Anna Kydd

Patent foramen ovale: anatomy, outcomes, and closure.

Patent foramen ovale (PFO) is a normal fetal communication between the right and left atria that persists after birth. PFO is a common finding that occurs in 20–34% of the population, although its prevalence decreases with age. In most cases, a PFO poses no threat to health. However, some PFOs have the ability to open widely under certain hemodynamic conditions, which enables any bloodborne material, such as thrombi, air, or vasoactive substances, to pass from the venous to the arterial circulation, with the potential to cause a cerebrovascular event. PFO has been linked to several conditions, including cryptogenic stroke, migraine with aura, decompression illness, and systemic arterial embolism. However, the data that support PFO closure in these conditions are mostly from nonrandomized cohort series, and are often contradictory. In this Review, we discuss the existing data on PFO closure, including results of the first randomized, controlled trial comparing device closure of PFO with medical therapy for cryptogenic stroke, and we examine controversies in the literature as well as ongoing studies. We also focus on the anatomy of a PFO and how it impacts on the procedure of PFO closure with a percutaneous device.

Dynamics of the tricuspid valve annulus in normal and dilated right hearts: a three-dimensional transoesophageal echocardiography study

BACKGROUND The tricuspid valve annulus (TVA) is a complex three-dimensional structure that is incompletely understood. Three-dimensional transoesophageal echo (TOE) provides us with the opportunity to examine this structure in detail. METHODS AND RESULTS Fifty patients were included, divided into two groups: controls (n = 20), and dilated right hearts (DRH, n = 30). Three-dimensional zoom images of the TVA were acquired using an iE33 machine and X7-2t transducer. Antero-posterior (AP) diameter, septo-lateral (SL) diameter, area, circumference, and height were measured at 6 points of the cardiac cycle adapting commercially available software designed for assessing the mitral valve (MVQ, Philips). The eccentricity ratio was calculated as AP/SL. The tricuspid annular area decreases during systole in both groups, and is greatest in mid-diastole. The area is significantly larger in the DRH group (mean 1566 mm(2) DRH vs. 1097 mm(2) controls; P < 0.01). The SL diameter increases proportionately more in the DRH group, resulting in a more circular orifice and lower eccentricity ratios (eccentricity ratio mean 1.01 DRH vs. 1.24 controls; P < 0.01). The dynamic diastolic to systolic change in the SL diameter is lost in patients with DRH, contributing to the more circular TVA orifice throughout systole. CONCLUSION Three-dimensional TOE allows us to examine the TVA in great detail. In patients with DRH, the TVA dilates in a SL direction, resulting in a more circular orifice. The dynamic changes of the TVA are lost in patients with DRH, potentially contributing to functional tricuspid regurgitation.

Provision of magnetic resonance imaging for patients with ‘MR-conditional’ cardiac implantable electronic devices: an unmet clinical need

Aims Increasing need for magnetic resonance imaging (MRI) has driven the development of MR-conditional cardiac implantable electronic devices (CIEDs; pacemakers and defibrillators); however, patients still report difficulties obtaining scans. We sought to establish current provision for MRI scanning of patients with CIEDs in England. Methods and results A survey was distributed to all hospitals in England with MRI, to assess current practice. Information requested included whether hospitals currently offer MRI to this patient group, the number and type of scans acquired, local safety considerations, complications experienced and perceived obstacles to service provision in those departments not currently offering it. Responses were received from 195 of 227 (86%) of hospitals surveyed. Although 98% of departments were aware of MR-conditional devices, only 46% (n = 89) currently offer MRI scans to patients with CIEDs; of these, 85% of departments perform ≤10 scans per year. No major complications were reported from MRI scanning in patients with MR-conditional devices. Current barriers to service expansion include perceived concerns regarding potential risk, lack of training, logistical difficulties, and lack of cardiology support. Conclusion Provision of MRI for patients with CIEDs is currently poor, despite increasing numbers of patients with MR-conditional devices and extremely low reported complication rates.

Mitral annular caseous necrosis: insights from multimodality imaging

A 77-year-old man was investigated following a syncopal episode, the finding of a systolic murmur on examination and a calcified lesion on chest x-ray ( Panel A ). Transthoracic echocardiography demonstrated a well-demarcated, bright, homogeneous mass in the mitral valve annulus ( Panel B ). He was referred for further imaging with a presumed diagnosis of a cardiac tumour. Real-time three-dimensional transoesophageal echocardiography (TOE) …

USE OF SPECKLE TRACKING ECHOCARDIOGRAPHY TO DETERMINE SEGMENTAL MYOCARDIAL SCAR BURDEN: INSIGHTS FROM THE TARGET STUDY

Presence and extent of viability in the region of the left ventricular (LV) lead tip is related to cardiac resynchronization therapy (CRT) response in patients with heart failure. Myocardial deformation imaging allows assessment of transmurality of myocardial scar and therefore viability. Published

Cardiac Protection via Metabolic Modulation: An Emerging Role for Incretin-Based Therapies?

Cardiovascular disease continues to be a major cause of morbidity and mortality in patients with Type 2 Diabetes Mellitus. Whilst a focus on improved glucose control and HbA1c has led to a reduction in the progression and development of microvascular complications, the potential for this strategy to reduce cardiovascular event rates is less clearly defined. Identification of the incretin axis has facilitated the development of several novel therapeutic agents which target glucagon-like peptide-1 (GLP-1) pathways. The effects on glucose homeostasis are now established, but there is also now an increasing body of evidence to support a number of pleiotropic effects on the heart that may have the potential to influence cardiovascular outcomes. In this article, we review myocardial energy metabolism with particular emphasis on the potential benefits associated with a shift towards increased glucose utilisation and present the pre-clinical and clinical evidence regarding incretin effects on the heart. In addition we discuss the potential mechanism of action and benefit of drugs that modulate GLP-1 in patients with type 2 diabetes mellitus and coronary artery disease.

Current provision for MRI scanning of patients with cardiac implantable electronic devices - a national survey of hospitals in England

Background With increasing numbers of patients requiring implantation of a cardiac implantable electronic device (pacemaker or defibrillator), and MRI becoming the gold standard investigation for the diagnosis and monitoring of many medical conditions, device manufacturers have developed MRI conditional CIEDs. Many hospitals now implant MRI conditional devices as standard, meaning that there are large numbers of patients with these devices who believe that accessing and undergoing MRI scans with their devices should be straightforward. Unfortunately the reality is often very different; patients anecdotally report extreme difficulties with many MRI units refusing to scan them. We sought to establish current provision for MRI scanning of patients with CIEDs in England, and the potential barriers to service expansion.

The Eustachian ridge: not an innocent bystander.

A prominent right atrial Eustachian ridge (ER), which inserts into the roof of the fossa ovalis (FO), can impede successful placement of a patent foramen ovale (PFO) closure device, resulting in residual shunting. This can be mitigated by selecting a more flexible or smaller device, illustrated by

140 Does The Gore Septal Occluder Offer Excellent Closure of all PFO Phenotypes when Guided by 3D Imaging

Purpose Device characteristics are key in ensuring effective sealing of Patent Foramen Ovale (PFO). With a unique design and biocompatible material allowing device conformity to varying PFO anatomies, the Gore Septal Occluder (GSO) might be ideal for percutaneous closure of complex PFO. Methods Between August 2011 to September 2013, 58 consecutive patients underwent PFO closure using GSO device at our institution. Indications for closure included stroke or transient ischaemic attack (n = 44), paradoxical embolus (n = 8), migraine (n = 1), decompression illness (n = 3) and shunt with hypoxia (n = 2). All patients underwent detailed assessment of PFO anatomy using 3D transoesophageal echocardiography (TEE). ‘Complex’ anatomical characteristics were recorded according to pre-defined criteria, see Table 1. Abstract 140 Table 1 ‘Complex’ anatomical features of PFO ‘Complex’ anatomical features No. of patients Long tunnel > = 10mm 6 Multiple openings in left atrium 3 Atrial septal aneurysm with septal sway > = 10mm 5 Thickened septum secundum 1 High eustachian ridge 20 Eustachian valve or Chiari network 11 Results All 58 patients (mean age 41 years; age range 17–71, male 54%) underwent successful GSO device implantation. 34/58 (59%) had one or more ‘complex’ PFO anatomical features as shown in Table 1. Devices used were: 15 mm (n = 1), 20 mm (n = 8), 25 mm (n = 41), 30 mm (n = 8). Procedure and fluoroscopy times were 59 ± 11 mins and 6.3 ± 3.8 mins respectively. There were no significant post-procedure complications except one patient developed migraine and another had asymptomatic paroxysmal atrial fibrillation. An immediate assessment post procedure with TEE confirmed good positioning of the device with no evidence of shunts in 58 patients. One patient had moderate shunting, however device position was excellent. Transthoracic echocardiography (TTE) at follow-up 12 weeks post procedure has been performed in 48 patients to date. In all patients this confirmed good device position with no evidence of a shunt on colour doppler. One year follow-up bubble TTE is available on 33 patients. 21 had no residual shunting, confirming complete PFO closure. 3 patients had moderate shunting and 9 patients had mild shunting on valsalva. All patients have remained clinically well. Conclusions ’Complex’ PFO closure with the GSO device is feasible and safe. Our data suggests that the role of 3D TEE in defining ‘complex’ features is essential in determining device selection and the GSO device appears to be promising in these complex PFOs. Further studies are needed.