Katarzyna Wdowiak-Okrojek

Fusion of morphological data obtained by coronary computed tomography angiography with quantitative echocardiographic data on regional myocardial function.

BACKGROUND Three-dimensional (3D) fusion of morphological data obtained by coronary computed tomography angiography (CCTA) with functional data from resting and stress echocardiography could potentially provide additional information compared to examination results analyzed separately and increase the diagnostic and prognostic value of non-invasive imaging in patients with suspected coronary artery disease (CAD). Using vendor-independent software developed in our institution, we aimed to assess the feasibility and reproducibility of 3D fusion of morphological CCTA data with echocardiographic data regarding regional myocardial function. METHODS Thirty patients with suspected CAD underwent CCTA and resting transthoracic echocardiography. From CCTA we obtained 3D reconstructions of coronary arteries and left ventricle (LV). Offline speckle-tracking analysis of the echocardiographic images provided parametric maps depicting myocardial longitudinal strain in 17 segments of the LV. Using our software, 3 independent investigators fused echocardiographic maps with CCTA reconstruc-tions in all patients. Based on the obtained fused models, each segment of the LV was assigned to one of the major coronary artery branches. RESULTS Mean time necessary for data fusion was 65 ± 7 s. Complete agreement between independent investigators in assignment of LV segments to coronary branches was obtained in 94% of the segments. The average coefficient of agreement (kappa) between the investigators was 0.950 and the intra-class correlation coefficient was 0.9329 (95% CI 0.9227-0.9420). CONCLUSIONS Three-dimensional fusion of morphological CCTA data with quantitative echocardiographic data on regional myocardial function is feasible and allows highly repro-ducible assignment of myocardial segments to coronary artery branches.

Feasibility and clinical benefit of cognitive-behavioral intervention for preparing patients for transesophageal echocardiography.

Objective: Despite premedication, anxiety in patients undergoing transesophageal echocardiography (TEE) is prevalent, often causing adverse physiological and psychological effects and contributing to decreased patient compliance. We aimed to evaluate the feasibility of cognitive–behavioral intervention (CBI) in patients undergoing TEE and to assess its impact on the severity of anxiety, patient’s and physician’s comfort, and administered dose of sedatives. Methods: Our study was designed as a prospective, single-center, single-blinded, case-controlled pilot study. The study group comprised 49 patients (26 men, 66±8 years old) referred for TEE. Before the examination, 26 randomly selected patients underwent CBI. Sedatives were administered, if necessary. After the examination, patient anxiety and patient’s and physician’s comfort were evaluated using dedicated questionnaires and scores. Intergroup comparison was performed using Student’s t-test for independent variables and Mann–Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Results: The mean level of pre-TEE distress and anxiety were significantly lower in patients receiving CBI than in those without intervention (p=0.022). Furthermore, the application of CBI significantly reduced patient’s discomfort (p<0.001) and resulted in increased comfort of physician (p<0.001) during TEE. The need of sedative administration (31% vs. 91%, p<0.001) and its mean dose was significantly lower in patients receiving CBI (1.6±0.5 mg vs. 2.7±1.6 mg midazolam, p=0.009). Conclusions: CBI is feasible in patients undergoing TEE. It decreases patient’s anxiety and discomfort and increases physician’s comfort. It also results in reduced use of sedatives during the examination.

Nietypowa fala zwrotna po złożonym zabiegu naprawczym zastawki mitralnej

Pacjent w wieku 59 lat ze stabilną chorobą wieńcową w II klasie Canadian Cardiovascular Society (CCS) oraz ciężką niedomykalnością zastawki mitralnej na podłożu wypadania tylnego płatka został poddany planowemu zabiegowi operacyjnemu, polegającemu na wszyciu pomostu żylnego do prawej tętnicy wieńcowej (choroba jednonaczyniowa) oraz jednoczasowej plastyce zastawki mitralnej. W badaniu echokardiograficznym przed operacją stwierdzano wypadanie segmentu P2 oraz częściowo P3 tylnego płatka zastawki mitralnej, bez cech zerwania strun ścięgnistych z istotną ekscentryczną falą zwrotną (ERO 0,4 cm, RVOL 91 ml); wymiar pierścienia mitralnego wynosił 35 mm, bez innych istotnych nieprawidłowości morfologicznych serca. Zabieg zastawkowy obejmował kwadrantektomię P2, plikację ściany przedsionka oraz wszycie pierścienia Carpentier Physio 30 mm. Okres okołooperacyjny był niepowikłany. W kontrolnym przezklatkowym badaniu echokardiograficznym (TTE, transthoracic echocardiography) 3 miesiące po operacji zaobserwowano pod płatkami mitralnymi szeroką falę zwrotną, w ocenie ilościowej o parametrach wskazujących jednak na jej umiarkowany stopień. Nie obserwowano skurczowego odwracania przepływu w żyłach płucnych, natomiast wizualnie talia fali zwrotnej w TTE obejmowała całą szerokość pierścienia (ryc. 1A). Wobec niejasności w ocenie naprawionej zastawki mitralnej wykonano badanie przezprzełykowe. Pomiar metodą Dopplera fali ciągłej wykazał typowe wartości po anuloplastyce; średni gradient przezzastawkowy wynosił 4,5 mm Hg, a maksymalna prędkość 1,5 m/s (ryc. 1B). Uwidoczniono także pozapierścieniowe ujście fali zwrotnej — perforację nasady płatka tylnego w okolicy segmentu P2 (ryc. 1C). Badanie trójwymiarowe pozwoliło jednoznacznie uwidocznić wąską falę zwrotną praktycznie równoległą do płaszczyzny pierścienia, bez istotności hemodynamicznej (szerokość ujścia ok. 13 mm — ryc. 1D, E). Uzyskane obrazy uzasadniły zakwalifikowanie chorego do dalszego leczenia zachowawczego. Leczenie operacyjne zespołu Barlowa jest zróżnicowane zależnie od morfologii wady i może obejmować kilka technik operacyjnych, takich jak: repozycja mięśnia brodawkowatego (w razie konieczności z repozycją strun ścięgnistych), skracanie strun ścięgnistych, implantacja goreteksowych strun ścięgnistych, resekcja nadmiarowej tkanki płatka (sliding plasty) — polegająca na odłączeniu podstawy płatka od pierścienia, wycięciu nadmiaru i ponownym jego zeszyciu z jednoczasowym zwężeniem pierścienia, resekcja trójkątna lub kwadrantektomia, resekcja edge-to-edge, plastyka/resekcja komisur, dekalcyfikacja pierścienia oraz wszycie pierścienia mitralnego [1–3]. W omawianym przypadku prawdopodobnie podczas kwadrantektomii/plikacji ściany przedsionka pozostała niewielka, niezszyta przestrzeń pozapierścieniowa powstała podczas plikacji płatka tylnego, dająca obraz nietypowej zewnątrzpierścieniowej fali zwrotnej, sugerujący znaczną niedomykalność mitralną, właściwie zinterpretowany dzięki obrazowaniu 3D z dokładną oceną ujścia i kierunku fali zwrotnej w wolumetrycznym zbiorze danych.

Association between left atrial function assessed by speckle-tracking echocardiography and the presence of left atrial appendage thrombus in patients with atrial fibrillation.

Objective: The aim of the study was to investigate whether the deformation of left atrium (LA) measured by speckle-tracking analysis (STE) is associated with the presence of LA appendage thrombus (LAAT) during non-valvular atrial fibrillation (AF). Methods: Eighty-seven patients (mean age 67 years, 59% men) were included to retrospective cross-sectional study. On top of standard echocardiography we assessed: LA longitudinal systolic strain (LS), systolic (LSSR) and early diastolic strain rate (LESR) in four-chamber and two-chamber apical views. All patients underwent transesophageal echocardiography disclosing LAAT in 36 (41%) patients. Results: Subgroups with and without thrombi did not differ with regard to clinical characteristics. Univariate factors associated with LAAT were as follows: CH2ADS2-VASc Score, left ventricular ejection fraction (LVEF), LV mass, and STE measurements. In a multivariate model only LVEF (p=0.002), LS (p=0.02), LESR (p=0.008), and LSSR (p=0.045) were independently associated with LAAT presence. Moreover, LVEF and LA STE measurements provided incremental value over the CH2ADS2-VASc Score. Conclusion: Speckle-tracking TTE may be used to describe LA reservoir and conduit function during AF, allowing the identification of patients with higher risk of LAAT and providing incremental value over the CH2ADS2-VASc Score.

Giant Aneurysm of Aortic Right Coronary Sinus: Diagnostic Doubts Related to Presentation of Valsalva Sinus Aneurysm in Transthoracic Echocardiography

Case Description: Seventy-nine-year-old woman with permanent atrial fibrillation and scoliosis was admitted to the Department of Internal Diseases because of effort intolerance and back pain. Her physical examination revealed body mass index 20 kg/m, small body surface area 1.38 m, and systolic murmur over the heart. Transthoracic echocardiography (TTE) indicated confusing oval structure filling the right ventricle and the lack of aortic wall in the parasternal long-axis view which raised the suspicion of some septal or artery wall defect (Figs. 1–2). Considering these doubts, the patient was transferred to Cardiology Department. Detailed 2D and 3DTTE demonstrated huge aneurysm of right Valsalva sinus causing dilatation of aorta reaching 73 mm, which modeled right ventricle (RV) and was seen as oval structure filling RV cavity. Interestingly, aortic annulus was not dilated (23 mm) with only mild aortic insufficiency. Color Doppler did not corroborate septal defect but indicated on turbulent flow inside RV (Fig. 3 and movie clip S1). Computed tomography confirmed the diagnosis of unruptured aneurysm of right aortic sinus (Fig. 4). Our case is atypical due to relatively large dimensions of aneurysm, which seemed to fill completely RV cavity and was misdiagnosed by less experienced echocardiographer. Aneurysm of Valsalva sinus (SVA) is a rare, usually congenital anomaly, sometimes connected with supracristal VSD, although traumatic, infective, and inflammatory origins were also described. Unruptured SVA may be asymptomatic, cause RV outflow tract obstruction, compress coronary arteries, or lead to thrombotic complications—acute coronary syndrome or stroke. Surgical and percutaneous interventions with occluding devices are applied in patients with SVA.

Echocardiographic Diagnosis of Hodgkin's Lymphoma in a Patient with Suspected Endocarditis

A 30-year old, previously healthy female was sent for a cardiology consult because of exercise intolerance, night sweats, and chest pain. The preliminary diagnosis was endocarditis as suggested by increased inflammatory markers (CRP and WBC) and mild anemia. Echocardiographic examination (GE Vivid 7, GE Medical Systems, Warsaw, Poland) revealed no vegetations. Cardiac chambers dimensions, left ventricular ejection fraction, and valvular function were normal. However, the study revealed pericardial effusion behind the left ventricular posterior wall (up to 21 mm) and pathological masses invading the wall of left atrium were seen. One mass was located behind the left atrium (Fig. 1) and the other next to the right-sided pulmonary veins (Fig. 2). With preliminary diagnosis of mediastinal malignancy, the patient underwent computed tomography (GE Lightspeed VCT, GE Medical Systems) of the chest which showed the enlargement of mediastinal lymph nodes (Fig. 3). Detailed oncological assessment lead to the definitive diagnosis of moderately advanced (stage CS IIB) Hodgkin’s lymphoma. The patient received several cycles of chemotherapy and finally peripheral-blood progenitor cells transplantation as a result of only partial response for primary treatment. Five months after the treatment termination, positron emission tomography (GE Discovery STE 16, GE Medical Systems) was performed uncovering a complete regression of neoplasm. The control echocardiogram was done after 12 months; pericardial fluid and additional masses were undetectable (Figs. 4 and 5). The patient has been uneventful over 30-month follow-up. Tumors are uncommonly seen in echocardiograms and the heart is a very rare primary location of neoplasms. The differential diagnosis of pathological masses which can be found during cardiac ultrasound include primary neoplasms (most commonly benign: myxoma, lipoma, papillary fibroelastoma, fibroma, rhabdomyoma, teratoma, and malignant sarcomas: angiosarcoma, rhabdomyosarcoma) and secondary tumors. Among the secondary neoplasms, metastatic tumors are most common, whereas leukemic cardiac involvement is less frequent. However, the diagnosis of extracardiac neoplastic disease as a by-product of echocardiographic examination is rare. The homogenous echogenicity and extracavitary location of multiple masses discovered in our patient raised the suspicion of lymphatic growth. There are reports of cardiac lymphomas (which is defined as nonHodgkin’s lymphoma) in available literature, although those originally involving heart or/and