the left ventricle (Optison GE Healthcare) was conducted excluding the thrombus in the left ventricle and showing the extent of left ventricular trabeculation (Figure 1). Finally, patient was transplanted after three weeks of extracardiac LVAD support and was discharged from hospital in good condition. As addition, it is interesting that a patient has twin brother without diabetes mellitus, and his echocardiographic report is suggestive of dilative cardiomyopathy –noncompaction but with far better left ventricular contractility and ejection fraction of LV of 35%. Conclusion: Use of contrast echocardiography to guide urgent treatment decisions in critically ill patients and making treatment decisions as in device therapy provides a valuable option for improving endocardial border resolution and outcome in these patients

Povezanost ehokardiografskih pokazatelja funkcije desne klijetke srca i vrijednosti širine distribucije volumena eritrocita u bolesnika sa sustavnom sklerozom [Relationship between echocardiographic right ventricular function parameters and red cell distribution width in patients with systemic sclerosis]

Objective: The aim of this study was to evaluate echocardiographic parameters of right ventricular function in patients with systemic sclerosis (SSc) without pulmonary hypertension and its correlation to red cell distribution width (RDW). Methods: 21 consecutive SSc patient undervent echocardiography with tissue Doppler imaging to assess RV function. 19 study patients were investigated at baseline and in four visits of one year follow up. Echocardiographic measuremets and RDW was assessed at each visit (0-month visit, 4-month visit, 8-month visit, 12-month visit). Results: In the highest tertile RDW group (>14,25 for first follow-up visit) RV FAC was significantly lower 48,00 (45,00-51,00) compared to 50,80 (49,08-53,40); P=0,023., and in the highest tertile RDW group (>13,95 for second follow-up visit) PV Acct was significantly lower (P=0,007) in the follow-up at first and second visit respectively. In the highest tertile RDW group (>14,25 for first follow-up visit) RV FAC was significantly lower 48,00 (45,00-51,00) compared to 50,80 (49,08-53,40); P=0,023., and in the highest tertile RDW group (>13,95 for second follow-up visit) PV Acct was significantly lower (P=0,007) in the follow-up at first and second visit respectevely. RDW showed a positive correlation with RIMP (rho=0,537, P=0,012) on the first visit and negative correlation with PVAcct on the firs (rho=-0,495, P=0,023) and second (rho=-0,497, P=0,022) visit during the follow-up, respectively. Conclusion: RDW in SSc may represent an integrative measure of multiple pathological processes including fibrosis and ongoing inflammation. An increase in RDW may indicate an impairment of cardiorespiratory function and right ventricular function but further investigation is needed

Multimodality imaging of cor triatriatum sinister

Introduction: Cor triatriatum sinister (CTS) is a very rare congenital cardiac malformation in which the left atrium (LA) is divided into two chambers by a fold of tissue, a membrane, or a fibromuscular band. The anomaly is usually diagnosed in childhood, but in adult age is less common. Clinical symptoms can mimic mitral stenosis.1-5 Case report: We report a case of 54-year-old woman referred to our hospital for transesophageal echocardiography (TEE). She had in history of dyspnea, headache, dizziness and effort intolerance for five years. Physical examination and laboratory values were unremarkable. Two-dimensional and threedimensional transesophageal echocardiography revealed fibromembranous structure in the dilated LA (Figure 1 and Figure 2). The membrane attached laterally to the junction of the left upper pulmo-nic vein and left atrial appendage, and medially to the interatrial septum. The membrane divided LA into two chambers (proximal chamber and distal chamber). Proximal chamber was receiving the pulmonary veins, and distal chamber contained left atrial appendage and mitral valve orifice. We found few fenestrations connecting the two chambers (Figure 3). Multislice computed tomography (MSCT) confirmed diagnosis of CTS (Figure 4). Coronary angiography revealed normal coronary arteries. The patient was referred to surgery following a TEE and MSCT diagnosis of CTS. The atrial membrane was excised around its periphery. Recovery from the surgery was uneventful and she was asymptomatic on further hospital stay and follow-up. Conclusion: The diagnosis of cor triatriatum sinister is paramount because of possibility of surgical repair with excellent long-term prognosis. 3D TEE is noninvasive method for comprehensive imaging and correct diagnosis of this rare congenital cardiac malformation. Surgical repair is an easy and definitive treatment choice of CTS should be considered in patients with left heart chamber obstruction symptoms

Right ventricular strain for detecting subclinical dysfunction of the right ventricle in systemic sclerosis

Introduction: Right ventricular (RV) function and cardiac involvement in systemic sclerosis (SSc) is important factor for the prognosis of SSc but often remains undetectable despite echocardiographic screening. 1,3 Speckle derived strain (2D-STE) of the right ventricle (RV GLS) was utilized to detect subclinical abnormalities in regional and global contractility in SSc patients with no echocardiographic signs of pulmonary arterial hypertension. Aim of pilot study was to study the advantages of 2D speckle-tracking echocardiographic derived parameters in identifying RV dysfunction in SSc patients for quantifying myocardial deformation and conventional RV indexes in patients with SSc and to investigate whether these could be indicative of right heart failure or can be used as non-invasive methods of screening in SSc. Methods and Results: 27 SSc patients (mean age, 54.3 years; 96% female) with technically adequate echocardiograms were studied. Standard morphological measurements of RV chamber function, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), tricuspid tissue Doppler annular velocities (TDIs,), right ventricular myocardial performance index (RIMP) and global longitudinal right ventricular free wall strain (RV FW GLS) were obtained. Twenty-two patients without pulmonary arterial hypertension (PAH) due to systemic sclerosis were studied. When we used the cutoff value recommended by the American Society of Echocardiography Guidelines to identify abnormal RV function4, patients were determined to have normal RV function, TAPSE 21.9 (±2.21), RV FAC 49.4 (±3.45), RIMP 0.44 (±0.08) respectively. Global longitudinal strain (LS) of the RV was calculated by averaging the LS value of 3 segments of the RV free wall in RV focused apical 4-chamber view (Figure 1). 40.9% of those patients had abnormal RV FW GLS (-14.8%) more pronounced in the basal regional longitudinal strain. Conclusion: Right ventricular strain reveals a diverse pattern of regional strain in SSc that is not detected by conventional measures of function, suggestive of subclinical RV myocardial disease and could be used as non-invasive method in screening for PAH in SSc to select patients eligible for right heart catheterization or to monitor the effects of PAH therapy.1-

Akutni infarkt miokarda u 58-godišnje žene s anomalnim polazištem lijeve koronarne arterije iz desnog Valsalvina sinusa

We report a case of a 58-year-old female with a history of hypertension, hypercholesterolemia and diabetes type 2, who was admitted to the coronary care unit with continuous substernal severe chest pain persisting for two hours. Her electrocardiogram showed ST-elevation acute myocardial infarction. ST-segment elevation was noted in leads I and aVL and ST-segment depression in leads II, III and V3-V5. The troponin-I level was elevated (1.97 ng/L). Coronary angiography showed anomalous origin of the left coronary artery from the right sinus of Valsalva and subocclusion in the proximal portion of the diagonal branch. In conclusion, primary percutaneous coronary intervention (PCI) of diagonal branch was performed with balloon dilatation and thrombolysis in myocardial infarction TIMI 3 flow was achieved. After PCI, she had no chest pain. At 5-year clinical follow-up, the patient was asymptomatic.Prikazujemo slučaj 58-godišnje žene koja boluje od hipertenzije, hiperkolesterolemije i dijabetesa melitusa tip 2 te koja je primljena u koronarnu jedinicu s bolovima u prsima u trajanju od dva sata. Elektrokardiogram je pokazivao infarkt miokarda sa ST elevacijom. Elevacija ST-segmenta bila je prisutna u I odvodu i aVL odvodu, a depresija ST-segmenta u odvodima II, III i V3-V5. Zabilježene su povišene vrijednosti troponina-I (1,97 ng/L). Koronarografija je pokazala anomalno polazište lijeve koronarne arterije iz desnog Valsalvina sinusa i subokluziju u proksimalnom dijelu dijagonalne grane. U zaključku, primarna perkutana intervencija (PCI) dijagonalne grane izvedena je balonskom dilatacijom uz postignut TIMI 3 protok. Nakon PCI bolesnica je bez bolova i u kliničkom praćenju od pet godina asimptomatska

A case of right heart failure in a 48-year-old patient with constrictive pericarditis treated by pericardiectomy

Background: Constrictive pericarditis (CP) is uncommon cause of predominantly right heart failure1. In CP pericardium creates a stiff ventricular-pericardial unit which leads to increased diastolic pressures, limitation of ventricular relaxation and equalization of intracardiac diastolic pressures producing „single diastolic chamber”2. Case report: 48-years-old male was admitted to Department of Gastroenterology for the investigation of upper abdominal pain. Investigations showed deranged liver biochemistry tests and computed tomography showed widespread ascites and small pleural effusion. Abdominal ultrasonography showed increased size of liver with dilated hepatic veins. The patient was referred to a cardiologist. A transthoracic echocardiogram (TEE) showed normal both ventricular dimensions, dyskinetic motion of intraventricular septum, small pericardial effusion without thickened pericardium. Inferior vena cava (IVC) was dilated with minimal respiratory variation. Because of nonconclusive TTE further diagnostic test including cardiac magnetic resonance imaging (MRI) was recommended. The patient was treated with diuretics and was discharged from hospital after clinical improvement. After three months he was admitted to Department of cardiology with signs and symptoms of right heart failure. On this admission, TTE showed paradoxical cardiac septal motion (“septal bounce”). Doppler inflow study showed respiratory variations of E-wave in mitral inflow (decreased >25% during inspiration) and increased E-wave during inspiration in tricuspid inflow. Pericardium was thickened (7mm) now without pericardial effusion. Estimated pulmonary artery pressure was around 40mmHg. The IVC was dilated without respiratory variation. MRI showed intensive T2 signal on pericardium, late gadolinium enhancement: pathologic imbibition in thickened pericardium. Right heart catheterization showed prominent x-descent and y descent, “square root“ sign, drop of left ventricular pressure and increased right ventricular pressure during inspiration, equalization of left ventricular end-diastolic pressure and end-diastolic right ventricular pressure (16mmHg). This finding was consistent with constrictive pericarditis. The patient was referred to a cardiothoracic surgeon and underwent a successful pericardiectomy. Conclusion: CP should be considered in all patients with unexplained right heart failure. Because diagnosis is sometimes difficult to establish it may be necessary to use multiple diagnostic tools

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