Claudia Marini

Multimodality imaging of the tricuspid valve with implication for percutaneous repair approaches

Nowadays some percutaneous options for tricuspid valve (TV) repair are available: Tricinch (4Tech Cardio, Galway, Ireland) mimicking the Kay procedure, Trialign (Mitralign, Boston, MA, USA) aiming to bicuspidise TV, MitraClip (Abbott Vascular, Abbott Park, Illinois, USA) mimicking Alfieri’s stitch, direct transcatheter annuloplasty with Cardioband (Valtech Cardio, Or Yehuda, Israel) and transcatheter Forma Repair (Edwards Lifesciences, Irvine, California, USA) providing a surface for leaflet coaptation. A multimodality imaging approach is fundamental for defining the pathophysiology of tricuspid regurgitation (TR), preprocedural planning and intraprocedural monitoring. Both 2-dimensional and 3-dimensional (3D) transthoracic echocardiography and transoesophageal echocardiography (TOE) are essential for grading and anatomical characterisation of TR, and evaluation of dimensions and function of right ventricle (RV) and estimation of pulmonary pressure. In particular, 3D echocardiography provides a better anatomical definition of TV apparatus and tricuspid annulus (TA) and additional information about the anatomical relationships of TV and surrounding structures. CT offers complementary information during the preprocedural planning especially for procedures targeting TA such as annular structure and dimensions, quality and amount of annular tissue and its relationship with the right coronary artery, and the sizing of the inferior vena cava. Moreover, appropriate patient selection is crucial. The best candidate seems to be a patient with functional TR due to predominant annular dilatation with modest apical tethering, at least partial preservation of leaflets coaptation, not severe pulmonary hypertension and not advanced RV dilation and dysfunction. An example of intraprocedural multimodality imaging approach with TOE, fluoroscopy, angiography and intracardiac echocardiography is also reported.

First-in-Man MitraClip Implantation to Treat Late Postoperative Systolic Anterior Motion Rare Cause of Tardive Mitral Repair Failure

A 52-year-old man underwent surgical mitral repair for P2 flail. A conventional Carpentier technique was used (quadrangular resection+sliding plasty and annuloplasty with a 35-mm flexible band). Predischarge echocardiography showed no residual MR and no systolic anterior motion (SAM). One year after surgery, the patient came to our attention complaining dyspnoea on effort (New York Heart Association III). Rest echocardiography showed absence of recurrent MR, but evidence of SAM with mild left ventricular outflow tract (LVOT) obstruction. Exercise echocardiography revealed a significant SAM with severe LVOT obstruction (Figure 1; Movies I–III in the Data Supplement). An induced pressure gradient of 144 mm Hg and a dynamic flow acceleration with late systolic peak velocity were observed across the LVOT with concomitant moderate MR and mild pulmonary hypertension (systolic pulmonary pressure, 40 mm Hg; Figure 1). A pharmacological approach was attempted first (atenolol, 100 mg QID; diltiazem 180 mg QID) without clinical improvements and changes in SAM and LVOT obstruction. Therefore, an interventional strategy was considered. A MitraClip procedure was planned to correct the SAM. Adrenaline infusion was used to induce SAM. After ineffective attempts to place the clip in the central …

Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure

AIMS Thoracic endovascular aortic repair (TEVAR) is commonly considered as a valid alternative to surgery. Endoleaks occurrence is one of the principal limitations of TEVAR. Transoesophageal echocardiography (TEE) is often adopted in adjunct to fluoroscopy and angiography (ANGIO) during stent-graft implantation. In the present study, we compare intraprocedural ANGIO, TEE, and contrast-enhanced TEE (cTEE), and we also evaluate their accuracy in early endoleaks detection and characterization. METHODS AND RESULTS Fifty-four patients with thoracic aortic disease suitable for TEVAR were prospectively enrolled in the study. After stent placement, the result of the procedure was assessed by ANGIO, TEE, and cTEE. The use of contrast (Sonovue, Bracco) significantly improved TEE quality (P = 0.0001). cTEE was superior in entry tears, false and true lumen and aneurysm thrombosis identification, and microtears and ulcer-like projections detection before stent deployment. After stent deployment, cTEE was more accurate than TEE and ANGIO in the detection of slow flow in the false lumen and in the aneurismal sac (P = 0.0001), and in the remaining flow identification (P = 0.0001). Notably, cTEE is more accurate in the endoleaks detection (P = 0.0001) and in the incomplete stent expansion diagnosis and need for a further balloon inflation (P 0.002), or a further stent implantation (P 0.006), compared with TEE and ANGIO. CONCLUSION TEVAR procedures are improved by the complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and cTEE. This triple imaging approach provides additional information in all phases of the procedure improving safety of stent-grafting and the procedural outcomes.

Effects of functional tricuspid regurgitation on renal function and long-term prognosis in patients with heart failure.

Aims Renal dysfunction is common in heart failure. Recent evidence suggests a pivotal role for systemic venous congestion and functional tricuspid regurgitation (FTR) in the pathophysiology of renal dysfunction. We investigated the role of FTR as a determinant of renal dysfunction and a predictor of long-term prognosis in chronic systolic heart failure patients. Methods and results Four hundred and thirteen consecutive patients (mean age 74.2 ± 11 years) with chronic heart failure and left ventricular ejection fraction below 50% were enrolled. The FTR severity was quantified by transthoracic echocardiography. Renal function was evaluated with the estimated glomerular filtration rate measured by the simplified Modification of Diet in Renal Disease formula. The association between moderate/severe FTR and renal dysfunction, and its impact on heart failure episodes and overall mortality were also assessed. The median follow-up was 36 months (range 1–144 months). Through multivariate analysis, the interaction between moderate/severe FTR with tricuspid annular plane systolic excursion less than 16 mm was found to be an independent determinant of renal dysfunction [odds ratio 1.2, 95% confidence interval (CI) 1.1–1.5, P = 0.04]. Moderate/severe FTR (hazard ratio 1.3, 95% CI 1.2–2.7, P = 0.02) and tricuspid annular plane systolic excursion below 16 mm (hazard ratio 1.2, 95% CI 1.0–3.7, P = 0.01) were significantly related to the heart failure episodes. Moreover, the Kaplan–Meier analysis showed a worse outcome in patients with moderate/severe FTR (log-rank test 8.6, P = 0.003). Conclusions The combination of significant FTR and right ventricular dysfunction, but not FTR and right ventricular dysfunction alone, is independently associated with renal dysfunction. The presence of significant FTR is related to an excess event rate of heart failure and has significant impact on outcome.

Use of Echocardiography for Guiding Percutaneous Tricuspid Valve Procedures

Percutaneous tricuspid valve (TV) repair procedures are emerging therapies for patients with symptomatic severe tricuspid regurgitation (TR) who are deemed inoperable. Some of these procedures target the tricuspid annulus (TA), mimicking the Kay procedure, or the leaflets, mimicking Alfieri stitch

Acute Pulmonary Edema Caused by a Giant Atrial Myxoma

Atrial myxoma is the most common primary cardiac tumor. Its clinical presentation spreads from asymptomatic incidental mass to serious life-threatening cardiovascular complications. We report the case of a 44-year-old man with evening fever and worsening dyspnea in the last weeks, admitted to our hospital for acute pulmonary edema. The cardiac auscultation was very suspicious for mitral valve stenosis, but the echocardiography revealed a huge atrial mass with a diastolic prolapse into mitral valve orifice causing an extremely high transmitral gradient pressure. Awareness of this uncommon acute presentation of atrial myxoma is necessary for timely diagnosis and prompt surgical intervention.

Echocardiographic features of post-transcatheter aortic valve implantation thrombosis and endocarditis.

Transcatheter heart valve thrombosis (THV‐t) and endocarditis (THV‐e) are relevant complications after transcatheter aortic valve implantation (TAVI). Transcatheter heart valve (THV) dysfunction definition is mostly based on Doppler (stenosis/regurgitation) without considering leaflets characteristics.

Mechanical dyssynchrony and deformation imaging in patients with functional mitral regurgitation

Chronic functional mitral regurgitation (FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy (DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle (LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy (CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.

Post-contrast T1-mapping provides a novel approach to optimal myocardial nulling for late gadolinium enhancement imaging: a quantitative prescription for the correct TI without the guesswork

Background Late gadolinium enhancement (LGE) is a well-established technique that generates excellent contrast between normal and pathologic myocardium. Selecting the correct inversion time (TI) for nulling normal myocardium is essential for good quality images and accurate diagnosis. The Look-Locker (LL) TI scout is commonly used for TI estimation but is subjective and requires a long breathhold (20 heartbeats). T1-mapping is a quantitative method that can provide a direct numeric TI prescription in a shorter breath-hold but has not been tested in practice.

Contrast-Enhanced TEE During Thoracic Endovascular Aortic Repair Procedure.

Thoracic endovascular aortic repair (tevar) is commonly performed in selected patients to treat thoracic aortic pathologies. Transesophageal echocardiography (TEE) is often used as adjunct to fluoroscopy and angiography (ANGIO) during TEVAR, mainly reducing radiation exposure and contrast load.