Jacob Easaw

Right ventricle in pulmonary arterial hypertension: haemodynamics, structural changes, imaging, and proposal of a study protocol aimed to assess remodelling and treatment effects.

Although right ventricular (RV) failure is the main cause of death in patients with pulmonary arterial hypertension (PAH), there is insufficient data about the effects of PAH treatment on RV geometry and function mainly because the RV assessment has been hampered by its complex crescentic shape, large infundibulum, and its trabecular nature. Echocardiography is a widely available imaging technique particularly suitable for follow-up studies, because of its non-invasive nature, low cost, and lack of ionizing radiation or radioactive agent. Real-time three-dimensional echocardiography (RT3DE) has been shown to be accurate in assessing RV and left ventricular (LV) volumes, stroke volumes, and ejection fractions in comparison with cardiac magnetic resonance imaging. In this review, we describe RV structural and functional changes which occur in patients with PAH and strengths and weaknesses of current non-invasive imaging techniques to assess them. Finally, we describe an ongoing multicentre, prospective observational study involving seven centres expert in treating patients with PAH from four different countries. Investigators will use conventional and advanced echo parameters from RT3DE and speckle-tracking echocardiography to assess the extent of LV and RV remodelling before symptom onset and during pharmacological treatment in patients with PAH. Seventy patients who will survive for at least 1 year will be recruited. All the participating institutions will perform comprehensive standard 2D and Doppler as well as RT3DE examinations with a pre-defined imaging protocol. Measurements will be performed at the core echocardiography laboratory by experienced observers who will be unaware of each patients treatment assignment and whether the examination was a baseline or a follow-up study. Enrolment duration is expected to be 1 year.

Who should be referred to a specialist pulmonary ­hypertension centre – a referrer’s guide

The introduction of pulmonary hypertension (PH)-specific drugs has allowed certain forms of PH to become more treatable. However, patients with these diseases can present to a number of medical specialties and can be challenging to identify, particularly in a non-specialist setting. This article provides guidance on who should be investigated and referred on to a specialist centre, highlighting the potential pitfalls during assessment.

Austrian syndrome: a case report and review of the literature

A usually fit and well 69-year-old woman presented with headache and altered consciousness. Initial clinical findings and investigations were consistent with a diagnosis of pneumococcal meningitis and pneumonia. Cultures of blood and cerebrospinal fluid grew Streptococcus pneumoniae. The patient continued to spike temperatures and developed cardiac failure. A transoesophageal echocardiogram demonstrated a large vegetation of the aortic valve causing severe aortic regurgitation. A diagnosis of Austrian syndrome, the triad of pneumococcal meningitis, pneumonia and endocarditis, was made. The patient has completed a course of appropriate antibiotic therapy and is awaiting aortic valve surgery.

44 Are We Using BNP Wisely? Audit of the Utility of Natriuretic Peptide Testing (NT-Probnp) in Banes, Wiltshire and Somerset for Patients with Suspected Heart Failure

Introduction The NICE guidelines on Chronic Heart Failure 2010 recommend the use of natriuretic peptide (NP) testing in patients with suspected heart failure without previous myocardial infarction (MI). NP testing is felt to be the single most useful test to add to the diagnostic pathway for heart failure in primary care and has been shown to be cost effective. We evaluated the utility of NT-proBNP testing by GPs in BaNES (Bath and North East Somerset), Wiltshire and Somerset and their perceptions of this test. Methods GPs from this region who requested an NT-proBNP test at the Royal United Hospital (RUH), Bath from 1/7/11–30/6/12 were asked to complete a questionnaire. The first 100 random responses formed our study sample. Patient outcome was assessed by reviewing their echo reports, clinic letters and discharge summaries. Results There was an exponential rise in NT-proBNP requests over the study period (Figure 1). The majority of patients were female (66%) with a mean age of 77 (range 51–97). NT-proBNP was requested appropriately in 93% of our study sample. Seven patients had a previous MI. Abstract 44 Figure 1 Number of NT-proBNP requests from 1/7/11–30/6/12 Figure 2 shows a breakdown of NT-proBNP results, referral for echocardiography and outcome. GPs followed local RUH cut-off criteria, which are age-based and lower than NICE criteria. All echos performed in patients with a normal NT-proBNP result (by both criteria), were reassuringly ‘Normal’ (Good biventricular systolic function, no more than mild diastolic dysfunction and no more than mild valvular regurgitation). This implies it may be safe to follow NICE cut-off criteria, which would reduce echo referrals. The ESC optimum exclusion cut-off point is 125pg/ml for patients presenting in a non-acute way and 300pg/ml for acute heart failure. Abstract 44 Figure 2 Breakdown of NT-proBNP results by local RUH cut-off criteria and NICE criteria. Proportion of patients who subsequently had an echocardiogram and result Left ventricular systolic dysfunction was found in 10 patients (almost all had high NT-proBNP levels). A normal NT-proBNP level appears to reliably exclude heart failure with 100% sensitivity in our study sample, as none of these patients had an abnormal echocardiogram, heart failure diagnosis in cardiology outpatients or admission to hospital with heart failure. Tables 1 and 2 illustrate the perception of GPs on NT-proBNP testing and their comments. Most GPs were familiar with the NICE algorithm and felt the test is useful. The majority (56%) also felt the test was more expensive than it actually is, with 3 GPs thinking it costs £100 pounds or more. Abstract 44 Table 1 GPs perception on the utility of NT-proBNP Abstract 44 Table 2 Comments from GPs Conclusion GPs in BaNES, Wiltshire and Somerset are increasingly utilising NT-proBNP in patients with suspected heart failure. They are familiar with NICE guidelines, are using this test appropriately, and have very positive perceptions of it. This is despite also thinking the test is more expensive than it actually is. A normal NT-proBNP in our study sample excluded heart failure with 100% sensitivity, by both local and NICE criteria. These results have been presented to GPs in this region, who have been encouraged to utilise this excellent test confidently and wisely.

Platypnoea-orthodeoxia syndrome

A 78-year-old man with a history of gastric ulcer and pulmonary embolism was admitted for elective revision of a right total hip replacement. He was mildly hypoxic preoperatively (saturation 89% on air). He became profoundly breathless postoperatively (saturation 75%). He was treated for presumed pulmonary oedema but failed to improve. A CT pulmonary angiogram and transthoracic echo showed no clear cause for his symptoms. Because the patient’s symptoms were postural, exacerbated in the upright position and relieved by lying supine, the authors suspected a diagnosis of platypnoea-orthodeoxia syndrome associated with a patent foramen ovale (PFO). Transoesophageal echo and microbubble study confirmed he had a PFO. The patient’s PFO was percutaneously closed and his symptoms and positional hypoxia completely resolved.

085 Two dimensional right ventricular size assessments in a healthy population—time to index?: Abstract 085 Table 1

Background Two dimensional (2D) measurements of the right ventricle (RV) were first validated by Foale et al in 1986 using a cohort of 41 volunteers. The British Society of Echocardiography (BSE) published the current guidelines for chamber quantification of the RV. These ranges are taken from recommendations made between the American and European Society of echocardiography3, which itself is an adaptation of Foales’ initial findings. BSE guidelines for the assessment of 2D RV are based on absolute dimensions rather than values indexed to body surface area (BSA). Aim To evaluate RV dimensions in a group of healthy volunteers. Methods One hundred and fifty three subjects aged between 21 and 71 (mean 44 yrs) were enrolled and following screening (12 lead ECG, health questionnaire and physical examination) underwent a standardised echocardiogram. Height and weight were measured to estimate BSA. Standard 2D echocardiography assessed the right ventricular outflow tract diameter above the aortic valve (RVOT1), above the pulmonary valve (RVOT2), the RV basal (RVD1) and RV mid (RVD2) diameter, the RV base to apex length (RVD3), RV diastolic (RVDA) and systolic (RVSA) area. Absolute measurements and results corrected for BSA are presented as mean (2SD). Ten randomly chosen studies were analysed on separate occasions by a second accredited echocardiographer providing an Inter observer agreement index (IOA) and coefficient of variation (CoV). Ethical approval was obtained. Results The IOA shows high percentage agreement (92.81–97.92%) for 2D caliper measurements. Satisfactory (<15%) CoV results were also obtained within the same measurements. A lower IOA (83.38–91.33%) and higher CoV (20.73–20.83%) were calculated for RVDA and RVSA. All measurements were normally distributed. When compared to current guidelines up to 52% of all absolute RV dimensions measured were outside the reference range. However, when indexed to BSA this fell to a maximum of 13% using the indexed range initially proposed by Foale et al. Due to image quality not every measurement was available on all volunteers. Conclusion Indexing echocardiographic measurements to BSA is standard practice with indices of normality already established for the left ventricle. We have shown that a substantial degree of individual variability of absolute RV dimensions exists within this clinically normal population. These data suggest that indexing absolute RV dimensions according to BSA would be clinically more valuable and accurate than using absolute RV dimensions alone. Absolute and indexed ranges from our data are shown in abstract 085 table 1. Abstract 085 Table 1 Willis et al (2009) Foale et al1 BSE/Lang et al2 Absolute mean-cm (SD) Absolute range (n) Indexed range (cm/m2) Indexed range (cm/m2) Absolute range RVD1 2.19 (0.35) 1.49–3.0 (122) 0.85–2.0 1.1–1.8 2.0–2.8 RVD2 2.99 (0.37) 2.25–3.73 (106) 1.31–2.19 1.4–2.2 2.7–3.3 RVD3 7.13 (0.53) 6.09–8.17 (116) 3.3–5.6 3.6–5.4 7.1–7.9 RVOT1 2.7 (0.36) 1.96–3.44 (141) 1.09–2.0 1.2–2.0 2.5–2.9 RVOT2 2.01 (0.30) 1.41–2.61 (134) 0.82–1.5 0.9–1.4 1.7–2.3 RVEDA 13.73 (3.06) 7.0–21.20 (120) 4.13–13.06 RVESA 7.24 (2.04) 11.23–3.25 (120) 3.70–12.00

10p for an angiogram: the cardio-oesophageal reflex

A 57-year-old man presented at our institution with central chest pain. Serial ECGs showed dynamic T-wave changes, suggesting the possibility of unstable angina. Urgent coronary angiography revealed an unexpected finding of a radio-opaque lesion seen in the xiphisternal region during screening. Oesophogastroduodenoscopy confirmed this to be a 10p coin. The coin passed through the gastrointestinal tract without complications and the patients symptoms and ECG changes resolved. This unusual case is a reminder that many diseases may electrocardiographically imitate an acute coronary syndrome.