Transesophageal echocardiography for clinical decision making

Transesophageal echocardiography was initially developed to supplement an inadequate precordial echocardiographic examination. With high frequency transducers providing high resolution and detailed imaging, the technique has gained importance as a diagnostic tool in a considerable number of patients with cardiovascular disease, by providing unique information. In this study, the diagnostic utility and benefits of the application of transesophageal echocardiography in the clinical practice of cardiology are investigated. The first part of the study (Chapter 1) provides a review of the technological developments in transesophageal echocardiography. This is followed by a description of the comparative diagnostic value and limitations of precordial and transesophageal echocardiography. Subsequently, the transesophageal cross-sectional echocardiographic anatomy; the execution of the transesophageal procedure; the indications; the contraindications; the limitations; the technical perspectives and recommendations for training are described. Finally, a survey of the Thoraxcenter experience is presented. An overview of the diagnostic value of trans esophageal echocardiography in solving diverse clinical problems is discussed in Chapter 2. In Chapters 3 to 7 the unique advantages of transesophageal echocardiography are described for the diagnosis of thoracic aorta pathology, the assessment of native and Bjork Shiley mitral valve regurgitation by color Doppler flow imaging, for diagnosis of infective endocarditis, the detection of intracardiac thrombus, and visualization of the left coronary arter

Hypertrophic cardiomyopathy in South African Blacks

Hypertrophic cardiomyopathy (HCM) has been considered rare among the Black population of southern Africa. We report 7 patients with the disease who presented during a 14-month period. Current concepts in the approach to the diagnosis and treatment of HCM are discussed. It is possible that with greater awareness of the occurrence of the condition in Blacks the diagnosis of HCM will be made in more members of this population group

Disappearance of Spontaneous Echographic Contrast after Balloon Mitral Valvuloplasty: An Indicator of Sustained Hemodynamic Improvement

In three patients undergoing mitral balloon valvuloplasty for mitral stenosis transesophageal echocardiography was performed before, immediately after, and 6 months after the procedure. In the one patient with persistent hemodynamically favorable result, the spontaneous echocardiographic contrast, which was seen in all three preoperatively, did not recur; in the other two patients the phenomenon was observed again after 6 months. We conclude that the disappearance of spontaneous echocardiographic contrast might be a functional morphological measure of sustained hemodynamic improvement after balloon mitral valvuloplasty. Copyrigh

Initial results of combined anterior mitral leaflet extension and myectomy in patients with obstructive hypertrophic cardiomyopathy

Objectives. The purpose of this study was to describe the clinical and functional results of combined anterior mitral leaflet extension and myectomy in patients with hypertrophic obstructive cardiomyopathy. Background. Septal myectomy is the most commonly performed surgical procedure in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction. Because of the role of the mitral valve in creating the outflow tract gradient, mitral valve replacement or plication is performed in selected cases in combination with myectomy, often with better hemodynamic results than those of myectomy alone. Mitral valve leaflet extension, in which a glutaraldehyde-preserved autologous pericardial patch is used to enlarge the mitral valve along its horizontal axis, is a novel surgical approach in patients with hypertrophic obstructive cardiomyopathy. Methods. Eight patients with hypertrophic obstructive cardiomyopathy were treated with mitral leaflet extension and myectomy. Preoperative and postoperative data (New York Heart Association functional class, number of drugs prescribed, width of the interventricular septum, severity of mitral valve regurgitation, severity of systolic anterior motion of the mitral valve and outflow tract gradient) were compared with those of 12 patients undergoing myectomy alone. Results. Preoperative evaluation demonstrated that mitral regurgitation and systolic anterior motion of the mitral valve were more severe in the group undergoing mitral valve extension (p < 0.001 and p < 0.05, respectively). There were no deaths associated with either surgical procedure. Two patients, both treated by myectomy alone, died during the follow-up period. Postoperatively, patients treated with mitral valve extension had less mitral regurgitation (p < 0.005), less residual systolic anterior motion (p < 0.01), greater improvement in functional class (p = 0.05) and greater reduction in the number of drugs (p < 0.005) and in septal thickness (p < 0.05). Conclusions. Mitral leaflet extension in combination with myectomy is a promising new surgical approach that may provide superior results to those of myectomy alone. Further studies are needed to determine the clinical value of this procedure

Subcoronary implantation or aortic root replacement for human tissue valves: Sufficient data to prefer either technique?

The aortic root replacement technique with aortic allograft or pulmonary autograft might be superior to the subcoronary allograft implantation technique with regard to aortic regurgitation. We explored the influence of the learning process on the incidence of reoperation and the severity of postoperative aortic regurgitation as assessed by color Doppler echocardiography. The subcoronary implantation technique was used in 81 patients, and root replacement was done in 63 patients. The first 30 patients of each group were considered as the surgeons' learning curve. Reoperations were more common in the subcoronary implantation group. After exclusion of early reoperations, the median regurgitation score based on echocardiographic examination was 0.22 in the first 30 patients from the subcoronary implantation group and 0.14 in the root replacement group. The subsequent patients from these groups had regurgitation scores of 0.20 and 0.17, respectively. Statistical analysis of these data showed no significant difference. This interim report suggests that the learning curve for the surgical procedure and the grouping of echocardiographic data influence the interpretation of follow-up studies. The superiority of either technique with regard to aortic regurgitation has yet to be proved

Diet quality and chronic axonal polyneuropathy: a population-based study

Objective: To investigate the association between diet quality and chronic axonal polyneuropathy. Methods: Between June 2013 and January 2017, among 1650 participants of the Rotterdam Study (median age 69.1 years, 54.2% women), diet quality was quantified based on food frequency questionnaires as a sum score of adherence (yes/no) to 14 components of the Dutch dietary guidelines. Presence of polyneuropathy was determined based on a questionnaire, neurological examination of the legs, and nerve conduction studies. We used logistic regression to associate diet quality with the presence of chronic axonal polyneuropathy and linear regression to associate with sural sensory nerve action potential (SNAP) amplitude in participants without polyneuropathy. Results were adjusted for age, sex, time between measurement

Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses

To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1–11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely

Treatment of stable angina pectoris with Verapamil hydrochloride: a double blind cross-over study

Verapamil hydrochloride, a calcium antagonist, has been recommended for the treatment of angina pectoris. The effectiveness of 3 × 120 mg verapamil was tested in 33 male patients with stable angina pectoris. The drug reduced the incidence of anginal episodes from 15 (1–98) to two (0–85) in four weeks (median, range); P < 0.01. The nitroglycerin consumption was similarly reduced. Exercise tolerance on a bicycle ergometer improved on the average by 10 W(P < 0.05). No side effects were observed. It is concluded that verapamil is an effective drug in the treatment of stable angina pectoris