Incremental value of advanced cardiac imaging modalities for diagnosis and patient management : focus on real-time three-dimensional echocardiography and magnetic resonance imaging

Advanced cardiac imaging modalities play a crucial role in the diagnostic process and clinical management of patients with different cardiac diseases, including heart failure, valvular heart disease, myocardial infarction and atrial fibrillation. RT3DE has made an important transition from a research tool to a clinically applicable imaging technique and has been demonstrated to provide important advantages over conventional 2D echocardiography, such as a more accurate quantification of cardiac chamber size and function and the possibility of unlimited image plane orientations for better understanding of valvular heart diseases. Contrast-enhanced echocardiography should be performed in every patient with suboptimal acoustic window, especially with RT3DE. Importantly, in patients underwent primary percutaneous coronary intervention, perfusion analysis can provide an accurate estimate of myocardial infarction size, which is crucial information for the patient management, together with more sophisticated assessment of LV mechanics. Myocardial deformation imaging has witnessed an enormous development in the last years and is now considered an accurate tool for a more sensitive assessment of LV regional and global function and for a more detailed assessment of LV mechanics and dyssynchrony. CMR represents the reference imaging modality for the quantification of LV volumes and function and for the identification of myocardial scar/fibrosis. It should be therefore considered for a comprehensive evaluation of heart failure patients, including more novel and sophisticated assessments of transvalvular flow and LV dyssynchrony. Advanced cardiac imaging modalities can be applied in heart failure patients referred for CRT to explore novel physiopathological aspects, such as the effect on LV rotation mechanics, on functional mitral regurgitation and cerebral blood flow.Philips Healthcare, Meda Pharma, Boehringer Ingelheim, Roche, Servier, Biotronik, Boston Scientific Nederland BV and ServierUBL - phd migration 201

Implementing Quality Control of LV Longitudinal Strain Measurement

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The difficult decision of when and in whom to perform isolated tricuspid valve surgery

Cardiolog

Malignant arrhythmic mitral valve prolapse: a continuum of clinical challenges from diagnosis to risk stratification and patient management

Mitral valve prolapse (MVP) is a common valvular disease, which may remain a benign condition for a long period of time. However, some patients experience malignant ventricular arrhythmias and sudden cardiac death (SCD). It is still largely unknown how to risk-stratify these patients, and no specific recommendations have been proposed to help the clinical decision-making. We present the case of a young man whose first clinical presentation was an out-of-hospital cardiac arrest and was subsequently diagnosed with MVP. We highlighted the possible risk factors for SCD and the challenges in the clinical management of these patients.Cardiolog

Multi-modality imaging for interventions in tricuspid valve disease

Several studies have demonstrated that severe tricuspid regurgitation (TR) has a significant negative impact on morbidity and mortality. Nowadays, several therapeutic options to treat TR are available and patients at high surgical risk can also be treated with transcatheter procedures. For the management of patients with TR, an accurate assessment of the tricuspid valve and its surrounding structures is therefore of crucial importance and has gained significant interest in the medical community. Different imaging modalities can provide detailed information on the tricuspid valve apparatus, right ventricle, right atrium, and coronary circulation which are fundamental to define the timing and anatomic suitability of surgical and percutaneous procedures. The present review illustrates the role of 2D and 3D echocardiography, cardiac magnetic resonance, and multidetector row computed tomography for the assessment of the tricuspid valve and right heart with a particular focus on the data needed for planning and guiding interventional procedures.Cardiolog

Pacemaker lead-induced tricuspid regurgitation: consider leaflet remodeling

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Characterization of degenerative mitral valve disease: differences between fibroelastic deficiency and Barlow's disease

Degenerative mitral valve disease causing mitral valve prolapse is the most common cause of primary mitral regurgitation, with two distinct phenotypes generally recognized with some major differences, i.e., fibroelastic deficiency (FED) and Barlow's disease. The aim of this review was to describe the main histological, clinical and echocardiographic features of patients with FED and Barlow's disease, highlighting the differences in diagnosis, risk stratification and patient management, but also the still significant gaps in understanding the exact pathophysiology of these two phenotypes.Genetics of disease, diagnosis and treatmen

A structured approach to native mitral valve infective endocarditis: is repair better than replacement?

OBJECTIVES: Mitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients.METHODS: Between January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and patch' repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed.RESULTS: In-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504-2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002-6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52).CONCLUSIONS: Active mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.Cardiolog

Superimposed tissue formation in human aortic valve disease: differences between regurgitant and stenotic valves

The formation of superimposed tissue (SIT), a layer on top of the original valve leaflet, has been described in patients with mitral regurgitation as a major contributor to valve thickening and possibly as a result of increased mechanical stresses. However, little is known whether SIT formation also occurs in aortic valve disease. We therefore performed histological analyses to assess SIT formation in aortic valve leaflets (n = 31) from patients with aortic stenosis (n = 17) or aortic regurgitation due to aortic dilatation (n = 14). SIT was observed in both stenotic and regurgitant aortic valves, both on the ventricular and aortic sides, but with significant differences in distribution and composition. Regurgitant aortic valves showed more SIT formation in the free edge, leading to a thicker leaflet at that level, while stenotic aortic valves showed relatively more SIT formation on the aortic side of the body part of the leaflet. SIT appeared to be a highly active area, as determined by large populations of myofibroblasts, with varied extracellular matrix composition (higher collagen content in stenotic valves). Further, the identification of the SIT revealed the presence of foldings of the free edge in the diseased aortic valves. Insights into SIT regulation may further help in understanding the pathophysiology of aortic valve disease and potentially lead to the development of new therapeutic treatments.Cardiolog

Comparison of Left Ventricular Function and Myocardial Infarct Size Determined by 2-Dimensional Speckle Tracking Echocardiography in Patients With and Without Chronic Obstructive Pulmonary Disease After ST-Segment Elevation Myocardial Infarction

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