Extramedullary involvement of the endocardium is rare in multiple myeloma. Here we describe a case of multiple myeloma (plasma cell) with extramedullary plasmablastic transformation and endocardial involvement, which resulted in partial superior vena cava obstruction. We also conducted a literature review and summary analysis of space-occupying lesions in the heart in 12 patients with multiple myeloma (including the current case) in the last 10 years. Echocardiography is the preferred radiologic examination method for diagnosis and follow-up in multiple myeloma, and surgical resection is effective for alleviating symptoms.
Background: Identification of elevation in pulmonary pressures during exercise may provide prognostic and therapeutic implications in patients with connective tissue disease (CTD). Interstitial lung disease (ILD) is common in CTD patients and subtle interstitial abnormalities detected by lung ultrasound could predict exercise-induced pulmonary hypertension (PH). Methods and Results: Echocardiography and lung ultrasound were performed at rest and bicycle exercise in CTD patients (n=41) and control subjects without CTD (n=24). Ultrasound B-lines were quantified by scanning four intercostal spaces in the right hemithorax. We examined the association between total B-lines at rest and the development of exercise-induced PH during ergometry exercise. Compared to controls, the number of total B-lines at rest was higher in CTD patients (0 [0, 0] vs. 2 [0, 9], p<0.0001) and was correlated with radiological severity of ILD assessed by computed tomography (fibrosis score, r=0.70, p<0.0001). Pulmonary artery systolic pressure (PASP) was increased with ergometry exercise in CTD compared to controls (48±14 vs. 35±13 mmHg, p=0.0006). The number of total B-lines at rest was highly correlated with higher PASP (r=0.52, p<0.0001) and poor right ventricular pulmonary artery coupling (tricuspid annular plane systolic excursion/PASP ratio, r=-0.31, p=0.01) during peak exercise. The number of resting B-lines predicted the development of exercise-induced PH with an area under the curve 0.79 (p=0.0003). Conclusions: These data may suggest the value of a simple resting assessment of lung ultrasound as a potential tool for assessing the risk of exercise-induced PH in CTD patients.
Aims: We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. Methods: Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure or atrial fibrillation) and all-cause mortality data was available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (> median GLS) was compared to patients with better GLS ( median GLS). Results: Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P=0.57). There was no significant difference in all-cause mortality or individual end-points between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n=164, adjusted HR=1.51, 95% CI 0.76-3.0). Conclusions: GLS did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.
Pericarditis is a rare but debilitating complication of cytarabine therapy. While echocardiography can aid with the diagnosis, cardiac MRI has superior accuracy in establishing the diagnosis. In this case, we describe a 65-year-old patient receiving cytarabine as part of induction chemotherapy for acute myeloid leukemia who developed acute pericarditis. Her cardiac MRI revealed pericardial edema on T2-weighted STIR imaging and pericardial late gadolinium enhancement which confirmed the diagnosis.
Nonbacterial thrombotic endocarditis (NBTE) is a rare condition which most often accompanies a malignant disease and involves a hypercoagulable state. We report the incidental finding of a scarce case of NBTE affecting the tricuspid valve in a patient with metastatic pancreatic carcinoma complicated by severe venous and arterial thromboembolisms.
The manifestations of COVID-19 as outlined by echocardiography, lung ultrasound (LUS) and cardiac magnetic resonance (CMR) imaging are yet to be fully described. We conducted a systematic review of the current literature and included studies that described cardiovascular manifestations of COVID-19 using echocardiography, LUS and CMR. We queried PubMed, EMBASE and Web of Science for relevant articles. Original studies and case series were included. This review describes the most common abnormalities encountered on echocardiography, LUS and CMR in patients infected with COVID-19.
Accurate assessment of right ventricular (RV) function is drawing a growing attention. Pressure-volume (PV) loop analysis is the gold standard method for evaluating RV function; however, it is not widely employed due to its invasive nature and complexity. The present report is the first to have drawn a RV PV loop in a patient with pulmonary hypertension, with a simultaneous recording of RV pressure and volume using high fidelity micromanometry and 3D echocardiography. This allows for less invasive and simple assessment of RV function, potentially promoting better understanding and management of pulmonary hypertension and other cardiovascular diseases.
Introduction: Early repolarization pattern (ERP) has been known a benign electrocardiographic variant for decades. However, it can exist a silent substrate for arrhytmic events in accordance with the previous studies which have shown that there has been evidence of morphological changes in left ventricle (LV) in subjects with ERP. Despite structural changes in ERP subjects, it has not exactly known that whether a change in functional parameters of LV occur in these population. The aim of our study was to investigate LV functional parameters in subjects with ERP by the use of 2D- speckle tracking echocardiography (2D-STE). Method: In this study, subjects with ERP (n= 50) and subjects without ERP (n= 50) were recruited between 01.04.2018 and 01.09.2018. For each case, 2D- STE evaluation was performed by the same cardiologist. Results: Mean LV global longitudinal strain (GLS) and GLS in all apical chamber views, longitudinal peak systolic strain rate (SRS) at A3C, early diastolic strain rate (SRE) at A3C and late diastolic strain rate (SRA) at A3C in the ERP subjects were significantly lower than those in the subjects without ERP. Furthermore, LV basal segment circumferential SRS and SRE were significantly lower in ERP subjects compared to subjects without ERP. Conclusion: Our study suggests that ERP can be more associated with impaired LV longitudinal function than LV circumferential function. In addition, both LV inferolateral region and LV basal segment can be more affected functionally in ERP subjects.
A 60-year-old female was referred to our clinic for evaluation of her rapidly progressive dyspnea, she had no previuos history of heart disease. A murmur was noted on her examination and transthoracic echocardiography was so difficult to be performed due to poor acoustic windows so she was referred to do a transesophageal echocardiography that showed an ostium primum atrial septal defect (ASD) with left to right shunt and a quadrileaflet mitral valve with severe regurgitation. Later on, she underwent surgery with Ostium Primum ASD closure by a patch and double cleft repair by suture after right heart catheterization.
Background: The impact of the increased mitral gradient (MG) on outcomes is ambiguous. Therefore, we aimed to evaluate a) periinterventional dynamics of MG, b) the impact of intraprocedural MG on clinical outcomes, and c) predictors for unfavourable MG values after MitraClip. Methods: We prospectively included patients undergoing MitraClip. All patients underwent echocardiography at baseline, intraprocedurally, at discharge, and after six months. 12-month survival was reassessed. Results: 175 patients (age 81.2±8.2 years, 61.2% male) with severe mitral regurgitation (MR) were included. We divided our cohort into two groups with a threshold of intraprocedural MG of 4.5 mmHg, which was determined by the multivariate analysis for the prediction of 12-month mortality (<4.5 mmHg: Group 1, 4.5 mmHg: Group 2). Intraprocedural MG 4.5 mmHg was found to be the strongest independent predictor for 12-month mortality (HR: 2.33, p=0.03, OR: 1.70, p=0.05) and ≥3.9 mmHg was associated with adverse functional outcomes (OR: 1.96, p=0.04). The baseline leaflet-to-annulus index (>1.1) was found to be the strongest independent predictor (OR: 9.74, p=0.001) for unfavourable intraprocedural MG, followed by the number of implanted clips (p=0.01), MG at baseline (p=0.02) and central clip implantation (p=0.05). Conclusion: MG shows time-varying and condition-depended dynamics periinterventionally. Patients with persistent increased (≥4.5 mmHg) MG at discharge showed the worst functional outcomes and the highest 12-month mortality, followed by patients with an intra-hospital decrease in MG to values below 4.5 mmHg. Pre-interventional echocardiographic and procedural parameters can predict unfavourable postprocedural MG.
Background: The sustainability of the results of mitraclip procedures is a source of concern. Aims: To investigate risk factors of severe mitral regurgitation (MR) recurrence after Mitraclip in primary MR. Methods and results: Eighty-three patients undergoing successful Mitraclip procedures were retrospectively included. Valve anatomy and Mitraclips placement were comprehensively analyzed by post-processing 3D echocardiographic acquisition. The primary composite endpoint was the recurrence of severe MR. Mean age was 83±7 years-old, 37 (44%) were female. Median follow-up was 381 days (IQR 195-717) and 17 (20%) patients reached the primary endpoint. Main causes of recurrence of severe MR were relapse of a prolapse (64%) and single leaflet detachment (23%). Posterior coaptation line length (HR 1.06 95%CI 1.01-1.12 p=0.02), poor imaging quality (HR 3.84, 95%CI1.12-13.19; p=0.03), and inter-clip distance (HR 1.60, 95%CI 1.27-2.02; p<0.01) were associated with the occurrence of the primary endpoint. Conclusions: Recurrence of severe MR after a MitraClip procedure for primary MR is common and results from a complex interplay between anatomical (tissue excess) and procedural criteria (quality of ultrasound guidance and MitraClips spacing).
Background: Congenital pulmonary stenosis (PS) is a progressive disease. Balloon pulmonary valvuloplasty (BPV) is the treatment of choice in valvular PS. Aim: We aim to study the relationship between biomarkers and echocardiographic markers in valvular PS and to assess the impact of BPV on these markers. Patients & Methods Patients with moderate and severe valvular PS amenable for BPV were recruited. Serum troponin I was measured. Echocardiographic assessment of PS and right ventricular (RV)function were done. All patients underwent BPV. Troponin level and echocardiographic data were re-assessed two weeks & six months after BPV. Results: Fifty patients with valvular PS were recruited. There was significant correlation between peak SPG and troponin (p < 0.001). Troponin was significantly decreased 2 weeks after BPV. Similarly, there was an initial improvement in RV function. After 6 months of follow up, we divided patients into 2 groups: Group-A: 36 patients with no restenosis. Group-B: 14 patients with restenosis. There were high significant differences between both groups regarding troponin level and RV functions with re-elevated troponin in group-B that correlated with peak PG (r= 0.9, p < 0.001). RV function parameters in group-B became significantly worse 6 months after BPV than those after the initial 2 weeks. Conclusion Troponin correlates with the severity of PS and associates with RV dysfunction. Both troponin & RV functions improved with BPV. Recurrent elevation of troponin and impairment of RV function are associated with PV restenosis and could be set as an indication for repeated balloon dilatation of PV.
The diagnosis of acute myocarditis (AM) remains challenging because of its diverse clinical manifestations. Thus, a wide range of diagnostic tests may be warranted. Although cardiac magnetic resonance (CMR) is the preferred imaging technique, it may not be applicable in the acute AM phase. Our case report highlights the usefulness and diagnostic accuracy of echocardiographic examination. In the first 2-dimensional echocardiography, the focal echobright was presented. A reduced value of global longitudinal strain, and regional disturbances of segmental myocardial strain, both longitudinal and circumferential, in the epicardial layer, were detected with a good correlation with CMR results.
Objective: Cardiovascular involvement due to iron overload is the leading cause of morbidity and mortality in patients with beta-thalassaemia major (β-TM). However many patients remain asymptomatic until the late stage. In this study, we investigated the role of real-time three-dimensional echocardiography (RT3DE) findings and endothelial dysfunction parameters in asymptomatic β-TM patients, and the relationship between these parameters and cardiac magnetic resonance imaging (MRI) T2 * value. Methods: 51 asymptomatic β-TM patients who were receiving regular blood transfusions were evaluated by two-dimensional echocardiography (2DE) and RT3DE examinations including endothelial dysfunction parameters. The study population was divided into two subgroups based on their cardiac MRI T2* values (MRI T2* ≤20ms and >20ms). The relationships between serum ferritin levels, 2DE and RT3DE measurements, endothelial dysfunction parameters, and cardiac MRI T2* values were investigated. Results: Although all left ventricle ejection fraction (LVEF) values obtained by 2DE were within normal limits (≥50%), they were not associated with MRI T2* values. LVEFRT3D (53.25 +2.33 vs 58.81 +1.02), SDI12 (6.53 +0.56 vs 2.85 +0.48), SDI16 (7.65 +0.75 vs 3.26 +0.49) were significantly different and negatively correlated between two groups respectively . Flow-mediated dilatation (FMD) (6.08% + 0.34 vs 14.46% + 1.12), aortic strain (7.79% + 2.19 vs 12.76% + 4.19), and serum ferritin values were significantly different and negatively correlated between two groups respectively. Conclusion: Decreased LVEF and increased SDI by RT3DE could be parameters of early cardiac deterioration. Decreased FMD and aortic strain may be good predictors of subclinical cardiovascular involvement in asymptomatic patients with β-TM.
Purpose: An elevated left ventricular (LV) filling pressure is the main finding in patients with heart failure with preserved ejection fraction, which is estimated with an algorithm using echocardiographic parameters recommended by the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guideline. In this study, we sought to determine the efficacy of LV global longitudinal strain (GLS) to estimate the elevated LV filling pressure. Methods and Results: 73 prospectively selected patients undergoing left ventricular catheterization (mean age 63.19±9.64, 68.5% male) participated in this study. Using the algorithm, the LV filling pressure was estimated with the echo parameters obtained within 24hrs before the catheterization. The LV GLS was measured using the automated functional imaging system (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to mean left atrial pressure (LAP) was used as a reference, and >12 mm Hg was defined as elevated. The invasive LV filling pressure was elevated in 43 (58.9%) and normal in 30 patients (41.1%). In 9 (12.3%) patients of 73 are defined as indeterminate based on the 2016 algorithm. Using the ROC method, -18.1% of LV GLS estimated the LV filling pressure (AUC=0.79, 73% specificity, 84% sensitivity) with higher sensitivity compared with the algorithm (AUC=0.76, 77% specificity, 72% sensitivity). Conclusions: We confirmed that the LV GLS is feasible and reproducible in estimating LV filling pressure. In addition, LV GLS highly predicts elevated LAP as E/e’ and TR jet velocity and may be used as major criteria for the diagnosis of HFpEF
Background: Three-dimensional echocardiography (3DE) evaluation of left ventricular (LV) volume and function in pediatrics compares favorably with cardiac magnetic resonance imaging. The aim of this study was to establish from a multicenter, normal pediatric z-score values of 3DE left ventricular volumes and function. Methods: Six hundred and ninety-eight healthy children (ages 0 to 18 years) were recruited from five centers. LV 3DE was acquired from the 4-chamber view. A vendor independent software analyzed end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) using semi-automated quantification. Body surface area (BSA) based z-scores were generated. Intraobserver and interobserver variability were calculated using intraclass correlation (ICC) and repeatability coefficient (RC). Results: Z-scores were generated for ESV, EDV, and SV. The ICC for intraobserver variability for EDV, ESV, and SV were 0.99, 0.99, and 0.99 respectively. The ICC for interobserver variability for EDV, ESV, and SV were 0.98, 0.94, and 0.98 respectively. The RC for intraobserver and interobserver variability for LV EF was 4.39% (95% CI: 3.01, 5.59) and interobserver was 7.08% (95%CI: 5.51, 8.42). Conclusions: We report pediatric Z-scores for normal LV volumes using the semi-automated method from five centers, enhancing its generalizability. 3DE evaluation of LV volumes and EF in pediatric patients is highly reproducible.
Background: Left ventricular (LV) outflow tract (LVOT) obstruction increases mortality in patients undergoing transcatheter mitral valve implantation (TMVI) in degenerated bioprostheses, annuloplasty rings, and native mitral valves. We aimed to evaluate the left ventricular outflow tract area after TMVI using 3-diensional (3D) transesophageal echocardiography (TEE) and to investigate the pre-procedural cardiac geometry affects the LVOT area after TMVI. Methods: We retrospectively reviewed echocardiography data in 43 patients who had TMVI. A change in pressure gradient across LVOT from before to after TMVI (∆PG) and post-procedure 3D cross sectional area (CSA) at the level of the most distal portion of the mitral valve stent that was closest to the LV apex were assessed as evidence of LVOT narrowing. Results: TMVI with the use of balloon-expandable valve system was performed for 24 bioprostheses, 7 annuloplasty rings, and 12 native valves. Compared to patients without increase in LVOT gradient (∆PG <10 mmHg; n=33), patients with increase in LVOT gradient (∆PG ≥10 mmHg; n=10) had smaller LV end-systolic volume (LVESV), greater LV ejection fraction (LVEF) and smaller aorto-mitral (AM) angle. CSA at the valve stent distal edge showed strong association with ∆PG (r=-0.68, P<0.0001). Only small AM angle was associated with small CSA at the valve stent ventricular edge on multivariable analysis, independent of LVESV and LVEF. Conclusion: Pre-procedural AM angle as well as LVESV and LVEF were associated with LVOT narrowing in patients undergoing transcatheter mitral valve-in-valve, valve-in-ring, and valve-in-native valve implantation. These data may be useful for preprocedural planning.