Ljiljana Jovovic

Partial left ventriculectomy for idiopathic dilated cardiomyopathy: early results and six-month follow-up

BACKGROUND Recent reports show that partial left ventriculectomy improves hemodynamic and functional status in patients with dilated cardiomyopathy. This study sought to determine the effects of partial left ventriculectomy on clinical outcome and left ventricular function during 6-month follow-up. METHODS Twenty-two patients underwent partial left ventriculectomy. Mitral valve repair was performed whenever possible, otherwise the valve was replaced. Hemodynamic and functional data were obtained at baseline, as well as 2 weeks and 6 months postoperatively. RESULTS Overall, 7 of 22 patients died; there were three early and four late deaths. One-year survival was 68%+/-10%. Ejection fraction increased from 23.9%+/-6.8% before the operation to 40.7%+/-12.5% at 2 weeks and to 36.8%+/-7.7% at 6 months (p<0.001, for both). The cardiac index before the operation, at 2 weeks, and at 6 months was 2.3+/-0.8, 2.9+/-0.6, and 3.4+/-1.0 L/m2 per minute, respectively (p = 0.035, and p = 0.009, compared with baseline). The increase in ejection fraction 2 weeks postoperatively was less in patients with left circumflex artery dominance (10.9%+/-3.2% compared with 19.9%+/-10.7%, respectively, p = 0.017). At 6-month follow up, all surviving patients except one improved New York Heart Association functional class when compared with preoperative status (from 3.8+/-0.4 to 1.4+/-0.6, p = 0.0002). CONCLUSIONS Early hemodynamic improvement after partial left ventriculectomy was maintained during midterm follow-up.

Effects of partial left ventriculectomy on left ventricular performance in patients with nonischemic dilated cardiomyopathy

OBJECTIVES This study sought to assess the effects of partial left ventriculectomy (PLV) on left ventricular (LV) performance in a series of consecutive patients with nonischemic dilated cardiomyopathy. BACKGROUND Reduction of LV systolic function in patients with heart failure is associated with an increase of LV volume and alteration of its shape. Recently, PLV, a novel surgical procedure, was proposed as a treatment option to alter this process in patients with dilated cardiomyopathy. METHODS We studied 19 patients with severely symptomatic nonischemic dilated cardiomyopathy, before and 13+/-3 days after surgery, and 12 controls. Single-plane left ventriculography with simultaneous measurements of femoral artery pressure was performed during right heart pacing. RESULTS The LV end-diastolic and end-systolic volume indexes decreased after PLV (from 169 to 102 ml/m2, and from 127 to 60 ml/m2, respectively, p < 0.0001 for both). Despite a decrease in LV mass index (from 162 to 137 g/m2, p < 0.0001), there was a significant decrease in LV circumferential end-systolic and end-diastolic stresses (from 277 to 159 g/cm2, p < 0.0001 and from 79 to 39 g/cm2, p = 0.0014, respectively). Ejection fraction improved (from 24% to 41%, p < 0.0001); the stroke work index remained unchanged. CONCLUSIONS The PLV improves LV performance by a dramatic reduction of ventricular end-systolic and end-diastolic stresses. Further studies are needed to assess whether this effect is sustained during long-term follow-up and to define the role of PLV in the treatment of patients with dilated cardiomyopathy.

Cor Triatriatum Dexter and Atrial Septal Defect in a 43-Year-Old Woman

Cor triatriatum dexter is a rare congenital heart anomaly in which a membrane divides the right atrium into 2 chambers. We report the case of a 43-year-old woman who had cor triatriatum dexter and a large atrial septal defect. During attempted percutaneous closure, the balloon disrupted the membrane and revealed that the defect had no inferior rim, precluding secure placement of an Amplatzer Septal Occluder. Surgical treatment subsequently proved to be successful. In patients with an incomplete membrane and a septal defect with well-defined rims, percutaneous treatment can be the first choice. In patients who have cor triatriatum dexter and unfavorable anatomic features or concomitant complex heart anomalies, open-heart surgery remains the gold standard for treatment.

Exuberant accessory mitral valve tissue with possible true parachute mitral valve: a case report

IntroductionA parachute mitral valve is defined as a unifocal attachment of mitral valve chordae tendineae independent of the number of papillary muscles. Data from the literature suggests that the valve can be distinguished on the basis of morphological features as either a parachute-like asymmetrical mitral valve or a true parachute mitral valve. A parachute-like asymmetrical mitral valve has two papillary muscles; one is elongated and located higher in the left ventricle. A true parachute mitral valve has a single papillary muscle that receives all chordae, as was present in our patient. Patients with parachute mitral valves during childhood have multilevel left-side heart obstructions, with poor outcomes without operative treatment. The finding of a parachute mitral valve in an adult patient is extremely rare, especially as an isolated lesion. In adults, the unifocal attachment of the chordae results in a slightly restricted valve opening and, more frequently, valvular regurgitation.Case presentationA 40-year-old Caucasian female patient was admitted to a primary care physician due to her recent symptoms of heart palpitation and chest discomfort on effort. Transthoracic echocardiography showed chordae tendineae which were elongated and formed an unusual net shape penetrating into left ventricle cavity. The parasternal short axis view of her left ventricle showed a single papillary muscle positioned on one side in the posteromedial commissure receiving all chordae. Her mitral valve orifice was slightly eccentric and the chordae were converting into a single papillary muscle. Mitral regurgitation was present and it was graded as moderate to severe. Her left atrium was enlarged. There were no signs of mitral stenosis or a subvalvular ring. She did not have a bicuspid aortic valve or coarctation of the ascending aorta. The dimensions and systolic function of her left ventricle were normal. Our patient had a normal body habitus, without signs of heart failure. Her functional status was graded as class I according to the New York Heart Association grading.ConclusionsA recently published review found that, in the last several decades, there have been only nine adult patients with parachute mitral valve disease reported, of which five had the same morphological characteristics as our patient. This case presentation should encourage doctors, especially those involved in echocardiography, to contribute their own experience, knowledge and research in parachute mitral valve disease to enrich statistical and epidemiologic databases and aid clinicians in getting acquainted with this rare disease.

Idiopathic aneurysm of the pulmonary artery in a patient with coronary disease

When intracardiac or extracardiac shunts, chronic heart or lung disease, arterial disease of the pulmonary artery (PA) or an extensive atheromatosis or arteriosclerosis are excluded, idiopathic pulmonary artery aneurysm (PAA) is taken into consideration. Sporadic individual cases of idiopathic PAA [1–3] can be found in the literature [1–3]. Natural course of idiopathic PAA (which can reach enormous dimensions) or the corresponding therapeutic procedures are not clearly defined. In asymptomatic patients, no guidelines can be found indicating whether surgical or conservative treatment should be applied [1–4]. The incidence of PAA is 1 case per 13 700 autopsy cases [2]. Several cases can be found in the literature (with follow-up from 24 years [3] to 39 years [4]) with idiopathic PAA and without rupture. There are no data about cut-off dimensions of PAA diameters, which indicate the risk of rupture and, even more importantly, the potential risk of doing surgery in these cases.

Acute Effects of DDD Pacing in Patients With Pulmonary Infundibular Stenosis

We evaluated acute effects of DDD pacing (right atrium sensed and left ventricle paced) in 3 patients with pulmonary infundibular stenosis and found a decrease in dynamic right ventricular outflow gradient in all of them. It appears that acute temporary DDD pacing may decrease the dynamic obstruction of the right ventricular outflow tract in these patients, probably because of asynchronous contraction of the right ventricle induced by pacing from the left ventricular apex, with contraction of infundibular portion being delayed.

Left ventricular noncompaction: A rarity or something else

Nedovoljno formiran miokard je atipicna forma kardiomiopatije koju treba poznavati i na koju treba misliti pri rutinskim ehokardiografskim pregledima. Novija istraživanja ukazuju da LVNC ima vecu prevalenciju zahvaljujuci poboljsanju imaging tehnika. Kako su kriterijumi za dijagnozu LVNC prvenstveno ehokardiografski, potrebno je upoznati lekare koji se bave ultrazvucnim pregledima srca sa osnovnim karkteristikama ovog oboljenja, kako bi ga u buducnosti lakse prepoznali. Nedovoljno formiran miokard je udružen sa drugim nesrcanim oboljenjima, kao sto su neuromuskularna oboljenja. Predlaže se skrining bolesnika, narocito u porodicama sa neuromuskularnim oboljenjima da bi se pronasli bolesnici sa LVNC, kao i skrining bolesnika sa LVNC kako bi se otkrila neuromuskularna oboljenja. Kod familijarnog javljanja bolesti utvrđena je genetska osnova nasleđivanja. Zbog pretpostavke da postoji dug preklinicki period, potrebno je da se otkriju bolesnici u asimptomatskoj ili oligosimptomatskoj fazi, kako bi se pratili i pravilno tretirali. Iako postoje kontroverze koje se odnose na etiologiju, patogenezu, dijagnosticke kriterijume i prognozu, vecina istraživaca izražava stav da i ovu kardiomiopatiju SZO treba da svrsta u poseban entitet.

An (In)Significant Ventricular Septal Defect and/or Double-Chambered Right Ventricle: Are There Any Differences in Diagnosis and Prognosis in Adult Patients?

A double-chambered right ventricle (DCRV) is an uncommon congenital anomaly: the right ventricle (RV) is divided into two chambers due to the presence of an abnormally located muscular band or anomalous muscle hypertrophy in the subinfundibular part of RV outflow tract, with a variable degree of obstruction. Generally, DCRV is well recognized in childhood and misdiagnosed in adult patients. Transthoracic and/or transesophageal echocardiography are the mеthods of choice for the diagnosis of DCRV. Due to limitations of echocardiography in adult patients, this entity may be missed, particularly if it presents concomitant with other congenital defects, and therefore additional imaging methods such as MRI or cardiac catheterization are required for a definitive diagnosis.

Treatement solution by Tomic et al.

artery disease verified by coronary angiography. Transthoracic and transoesophageal echocardiography and computed tomography (MDCT) were performed. Electrocardiogram and physical examination were normal. Chest X-ray suggested a discrete pronounced shadow in the projection of the left hilus. Transthoracic two-dimensional echocardiography showed that the left and right heart chambers are within normal size and function, and also showed competent valves and turbulent colour flow Doppler at the level of the pulmonary valve without high pressure gradient or pulmonary regurgitation with vague contours of the wall of the PA. Transoesophageal echocardiography showed that the main trunk of the PA was dilated up to 4.7 cm. Dimension of the right branch was 2.1 cm and it was very difficult to visualize the wall of the left branch, which was 5.3 cm in aneurysmatic form. MDCT showed that the main trunk of PAwas 4.6 cm, the right branch PA measured 2.35 cm and the left branch PA measured 5.26 cm (Fig. 1). Preoperative coronary angiography revealed stenosis of the left main coronary artery up to 40% subocclusion of the left anterior descending coronary artery and right coronary artery. Inflammatory, infectious aetiologies and collagen vascular disease were excluded by laboratory tests. There were no history data for arthritis or obvious lesions of Behcet’s disease. The treatment of choice for this aneurysm of the PA is published below.

Challenges in treatment of postinfarction ventricular septal defect and heart failure.

INTRODUCTION Acquired ventricular septal defect (VSD) is uncommon, but serious mechanical complication of acute myocardial infarction with poor outcome and high mortality rate in surgically or medically treated patients. CASE REPORT We report a 58-year-old male patient admitted to our hospital six days following acute inferior myocardial infarction complicated by ventricular septal rupture with signs of heart failure. Coronary angiography revealed 3-vessel disease, with proximally occluded dominant right coronary artery. Transthoracic echo exam revealed aneurysm of a very thin inferior septum and the basal portion of the inferior left ventricular wall, with septal wall rupture. One of the VSD dimensions was 15 mm and left- to right shunt was calculated 2:1. Since the patient was at too high risk for surgical closure, transcatheter closure of VSD was chosen as a better option. Under short intravenous sedation, 24 mm Am- platzer device was implanted percutaneously with transesophageal echo guidance. The post-procedural result revealed a small residual shunt, but it was followed by significant improvement of the patients clinical status. A 24h Holter ECG monitoring did not show cardiac rhythm or conduction disturbances. Coronary angiography was repeated ten days following the procedure, after hemodynamic stabilization of the patient, with direct stenting of the circumflex artery and the intermediate artery. Ostial left descending artery lesion was left for further functional significance assessment. CONCLUSION Percutaneous closure with a septal occluder device can be definitive primary treatment for anatomically suitable patients or it can serve as a bridge to surgical treatment.