Arun Dahiya

Biventricular Mechanics in Constrictive Pericarditis Comparison With Restrictive Cardiomyopathy and Impact of Pericardiectomy

Background— The aim of our study was to compare myocardial mechanics of constrictive pericarditis (CP) with restrictive cardiomyopathy (RCM), or healthy controls; to assess the impact of pericardial thickening detected by cardiac magnetic resonance on regional myocardial mechanics in CP; and to quantitate the effect of pericardiectomy on myocardial mechanics in CP. Methods and Results— Myocardial mechanics were evaluated by 2-dimensional speckle tracking in 52 consecutive patients with CP who underwent cardiac magnetic resonance examination before pericardiectomy, 35 patients with RCM, and 26 control subjects. CP patients had selectively depressed left ventricular (LV) anterolateral wall strain (LWS) and right ventricular (RV) free wall longitudinal systolic strain (FWS) but preserved LV septal wall systolic strain (SWS). In a comparison of RCM and normals, CP patients had significantly lower regional longitudinal systolic strain ratios (CP versus RCM and normal; LVLWS/LVSWS: 0.8±0.2 versus 1.1±0.2 and 1.0±0.2; P<0.001, RVFWS/LVSWS: 0.8±0.4 vs. 1.4±0.5 and 1.2±0.2; P<0.001). LVLWS/LVSWS was more robust than the LV lateral wall to LV septal wall ratio of early diastolic velocities at the LV base (LE′/SE′) in differentiating CP from RCM (area under the curve=0.91 versus 0.76; P=0.011). There was a significant inverse correlation between pericardial thickness and respective ventricular strains (P=0.001). Pericardiectomy resulted in the improvement of the depressed LVLWS/LVSWS (0.83±0.18–0.95±0.12; P<0.001). Conclusions— Regional longitudinal systolic strain ratios are robust novel diagnostic tools for CP. Regional myocardial mechanics inversely correlates with adjacent pericardial segment thickness detected by cardiac magnetic resonance, and pericardiectomy leads to systolic strain improvement, which is more pronounced in right ventricular and LV free walls.

Isolated left ventricular non-compaction controversies in diagnostic criteria, adverse outcomes and management

Isolated left ventricular non-compaction (LVNC) is a morphological abnormality of excessive trabeculation of the LV, often complicated by ventricular dysfunction, arrhythmias and cardioembolism. Advances in cardiovascular imaging and widespread availability of imaging technology have led to an increase in the diagnosis of LVNC imposing a need for evidence-based imaging diagnostic criteria. Although recent studies have addressed the utility of newer diagnostic methodologies and the incidence of adverse events in this condition, the diagnosis and management remain controversial. In this review, we provide an overview of the current controversies in the clinical diagnosis of LVNC, and suggest a management approach.

Improved Interobserver Variability and Accuracy of Echocardiographic Visual Left Ventricular Ejection Fraction Assessment through a Self-Directed Learning Program Using Cardiac Magnetic Resonance Images

BACKGROUND Although not recommended in isolation, visual estimation of echocardiographic ejection fraction (EF) is widely applied to confirm quantitative EF. However, interobserver variability for EF estimation has been reported to be as high as 14%. The aim of this study was to determine whether self-directed education could improve the accuracy and interobserver variability of visual estimation of EF and whether a multireader estimate improves measurement precision. METHODS Thirty-one participants provided single-point EF estimates for 30 echocardiograms with a spectrum of EFs, image quality, and clinical contexts in patients undergoing cardiac magnetic resonance (CMR) within 48 hours. Participants received their own case-by-case variance from CMR EF, and the 10 cases with the largest reader variability were discussed along with corresponding CMR images. Self-directed learning was undertaken by side-by-side review of echocardiographic and CMR images. Two months later, 20 new cases were shown to the same 31 participants, using the same methodology. RESULTS The baseline interobserver variability of ±0.120 improved to ±0.097 after the intervention. EF misclassification (defined as ±0.05 of CMR EF) was reduced from 56% to 47% (P < .001), and the intervention also resulted in a decrease in the absolute difference between CMR and echocardiography for all cases and all readers (from 0.07 ± 0.01 to 0.06 ± 0.01, P = .0001). This improvement was most prominent for the readers with lower baseline accuracy. A combined physician-sonographer EF estimate improved the precision of EF determination by 25% compared with individual reads. CONCLUSIONS In readers with varying levels of experience, a simple, mostly self-directed intervention modestly decreased interobserver variability and improved the accuracy of EF measurements. Combined physician-sonographer EF reporting improved the precision of EF estimates.

Prospective ECG-triggered, axial 4-D imaging of the aortic root, valvular, and left ventricular structures: a lower radiation dose option for preprocedural TAVR imaging.

BACKGROUND Transcatheter valve interventions rely on imaging for patient selection, preprocedural planning, and intraprocedural guidance. OBJECTIVE We explored the use of prospective electrocardiogram (ECG)-triggered 4-dimensional (4-D) CT imaging in patients evaluated for transcatheter aortic valve replacement (TAVR). METHODS A total of 47 consecutive patients underwent 128-slice dual-source CT with wide-window dose-modulated prospective ECG-triggered, axial acquisition of the aortic root, reconstructed during diastolic and systolic cardiac phases. Image quality was evaluated, aortic root and left ventricular (LV) geometry and function were analyzed, and radiation exposure was estimated. RESULTS Image quality was generally good, with 41 of 47 (87%) patients scored as good or excellent. The mean aortic valve area was 0.93 ± 0.24 cm(2). Mean LV ejection fraction was 56.8% ± 16.4%, and mean LV mass was 130.4 ± 43.8 g. The minor diameter of the annulus was larger in systole (systole, 2.29 ± 0.24 cm; diastole, 2.14 ± 0.25 cm; P = 0.006), but the mean and major diameters did not vary significantly between systole and diastole. The mean estimated effective dose was 5.9 ± 2.4 mSv. CONCLUSION Multiphase, prospective ECG-triggered axial image acquisition is a lower dose acquisition technique for 4-D aortic root imaging in patients being considered for TAVR.

Relation of reduced preclinical left ventricular diastolic function and cardiac remodeling in overweight youth to insulin resistance and inflammation

Insulin resistance (IR) and inflammation are associated with an increased risk of cardiovascular disease and may contribute to obesity cardiomyopathy. The earliest sign of obesity cardiomyopathy is impaired left ventricular (LV) diastolic function, which may be evident in obese children and adolescents. However, the precise metabolic basis of the impaired LV diastolic function remains unknown. The aims of this study were to evaluate cardiac structure and LV diastolic function by tissue Doppler imaging in overweight and obese (OW) youth and to assess the relative individual contributions of adiposity, IR, and inflammation to alterations in cardiac structure and function. We studied 35 OW (body mass index standard deviation score 2.0±0.8; non-IR n=19, IR n=16) and 34 non-OW youth (body mass index standard deviation score 0.1±0.7). LV diastolic function was reduced in OW youth compared with non-OW controls, as indicated by lower peak myocardial relaxation velocities (p<0.001) and greater filling pressures (p<0.001). OW youth also had greater LV mass index (p<0.001), left atrial volume index, and LV interventricular septal thickness (LV-IVS; both p=0.02). IR-OW youth had the highest LV filling pressures, LV-IVS, and relative wall thickness (all p<0.05). Homeostasis model of assessment-insulin resistance and C-reactive protein were negative determinants of peak myocardial relaxation velocity and positive predictors of filling pressure. Adiponectin was a negative determinant of LV-IVS, independent of obesity. In conclusion, OW youth with IR and inflammation are more likely to have adverse changes to cardiovascular structure and function which may predispose to premature cardiovascular disease in adulthood.

Congenital Absence of the Left Atrial Appendage

A 73-year-old woman with no history of cardiac surgery presented with symptomatic atrial fibrillation. A transesophageal echocardiogram was scheduled to exclude thrombus before cardioversion. No obvious intracardiac thrombus was identified, but the patient could not be cleared for cardioversion because the left atrial appendage (LAA) had not been visualized, raising concerns for either a flush occlusion with thrombus or a small ectopic appendage (Figure 1 and online-only Data Supplement Videos I-IV). Contrast-enhanced multidetector computed tomography revealed moderate biatrial enlargement without intracardiac thrombus and confirmed a diagnosis of …

Pericardiectomy is Associated with Improvement in Longitudinal Displacement of Left Ventricular Free Wall Due to Increased Counterclockwise Septal-to-Lateral Rotational Displacement.

BACKGROUND Pericardiectomy is an effective intervention for constrictive pericarditis. Speckle-tracking echocardiography can provide quantitative information not only about longitudinal strain (LS) but about longitudinal displacement (LD) and septal-to-lateral rotational displacement (SLRD). The aim of this study was to investigate whether pericardiectomy improves myocardial mechanics using speckle-tracking analysis. METHODS Eighty-three patients with constrictive pericarditis who underwent echocardiography were retrospectively assessed (mean age, 58 ± 12 years; 72 men; 50 idiopathic, 20 postoperative, four viral, three radiation, and six others) and compared with 20 healthy volunteers. LD and SLRD were measured from the apical four-chamber view and global LS from three apical views. RESULTS LD was less in the constrictive pericarditis group compared with control subjects (P < .001). Only lateral LS was significantly less than that of control subjects (P < .001), but septal LS was similar (P = .48). In pre- and post-pericardial surgery comparisons (n = 27), values of septal and lateral LD were almost identical (mean, 13.6 ± 4.7 vs 13.3 ± 5.4 mm; P = .70) before pericardiectomy, but septal LD decreased (mean, 9.3 ± 3.5 mm; P < .001) and lateral LD increased (mean, 16.8 ± 4.7 mm; P = .0106) after the surgery, even though the difference in LS between the septal and lateral walls decreased (from 5.6 ± 5.3% to 2.5 ± 4.2%, P = .008). Systolic whole-heart swinging motion significantly increased to a counterclockwise direction after surgery (mean SLRD, -0.8 ± 3.3° vs 2.1 ± 3.0°; P = .001). Although the change in SLRD after pericardiectomy was not different between patients with decreases and increases in New York Heart Association class, SLRD change was significantly greater in patients who received fewer diuretics after surgery (mean, 4.00 ± 0.91 vs 0.27 ± 1.47; P = .027). CONCLUSIONS After surgical removal of the pericardium, LD of the septal and lateral walls became significantly different, and counterclockwise SLRD increased, reflecting loss of pericardial support.

Annular velocities in constrictive pericarditis: annulus and beyond.

An increasing incidence of constrictive pericarditis (CP) after open heart surgery and the availability of highly effective CP treatments continue to pique investigator interest in CP. Differentiating between CP and restrictive cardiomyopathy (RCM) remains clinically challenging and has been

Aorta–to–Pulmonary Vein Fistula in an Asymptomatic 25-Year-Old Man

A 25-year-old man with no significant medical history was found to have a continuous murmur along the left sternal border on routine physical examination performed in preparation for running a marathon. Echocardiography showed a dilated left ventricle with normal function and continuous high-velocity flow in an aberrant vessel in close vicinity to the abdominal aorta (Movie I in the online-only Data Supplement). Chest x-ray (posterior-anterior and lateral projections, Figure 1) disclosed conglomeration of tubular densities in a scimitar pattern in the right lower lobe suggestive of anomalous pulmonary venous return of right lower lobe (scimitar syndrome; anomalous drainage of right lung pulmonary veins into the inferior vena cava). Cardiac magnetic resonance imaging (MRI) not only demonstrated normal drainage of all 4 pulmonary veins into the left atrium but also revealed an aberrant vessel (Movie II in the online-only Data Supplement) extending between the abdominal aorta and the right inferior pulmonary vein with an elevated systemic-to-pulmonary flow ratio of 1.8, consistent with a large left-to-left shunt. Cardiac computed tomography (CT) confirmed the presence of a large fistulous connection between the abdominal aorta and the right inferior …

Apical Hypertrophic Cardiomyopathy With and Without Aneurysm

We present 2 cases of apical hypertrophic cardiomyopathy (HCM) with similar presentations but different imaging appearances. Case #1 is an 82-year-old female with exertional dyspnea and mildly elevated troponin. Electrocardiogram (ECG) (A, left panel) , echocardiogram (with contrast) ( B, left panel