MRI is the current way for the diagnosis of acute myocarditis, based on the Lake Louise criteria (presence of at least two of the three following criteria: myocardial edema, hyperaemia and/or a late ...Gadolinium enhancement). The first-pass perfusion sequence, used for detecting myocardial ischemia, may also be used to highlight a myocardial hyperemia in acute myocarditis.
The aim of our study was to assess subepicardial hyperemia, seen on the first pass perfusion sequence by MRI, as a new method for the diagnosis of acute myocarditis.
47 patients (mean age = 42.4±15,6 years; 35 men) with acute myocarditis were included and compared to 16 healthy controls (without heart disease). The first-pass perfusion was evaluated by two blinded observers and compared to myocardial late Gadolinium enhancement, considered the reference method for the diagnosis of acute myocarditis, using both a qualitative (visual analysis) and a semi-quantitative method (ratio of the signals: infarction hyperaemia / healthy myocardium).
24 (51.1%) patients with myocarditis exhibited detectable hyperemia. Qualitative analysis showed good inter-observer variability (kappa = 0.75). There was an increase of the signal intensity in the myocardium with hyperhemia as compared to the adjacent normal myocardium (myocarditis vs controls: 1.08±0.03 vs 0.95±0.05, p=0.03; myocarditis with hyperhemia vs myocarditis non hyperhemia: 1.22±0.04 vs 0.94 ±0.04, p<0.0001). The correlation between the first-pass perfusion and late Gadolinium enhancement was good (kappa = 0,70). Considering the late Gadolinium enhancement as gold standard, the calculated values of sensitivity and specificity were 85% and 94%, respectively.
Hyperhemia on the First-pass perfusion sequence, is a valuable and reproducible tool for the diagnosis of acute myocarditis.
The author hereby declares no conflict of interest
Thirty-seven consecutively admitted patients with severe mitral stenosis underwent percutaneous mitral commissurotomy with a transthoracic and biplane or multiplane transesophageal echocardiographic ...examination before and between 24 and 48 hours after percutaneous mitral commissurotomy. Thirty patients (81%) were in sinus rhythm and 7 were in atrial fibrillation. Left atrial appendage (LAA) function was evaluated in both the transverse and the longitudinal planes by planimetry and pulsed Doppler echocardiographic interrogation at the LAA outlet. Percutaneous mitral commissurotomy resulted in a twofold increase in mitral valve area, and no severe mitral regurgitation occurred. With use of the planimetry method, there was no significant improvement in LAA ejection fraction, except in the transverse plane for patients in sinus rhythm (p = 0.03). With use of Doppler method, 3 distinct flow patterns were observed before the procedure: a “sinus pattern” in patients in sinus rhythm, and a “fibrillatory pattern” (n = 3) or a “no-flow pattern” (n = 4) in patients in atrial fibrillation. After commissurotomy, mere was a marked increase in LAA peak Doppler velocity (+62%) and in LAA velocity time integral (+31%). Of the 4 patients in atrial fibrillation with a no-flow pattern, 2 had recovery of a typical effective fibrillatory flow pattern after the procedure. The increase in peak Doppler velocity after commissurotomy was related to the decrease or regression in left atrial spontaneous echo contrast, and correlated with the increase in mitral valve area, the decrease in transmitral pressure gradient, and the increase in cardiac index; improvement in valve function after successful percutaneous mitral commissurotomy is associated with early improvement in LAA function.
Since its introduction 27 years ago by Andreas Gruntzig, interventional cardiology has expanded its scope from coronary disease to peripheral, congenital, and also valve diseases.Percutaneous mitral ...commissurotomy and aortic valvuloplasty have been performed since the mid 1980s. Balloon commissurotomy has been used in tens of thousands of patients worldwide and provides good short- and long-term results in a wide range of patients. It has virtually replaced surgical commissurotomy in the management of mitral stenosis. On the other hand, percutaneous aortic valvuloplasty is almost abandoned worldwide due to its lack of efficacy and the risks involved.
The new techniques of percutaneous valve intervention are aortic valve replacement, and mitral valve repair. Both are at an early stage since the first in-man applications only started in 2002. Preliminary series show that these techniques are feasible; however, they must be further evaluated in comparison with contemporary treatment to accurately assess efficacy and risks. Today potential applications concern high-risk patients, however, after thorough evaluation this may be extended to others in the future.
Therefore, percutaneous interventions already play an important role in management of valvular heart disease, which is likely to grow in the future.
To assess the results of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve System (MCS), through the transarterial approach, in high-risk patients with degenerated ...surgically implanted aortic bioprostheses (SP).
Of 241 patients who underwent TAVI, 10 (4%) had a degenerated SP. The approach was percutaneous transfemoral in 9 cases and surgical transaxillary in 1. Patients were age 75±10 years of age. All were in New York Heart Association classes III or IV and at high risk for repeated surgery. Seven patients had stented, 2 stentless, and 1 homograft SP. The failure mode was predominant regurgitation in 7 cases and stenosis (aortic valve area, 0.7±0.2 cm(2); mean gradient, 58±16 mm Hg) in 3. Based on the echographic measurements, 8 patients received a 26-mm, and 2 a 29-mm-diameter MCS. Procedural success rate was 100%. There was 1 in-hospital death, 1 stroke with moderate sequelae, and 1 pacemaker implantation. There were no other adverse events at 30 days. The mean postimplantation transprosthetic gradient was 13±7 mm Hg; periprosthetic regurgitation was absent or trivial in 9 cases and grade 2 in 1. After a median follow-up of 5 months, there were no additional adverse events. All but 1 of the hospital survivors were in New York Heart Association classes I or II.
These results suggest that transarterial MCS implantation in degenerated SP is feasible and may lead to hemodynamic and clinical improvement in patients who are poor candidates for repeated surgery, pending confirmation in larger series with longer follow-up.
To describe a new approach to percutaneous mitral valve repair and an illustrative first-in-man experience, we introduce a suture mediated "double orifice", "edge-to-edge" procedure which can be an ...effective surgical therapy for mitral regurgitation (MR) in selected patient.
We describe a novel percutaneous approach to double orifice mitral repair utilising an intra-cardiac suture based system. The procedure was performed in 15 patients in four international centres. Endovascular suture based double orifice mitral repair was feasible with an acute reduction in the severity of MR by > or = 1 grade in nine of 15 patients. At 30 days improvement in MR appeared durable in six patients. Clinical utility was limited by technical difficulties, the inadequacies of current imaging modalities and suture dehiscence.
Percutaneous endovascular suture based cardiac repair is feasible. However, in utilising the current device clinical benefit was limited and the repair not durable. In the future, similar endovascular approaches may enable more complex cardiac repair.
It has been suggested that myocardial systolic deformation parameters may be a more sensitive marker of left ventricular (LV) systolic dysfunction than LV ejection fraction (LVEF). However, its ...prognostic value in patients with aortic stenosis (AS) remains debated.
In an ongoing prospective cohort of asymptomatic patients with at least mild, pure, isolated AS, global longitudinal strain (GLS) was measured at baseline using 2D speckle tracking imaging, and AS related events (occur-rence of symptoms, congestive heart failure and sudden death) were prospectively collected.
We prospectively enrolled 176 patients (mean age 72 years, 70% male). Mean aortic valve area was 1.25cm2and mean gradient 28.8mmHg. Overall, 88 patients had mild AS, 50 patients moderate AS and 38 patients severe AS. During a mean follow up period of 2.2 years, 38 events occurred. GLS was not correlated to pic velocity, mean gradient or aortic valve area (AVA) (all p>0.05). In univariate analysis, neither in the whole cohort (p=0.75), nor in the subgroup of moderate/severe AS, GLS was predictive of future AS related events. Results were unchanged after adjustment for AS hemodynamic severity (p=0.66 and p=0.82, respectively).
Our data suggest that longitudinal strain assessed by 2D speckle tracking echocardiography, is not predictive of future symptomatic status in asymptomatic patients with AS and preserved LVEF. Thus, this index should not be recommended in daily practice, in order to select patients who should undergo an early aortic valve replacement.
Usefulness of exercise-stress echocardiography for risk-stratification of asymptomatic patients with aortic stenosis (AS) is still debated (Class IIb recommendation). The exercise-induced increase in ...transvalvular gradient has been proposed as a prognostic factor but data are scarce. We sought to evaluate the additional prognostic value of echocardiographic parameters during exercise-stress echocardiography.
In this observational prospective study, we enrolled all consecutive asymptomatic patients with moderate/severe AS and normal ejection fraction who underwent an exercise-stress echocardiography at our institution. Clinical and echocardiographic data at rest and at peak exercise were collected. The composite primary outcome variable was the occurrence of AS related events (symptoms or heart failure related to the AS or cardiovascular death during follow-up).
Among the 121 patients enrolled, 35 (29%) had an abnormal exercise test (occurrence of symptoms or abnormal blood pressure profile during exercise) and were operated on within the following weeks. Eighty-six patients (mean quartiles; age 67 57-75 years, 68 male, mean gradient 46 35-52mmHg, aortic valve area 0,97 0,82-1,11) had a normal exercise test and 39 (48%) reached the clinical endpoint during follow-up (17.5 10.9-36.4 months). The proposed threshold of 18mmHg mean gradient increase had no prognostic value. In multivariate analysis, rest mean gradient (p<0.001; HR 1.07 1.03-1.11) but not exercise-induced increase mean gradient (p=0.4; HR 0.69 0.29-1.65) were predictive of outcome.
Exercise-induced increase in mean gradient was not predictive of outcome in patients with normal exercise-test. Our results raise question regarding the additional value and therefore the use of exercise-stress echocardiography for risk-stratification of asymptomatic patients with AS.
Thoracic radiation therapy exposes to aortic stenosis and surgery is associated with high orbid-mortality rates. Trans-catheter aortic valve implantation (TAVI) may represent an interesting ...alternative, but experience remains limited in this setting. We compared late outcome in a Radiation group and a matched population undergoing TAVI and identified predictive factors of late survival.
Between October 2006 and April 2011, 288 consecutive patients underwent TAVI in our institution, of whom 27 had previous chest radiation. They were matched 1:1 on age, sex and TAVI approach with a control population.
Mean age was 72±13 years in the Radiation group versus 75±9 in the control group (p=0.52), 48% were male and 15% had a trans-apical approach. Procedural success was 89% (n=24) in the Radiation group versus 96% (n=26) in controls and 30-day survival was 93±5% in both groups. Follow-up was complete in all patients (median 3.4; interquartile range 2.6– 4.2 years). Five-years survival rates were 32±10% in the Radiation group and 41±11% in controls (p=0.27). In Radiation group, the cause of death was respiratory failure secondary to radiation-induced fibrosis or sepsis in 54% of cases. In multivariate analysis, we identified 3 predictive factors of late death in Radiation group: 1 pre-procedural variable: the absence of Beta-blockers therapy (HR=36.3 4.1–325.2, p=0.001), and 2 post-procedural variables: creatinine peak (HR=1.04 1.02-1.07, p<0.0001) and infectious complication (HR=7.8 1.7-36.0, p=0.009). In the radiation group, 89% of survivors were in NYHA class I-II at last follow-up.
Patients of the Radiation group displayed high mortality rates even though not significantly different from the control population. In patients with radiation valvular disease, the use of B-blockers was an independent predictor of late survival after TAVI which deserves further consideration. Moreover, respiratory failure was the main cause of death, emphasizing the need for a careful pulmonary evaluation. Finally, we show a sustained improvement in functional results after TAVI in this particular population.
The tricuspid annulus (TA) is a complex structure that has been rarely evaluated. Three-dimensional transesophageal echocardiography (3D-TEE) gives us the unique opportunity to evaluate TA shape and ...dimensions.
3D dynamic volumetric datas of the TA were acquired by TEE using a matrix array transducer (X7-2t, Philips) in 184 patients. Multiplanar reconstructions were performed offline using a dedicated software (QLab7, Philips). Long-axis (LA) diameter, short-axis (SA) diameter and the area of the TA at the time of its maximal opening were measured. The eccentricity index (EI) of the TA was defined as LA/SA and TA orientation as the angle between the interatrial septum axis (aortic valve on the top at 0°) and the LA in the surgical view.
Morphology of TA was more often oval (EI=1.35±0.22) but shapes were significantly different among indivuals, from circular to oval (EI values from 1 to 2.15). TA dilatation occurred homogeneously in all the directions of the right ventricle free wall as attested by the very good correlation between the TA area and both LA (r=0.89, p<0.0001) and SA (r=0.88, p<0.0001). TA dilatation, as shown by increase in TA area, was associated with a small decrease of EI (r=-0.21, p<0.0001), thus a trend to a more circular TA. All orientations of TA were observed, from 5 to 175° (mean=87°±57°) with a bimodal distribution (most frequently at 40° and 150°).
3D-TEE allowed a good assessment of the TA shape and orientation, which is significantly different among individuals. This method could be interesting to improve assessment of TA dilatation before left-heart valve surgery.
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Tricuspid annuloplasty is recommended during left-heart valve surgery when tricuspid annulus (TA) is dilated, independently of the degree of tricuspid regurgitation, but the methodology to measure TA ...and thresholds are not clearly defined. We aimed to compare TA diameter (TAD) measurements performed using bi-dimensional transthoracic echocardiography (2D-TTE) in the 4 different views to three-dimensional measurements performed during transesophageal echocardiography (3D-TEE) and to define thresholds of TA enlargement for routine practice.
2D-TTE measurement of the TAD was performed in parasternal long-axis view of the right ventricle inflow, parasternal short-axis, apical 4-chamber (A4C) and sub-costal views in 195 prospectively enrolled patients and 66 healthy volunteers. 3D dynamic volumetric datas of the TA were also acquired by TEE using a matrix array transducer (X7-2t, Philips) in the 195 patients. Multiplanar reconstructions were performed offline using dedicated software (QLab7, Philips) to measure the long-axis (LA) of the TA.
In the 195 patients, TAD measurements were not different between the 4 TTE views (P=0.13), but A4C was the most feasible and the most reproducible method (Table). TAD measurement in A4C view by TTE (3.90±0.62cm) was well correlated (r=0.84, p<0.0001) to LA by 3D-TEE (4.33±0.63cm), but with a systematic 4mm underestimation. In the healthy volunteers, mean value of TAD in A4C was 3.2±0.4cm or 1.8±0.23cm/m² and the upper limit of 95% confidence interval was 4.2cm or 2.3cm/m².
TAD measurement in A4C view by 2D-TTE was highly feasible, reproducible and accurately reflected TA size, even if it was systematically underestimating its maximal diameter. Based on measurements in healthy volunteers, we suggest to consider tricuspid annuloplasty during left-heart valve surgery when TA is more than 2.3cm/m² or 4.2cm in A4C.
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