Diagnostics of stenotic and occlusive changes of carotid arteries

Moždani udar je u razvijenim zemljama prvi uzrok invalidnosti i drugi uzrok smrti. Najnovije europske statistike o kardiovaskularnim bolestima navode da od kardiovaskularnih bolesti umire godišnje 4,3 milijuna ljudi u Europi. Nešto manje od polovine smrti uzrokovano je ishemičnom bolesti srca, a oko trećine CVB-om.31 Uzroci moždanog udara su u oko 30% slučajeva emboli koji potječu iz srca, u 25% slučajeva ateroskleroza velikih cerebralnih arterija (85% su zbog karotidne aterosklerotičke bolesti), u oko 20% slučajeva okluzije malih moždanih arterija (lakunarni infarkti), u 20% slučajeva uzroci su višestruki ili neodređeni, a u oko 5% slučajeva radi o neaterosklerotičkim vaskulopatijama, hiperkoagulabilnim stanjima i hematološkim bolestima. Moždani udar je, dakle, vrlo značajan uzrok smrtnosti, a aterosklerotička stenotičko-obliterativna bolest karotidnih arterija je uzrok moždanog infarkta u oko 20-25% bolesnika. Brojne su dijagnostičke metode razvijene za kvalitetno verificiranje karotidne patologije zbog njene velike važnosti u etiologiji moždanog infarkta.32 Doplerski pregled karotidnih arterija je dominantna neinvazivna slikovna metoda u dijagnostici karotidne patologije i u praksi se vrlo često indicira. Ultrazvuk je izvrsna metoda za rano otkrivanje, kvantifikaciju i karakterizaciju aterosklerotičnih promjena. Iako se dopler u početku smatralo metodom samo dijagnostičkog probira (screening) koja treba smanjiti broj nepotrebnih angiografija, danas je to i metoda postoperativnog praćenja uspješnosti samog kirurškog zahvata.4 No, danas na raspolaganju stoje i brojne druge dijagnostičke metode poput CT-angiografije i MR-angiografije kao i digitalne suptrakcijske angiografije, koja se dugo smatrala metodom zlatnog standarda u dijagnostici i stupnjevanju stenoza ACI i drugih promjena. Između ostalog, medikamentno liječenje te kirurški postupci poput karotidne endarterektomije (CEA) i endovaskularnog liječenja (CAS, CBA) su uvelike pridonijeli uspješnosti rješavanja stenotičko obliterativnih promjena karotidnih arterija.In developed countries, stroke is the primary cause of invalidity and the second cause of mortality. The newest European statistics of cardiovascular disease presumes that in one year 4,3 million people will die of cardiovascular disease. Little less of 50% of deaths is caused by ischemic heart disease, and one third of deaths is caused by CVD. Stroke is in 30% of cases caused by emboli emerging from the heart, in 25% of cases by atherosclerosis of large cerebral arteries (85% are due to carotid atherosclerotic disease), in about 20% of cases by occlusions of small cerebral arteries (lacunar infarct), in 20% of cases by multiple or unspecified causes, and in about 5% of cases by vasculopathies, hypercoagulable conditions and hematological diseases. Stroke is, therefore, a very significant cause of mortality, and stenotic-obliterative disease of carotid arteries is the cause of stroke in about 20-25% of patients. Numerous diagnostic methods were developed for efficient verification of carotid pathology due to its great importance in the etiology of stroke. Doppler examination of carotid arteries is a dominant non-invasive imaging method in the diagnosis of carotid pathology and is often indicated in practice. Ultrasound is an excellent method for early discovery, quantification and classification of atherosclerotic changes. Although Doppler was initially considered merely a method of diagnostic screening which was supposed to reduce the number of unnecessary angiographies, today it is a method of post-operative monitoring of success of the very surgical procedure. However, there are also other diagnostic procedures available today, such as CT-angiography, MR-angiography and digital subtraction angiography, which has long been considered a gold standard method for diagnosing and grading ACI stenosis and other changes. In addition to that, pharmacological treatment and surgical procedures like carotid endarterectomy (CEA) and endovascular treatment (CAS-carotid artery stenting, CBA-carotid balloon angioplasty) have substantially contributed to the success rate of treating stenotic-obliterative changes in carotid arteries

Diagnostics of stenotic and occlusive changes of carotid arteries

Moždani udar je u razvijenim zemljama prvi uzrok invalidnosti i drugi uzrok smrti. Najnovije europske statistike o kardiovaskularnim bolestima navode da od kardiovaskularnih bolesti umire godišnje 4,3 milijuna ljudi u Europi. Nešto manje od polovine smrti uzrokovano je ishemičnom bolesti srca, a oko trećine CVB-om.31 Uzroci moždanog udara su u oko 30% slučajeva emboli koji potječu iz srca, u 25% slučajeva ateroskleroza velikih cerebralnih arterija (85% su zbog karotidne aterosklerotičke bolesti), u oko 20% slučajeva okluzije malih moždanih arterija (lakunarni infarkti), u 20% slučajeva uzroci su višestruki ili neodređeni, a u oko 5% slučajeva radi o neaterosklerotičkim vaskulopatijama, hiperkoagulabilnim stanjima i hematološkim bolestima. Moždani udar je, dakle, vrlo značajan uzrok smrtnosti, a aterosklerotička stenotičko-obliterativna bolest karotidnih arterija je uzrok moždanog infarkta u oko 20-25% bolesnika. Brojne su dijagnostičke metode razvijene za kvalitetno verificiranje karotidne patologije zbog njene velike važnosti u etiologiji moždanog infarkta.32 Doplerski pregled karotidnih arterija je dominantna neinvazivna slikovna metoda u dijagnostici karotidne patologije i u praksi se vrlo često indicira. Ultrazvuk je izvrsna metoda za rano otkrivanje, kvantifikaciju i karakterizaciju aterosklerotičnih promjena. Iako se dopler u početku smatralo metodom samo dijagnostičkog probira (screening) koja treba smanjiti broj nepotrebnih angiografija, danas je to i metoda postoperativnog praćenja uspješnosti samog kirurškog zahvata.4 No, danas na raspolaganju stoje i brojne druge dijagnostičke metode poput CT-angiografije i MR-angiografije kao i digitalne suptrakcijske angiografije, koja se dugo smatrala metodom zlatnog standarda u dijagnostici i stupnjevanju stenoza ACI i drugih promjena. Između ostalog, medikamentno liječenje te kirurški postupci poput karotidne endarterektomije (CEA) i endovaskularnog liječenja (CAS, CBA) su uvelike pridonijeli uspješnosti rješavanja stenotičko obliterativnih promjena karotidnih arterija.In developed countries, stroke is the primary cause of invalidity and the second cause of mortality. The newest European statistics of cardiovascular disease presumes that in one year 4,3 million people will die of cardiovascular disease. Little less of 50% of deaths is caused by ischemic heart disease, and one third of deaths is caused by CVD. Stroke is in 30% of cases caused by emboli emerging from the heart, in 25% of cases by atherosclerosis of large cerebral arteries (85% are due to carotid atherosclerotic disease), in about 20% of cases by occlusions of small cerebral arteries (lacunar infarct), in 20% of cases by multiple or unspecified causes, and in about 5% of cases by vasculopathies, hypercoagulable conditions and hematological diseases. Stroke is, therefore, a very significant cause of mortality, and stenotic-obliterative disease of carotid arteries is the cause of stroke in about 20-25% of patients. Numerous diagnostic methods were developed for efficient verification of carotid pathology due to its great importance in the etiology of stroke. Doppler examination of carotid arteries is a dominant non-invasive imaging method in the diagnosis of carotid pathology and is often indicated in practice. Ultrasound is an excellent method for early discovery, quantification and classification of atherosclerotic changes. Although Doppler was initially considered merely a method of diagnostic screening which was supposed to reduce the number of unnecessary angiographies, today it is a method of post-operative monitoring of success of the very surgical procedure. However, there are also other diagnostic procedures available today, such as CT-angiography, MR-angiography and digital subtraction angiography, which has long been considered a gold standard method for diagnosing and grading ACI stenosis and other changes. In addition to that, pharmacological treatment and surgical procedures like carotid endarterectomy (CEA) and endovascular treatment (CAS-carotid artery stenting, CBA-carotid balloon angioplasty) have substantially contributed to the success rate of treating stenotic-obliterative changes in carotid arteries

Flail aortic valve leaflet due to high-voltage electrical injury

Introduction: Electric shock is the set of pathophysiological events resulting from the action of an electric current on the human body1. Electrical injuries involve both direct (caused by contact with electricity arc) and indirect mechanisms (mechanical trauma due to falls). The most common sequels after electrical injury in the heart are arrhythmias and myocardial contusion2. Large arteries like aorta are rarely affected because their rapid flow allows them to dissipate the heat produced by the electric current. However, they are susceptible to medial necrosis, with aneurysm formation and rupture at a later point of time. There is one case in the literature which described aortic valve rupture due to high-voltage electrical injury3. Case report: 47-year-old male patient was admitted to our echo lab for ultrasound examination of the heart. In the last two months he had been complaining about exertional dyspnea. His medical history was quite poor: he had never been admitted to the hospital until two months ago when he had been observed for 24 hours after he had suffered a high-voltage electric injury. The transthoracic echocardiography was performed, and we discovered moderately enlarged left ventricle (LVED volume 180 ml) due to severe aortic regurgitation on bicuspid aortic valve with holo-diastolic retrograde flow. The regurgitation jet that filled the two thirds of left ventricular outflow tract with laceration and flail of bicuspid cusps confirmed on transesophageal ultrasound. The patient underwent surgery. The aortic valve was removed and replaced with a mechanical prosthesis. Conclusion: Cardiac symptoms and echocardiographic findings that initiated two months after a high-voltage electric injury led us to conclusion that bicuspid valve was probably injured by electrical shock. To the authors’ knowledge, this is the first reported case of valvular rupture due to electrical injury in Croatian population

Unruptured non-coronary sinus of Valsalva aneurysm – case report

Introduction: Sinus of Valsalva aneurysm (SVA) is an abnormal dilatation of the aortic root located between the aortic valve annulus and the sinotubular junction. The estimated rate of SVA is approximately 0.09% of the general population and involve up to 3.5% of all congenital heart defects1. Aneurysm predominantly originates from the right coronary sinus and may rupture up to 35% of the time commonly to the right cardiac chambers2. We present an unusual case of a patient with SVA originating from the non-coronary sinus. Case report: 63-old-year male with no history of prior cardiovascular disease was presented to department with shortness of breath and chest pain. Physical examination showed blood pressure of 140/80mmHg, respiratory rate of 18/min and heart rate of 84 beats/min. Electrocardiogram revealed complete right bundle-branch block. A routine transthoracic echocardiography showed the enlargement of the left ventricle with large aneurysm originating from non-coronary sinus measuring 3.6x4cm. Echocardiography also revealed a trileaflet aortic valve with moderate aortic regurgitation and normal systolic function of the left ventricle. TEE demonstrated a non-coronary SAV protruding into the left atrium cavity with no signs of rupture. Selective angiography showed normal epicardial coronary arteries, and SAV with dilatation of ascending aorta measuring up to 40 mm. Moderate aortic insufficiency was also detected. The patient was referred to the cardiothoracic surgery ward for further operative treatment. Conclusion: Although rare, SAV can be a cause of sudden death. Therefore, a combination of transthoracic echocardiography with other imaging techniques, such as TEE, 3D echocardiography, CT angiography and aortic angiography is recommended to obtain comprehensive information and to improve diagnostic accuracy3

Percutaneous occlusion of malignant left atrial appendage in patient with recurrent ischemic stroke

Introduction: The left atrial appendage (LAA) is the most common place of thrombosis in patients with atrial fibrillation (AF). Numerous studies have shown that oral anticoagulation (OAC) significantly reduces the risk of thromboembolism. However, there are no recommendations regarding how to treat cardioembolic recurrent strokes when patients are well anticoagulated.1-3 Case report: 68-years-old male with permanent non-valvular AF, currently taking apixaban, was hospitalized for the second time due to recurrent ischemic cerebrovascular stroke. At the time of his first presentation six months ago, he was well anticoagulated with warfarin (international normalized ratio was 3.56) and have had a CHA2DS2VASc score 2. He had no significant carotid disease or mobile aortic arch atheroma. Transesophageal echocardiography (TEE) revealed a significantly dilated left atrium (LA) with dense spontaneous echo contrast (SEC). There was no organized thrombus in the LA nor in the LAA. The contractile function of the LAA was severely decreased, with peak systolic velocity of 33 cm/s on Doppler evaluation. Despite taking effective anticoagulant medications for both times our patient experienced recurrent ischemic stroke and yet again had dense SEC in the LA and LAA. In order to prevent upcoming cardioembolic event, we decided to preform percutaneous LAA closure with Amplatzer Amulet device under TEE guidance. Successful LAA closure was confirmed by color Doppler imaging and a single postocclusion angiography. The patient was discharged with OAC (warfarin) in addition of 100 mg/day of acetylsalicylic acid to prevent thrombus formation on device. Follow up TEE was performed one month after the procedure. Good position of LAA occluding device was confirmed with no evidence of thrombus formation on the left atrial face of the device. Conclusion: In general, after implantation of LAA occluding device, OAC is not indicated. However, combination therapy with indefinite OAC plus LAA closure in patients with AF with recurrent strokes despite good anticoagulation should be considered in order to prevent a new stroke

Diagnostics of stenotic and occlusive changes of carotid arteries

Moždani udar je u razvijenim zemljama prvi uzrok invalidnosti i drugi uzrok smrti. Najnovije europske statistike o kardiovaskularnim bolestima navode da od kardiovaskularnih bolesti umire godišnje 4,3 milijuna ljudi u Europi. Nešto manje od polovine smrti uzrokovano je ishemičnom bolesti srca, a oko trećine CVB-om.31 Uzroci moždanog udara su u oko 30% slučajeva emboli koji potječu iz srca, u 25% slučajeva ateroskleroza velikih cerebralnih arterija (85% su zbog karotidne aterosklerotičke bolesti), u oko 20% slučajeva okluzije malih moždanih arterija (lakunarni infarkti), u 20% slučajeva uzroci su višestruki ili neodređeni, a u oko 5% slučajeva radi o neaterosklerotičkim vaskulopatijama, hiperkoagulabilnim stanjima i hematološkim bolestima. Moždani udar je, dakle, vrlo značajan uzrok smrtnosti, a aterosklerotička stenotičko-obliterativna bolest karotidnih arterija je uzrok moždanog infarkta u oko 20-25% bolesnika. Brojne su dijagnostičke metode razvijene za kvalitetno verificiranje karotidne patologije zbog njene velike važnosti u etiologiji moždanog infarkta.32 Doplerski pregled karotidnih arterija je dominantna neinvazivna slikovna metoda u dijagnostici karotidne patologije i u praksi se vrlo često indicira. Ultrazvuk je izvrsna metoda za rano otkrivanje, kvantifikaciju i karakterizaciju aterosklerotičnih promjena. Iako se dopler u početku smatralo metodom samo dijagnostičkog probira (screening) koja treba smanjiti broj nepotrebnih angiografija, danas je to i metoda postoperativnog praćenja uspješnosti samog kirurškog zahvata.4 No, danas na raspolaganju stoje i brojne druge dijagnostičke metode poput CT-angiografije i MR-angiografije kao i digitalne suptrakcijske angiografije, koja se dugo smatrala metodom zlatnog standarda u dijagnostici i stupnjevanju stenoza ACI i drugih promjena. Između ostalog, medikamentno liječenje te kirurški postupci poput karotidne endarterektomije (CEA) i endovaskularnog liječenja (CAS, CBA) su uvelike pridonijeli uspješnosti rješavanja stenotičko obliterativnih promjena karotidnih arterija.In developed countries, stroke is the primary cause of invalidity and the second cause of mortality. The newest European statistics of cardiovascular disease presumes that in one year 4,3 million people will die of cardiovascular disease. Little less of 50% of deaths is caused by ischemic heart disease, and one third of deaths is caused by CVD. Stroke is in 30% of cases caused by emboli emerging from the heart, in 25% of cases by atherosclerosis of large cerebral arteries (85% are due to carotid atherosclerotic disease), in about 20% of cases by occlusions of small cerebral arteries (lacunar infarct), in 20% of cases by multiple or unspecified causes, and in about 5% of cases by vasculopathies, hypercoagulable conditions and hematological diseases. Stroke is, therefore, a very significant cause of mortality, and stenotic-obliterative disease of carotid arteries is the cause of stroke in about 20-25% of patients. Numerous diagnostic methods were developed for efficient verification of carotid pathology due to its great importance in the etiology of stroke. Doppler examination of carotid arteries is a dominant non-invasive imaging method in the diagnosis of carotid pathology and is often indicated in practice. Ultrasound is an excellent method for early discovery, quantification and classification of atherosclerotic changes. Although Doppler was initially considered merely a method of diagnostic screening which was supposed to reduce the number of unnecessary angiographies, today it is a method of post-operative monitoring of success of the very surgical procedure. However, there are also other diagnostic procedures available today, such as CT-angiography, MR-angiography and digital subtraction angiography, which has long been considered a gold standard method for diagnosing and grading ACI stenosis and other changes. In addition to that, pharmacological treatment and surgical procedures like carotid endarterectomy (CEA) and endovascular treatment (CAS-carotid artery stenting, CBA-carotid balloon angioplasty) have substantially contributed to the success rate of treating stenotic-obliterative changes in carotid arteries