Bahaa M. Fadel

Acquired Left Ventricular-Right Atrial Communication Gerbode-Type Defect

Left ventricular‐right atrial (LV‐RA) communications are rare intracardiac defects, often congenital in nature and clinically apparent during childhood. Acquired LV‐RA shunts are encountered occasionally in the adult population as a result of a defect in the upper portion of the membranous ventricular septum. We describe the clinical and echocardiographic features of an elderly patient with an acquired LV‐RA communication in the setting of an aortic composite valve graft and endocarditis. We also review the anatomical features and hemodynamic consequences of such defects.

Pseudoaneurysm of the Mitral-Aortic Intervavular Fibrosa: A Long-Term Complication of Infective Endocarditis

Pseudoaneurysms of the left ventricle are rare and may occur as a result of transmural myocardial infarction, chest trauma, cardiac surgery, or endocarditis. Although postinfarction pseudoaneurysms commonly arise in the mid and apical segments of the left ventricle, those resulting from endocarditis arise at the base of the heart. Here we report the case of a patient who developed a large pseudoaneurysm as a complication of aortic valve endocarditis. The pseudoaneurysm had two uncommon features; it originated from the intervalvular fibrous body connecting the mitral to the aortic valve, and it eroded through the chest wall, resulting in blood drainage through the skin.

Isolated Rheumatic Tricuspid Stenosis with Reverse Lutembacher's Physiology.

Tricuspid valve dysfunction occurs frequently in patients with rheumatic heart disease and is usually manifested as functional or organic tricuspid regurgitation. Rheumatic tricuspid stenosis is less common and occurs characteristically in the presence of concomitant mitral valve disease. In this report, we describe the clinical and echocardiographic findings in a patient with isolated rheumatic tricuspid stenosis and a right‐to‐left shunt across the interatrial septum, likely as a result of a patent foramen ovale, resulting in central cyanosis. This case illustrates an interesting association of tricuspid stenosis and an interatrial right‐to‐left shunt suggestive of a reverse Lutembachers physiology.

Echocardiography detects elevated left ventricular filling pressures in heart transplant recipients.

Diastolic dysfunction is a recognized complication in heart transplant (HTx) recipients that limits exercise capacity and is a risk factor for mortality. We investigated the ability of echocardiography to detect elevated pulmonary capillary wedge pressure (mean PCWP>15 mmHg) in HTx recipients. This retrospective study comprised HTx recipients with echocardiography and right heart catheterization within 24 hours (n = 100, 113 investigations). Echocardiographic assessment was performed using mitral inflow (E/A ratio, deceleration time [DT], isovolumic relaxation time [IVRT]), tissue Doppler (E/E′ lateral) parameters, and the Doppler‐estimated pulmonary artery systolic pressure (Doppler PASP). The right atrial pressure (RAP) was estimated based on size and the effect of respiration or sniffing on the inferior vena cava diameter. Cutoff values were determined from a derivation group (n = 57, receiver operator characteristic curve analysis) and evaluated in a test group (n = 56). Elevated PCWP were found in 38%. The RAP and PCWP were both normal in 58 investigations and elevated in 39 investigations (concordance rate of 86.6%). The presence of signs of increased RAP by echocardiography or with three of five parameters (E/A, DT, IVRT, E/E′ lateral, and Doppler PASP) reaching the cutoff values ruled in elevated PCWP with positive likelihood ratios ranging from 15.3 to 9. With normal RAP by echocardiography or none of the other parameters reaching cutoff values elevated PCWP can be ruled out with negative likelihood ratios ranging from 0.07 to 0.19. In conclusion, elevated PCWP in HTx recipients can be assessed using echocardiography.

Spectral Doppler of the Hepatic Veins in Tricuspid Valve Disease

Spectral Doppler recording of the hepatic veins (HV) provides a semiquantitative assessment of tricuspid regurgitation (TR) severity. It complements findings on two‐dimensional echocardiography and color Doppler imaging and helps to discriminate between hemodynamically significant and nonsignificant degree of regurgitation. In this manuscript, we discuss the usefulness of the HV Doppler for the diagnosis of tricuspid valve (TV) disease and provide examples of the various spectral Doppler patterns that assist in the quantification of TR.

The Various Hemodynamic Profiles of the Patent Ductus Arteriosus in Adults

The patent ductus arteriosus (PDA) has diverse clinical and hemodynamic manifestations depending on its size and the degree of the ensuing left‐to‐right shunt. A small PDA that causes minor shunting has no major hemodynamic consequences. Conversely, a large PDA with a significant left‐to‐right shunt may lead to various hemodynamic abnormalities. These include left‐sided volume overload that may result in heart failure and/or pulmonary hypertension, the latter being a flow‐dependent and mostly reversible phenomenon. The most feared complication is the development of severe and irreversible pulmonary hypertension (Eisenmenger physiology). In this manuscript, we provide examples of the various hemodynamic profiles of PDA as assessed by echocardiography in the adult population.

Spectral Doppler of the hepatic veins in pulmonary hypertension.

Pulsed‐wave Doppler interrogation of the hepatic veins (HVs) provides a window to right heart hemodynamics and function. Various pathologies that involve the right heart are manifested on the HV Doppler depending on the location and severity of the involvement and its hemodynamic consequences. Pulmonary hypertension (PHTN), a common finding on echocardiographic studies, imparts changes on the HV Doppler that are important to recognize. In this article, we provide a review of the main abnormalities that are encountered on the HV Doppler in patients with PHTN.

Spectral Doppler Interrogation of the Pulmonary Veins in Atrial Septal Defect

The various components of the pulmonary venous (PV) flow are linked to physiological and pathological changes that predominantly occur in the left heart. Thus, spectral Doppler interrogation of the PVs provides hemodynamic insight mainly into left‐sided cardiac function. An exception to the dependence of PV flow on left heart events occurs in the setting of an atrial septal defect (ASD). The latter causes a portion of the PV blood flow, intended to cross the mitral valve, to be channeled into the more compliant right heart. This phenomenon makes the PV flow more dependent on the left‐to‐right interatrial shunt. The identification on the PV Doppler of a pattern that suggests uncoupling with left heart hemodynamics should raise the suspicion of an underlying ASD.

Spectral Doppler Interrogation of the Patent Foramen Ovale–A Window to Left Heart Hemodynamics

Spectral Doppler interrogation of flow across a patent foramen ovale (PFO) allows recording of the instantaneous pressure gradient between left and right atrium (RA). The assessment of RA pressure using the size and collapsibility of the inferior vena cava would thus allow estimation of left atrial (LA) pressure. In this article, we illustrate the value of spectral Doppler interrogation of flow across the PFO by transthoracic echocardiography as a novel and simple tool for the assessment of LA pressure and left cardiac hemodynamics in addition to the conventional noninvasive parameters.

Spectral Doppler Interrogation of Mitral Regurgitation —Spot Diagnosis

Mitral regurgitation (MR) is one of the most common valvular lesions that are readily identified by transthoracic echocardiography. Color Doppler imaging is the modality of choice for the recognition of MR, and it plays an important role in the assessment of regurgitation severity. Continuous wave (CW) Doppler is commonly used to interrogate the MR signal, and this modality can provide highly useful data regarding several physiological and pathological parameters. In this manuscript, we present a series of cases that illustrate the various hemodynamic parameters that can be derived from analysis of the CW Doppler signal of MR.