Ratnasari Padang

Prevalence and predictors of intracranial aneurysms in patients with bicuspid aortic valve

Objective To determine the prevalence and outcomes of intracranial aneurysm (IA) in patients with bicuspid aortic valve (BAV). Methods Retrospective review of patients with BAV who underwent brain MR angiography at the Mayo Clinic from 1994 to 2013. Results There were 678 patients included in this study—mean age 57±13 years, men 480 (71%), mean follow-up 10±3 years (5913 patient-years). Coarctation of aorta (COA) was present in 154 (23%) patients. There were 59 IAs identified in 52 of 678 patients (7.7%). IA was present in 20/154 patients (12.9%) with COA and 32/524 patients (5.7%) without COA (p<0.001). For the patients without COA, female gender and right–left cusp fusion were risks factors for IA in women after adjustment for all potential variables (HR 1.76, CI 1.31 to 2.68, p=0.03). There was no significant trend in the risk for IA across age tertiles: age ≤40 years versus 41–60 years (HR 1.19, p=0.34), and age 41–60 years versus 61–80 years (HR 1.06, p=0.56). Among the 52 patients with IA, enlargement occurred in three patients (6%), rupture in two patients (4%) and four patients (8%) underwent coil embolisation. For the 626 patients without IA at baseline, no patient developed IA over 7±2 years of imaging follow-up. Conclusions BAV is associated with a higher prevalence of IA compared to the general population, and this risk is higher in patients with COA, right–left cusp fusion and female gender.

Prevalence and Impact of Coexistent Bicuspid Aortic Valve in Hypertrophic Cardiomyopathy

BACKGROUND The association between bicuspid aortic valve (BAV) and hypertrophic cardiomyopathy (HCM) has been reported but its true prevalence is unknown. This study investigated the prevalence and clinical impact of coexistent BAV in a large referral HCM population. METHODS Retrospective analysis of 3765 echocardiograms between 2004 and 2014 in 2640 consecutive patients with HCM was performed to assess for BAV. Patients with coexistent conditions were studied. RESULTS Twenty-three patients (0.9%) were identified with coexisting BAV and HCM. Mean age was 52±16years, 18 males (78%), 16 with NYHA functional class I/II at initial evaluation (70%). A family history of HCM was present in five patients (22%); none had a family history of BAV or aortopathy. Maximal left ventricular wall thickness was 24±6mm; the majority had either reverse curve or sigmoid septal morphology. Moderate or greater aortic valve dysfunction was present in seven patients (30%), BAV-related aortopathy in 18 patients (78%) and dynamic left ventricular outflow tract (LVOT) obstruction in nine patients (39%). Three patients had combined LVOT obstruction and aortic stenosis. Median time from diagnosis of BAV or HCM to last follow-up was 11±12.5years. At last follow-up, 22% had undergone BAV-related surgeries, 30% had septal reduction therapy (SRT), and 17% had combined SRT and BAV-related surgeries. Overall survival was 95% at 10 years. CONCLUSIONS This study reported a 0.9% prevalence of BAV among HCM population, similar to the general population. Aortopathy and LVOT obstruction were common, necessitating cardiac interventions in over one-third of cases. Long-term survival appeared favourable.

Not All Immobile Bioprosthetic Valve Cusps Are Thrombosed

Bioprosthetic valve thrombosis (BPVT) has been increasingly recognized [(1,2)][1]. Computed tomographic diagnosis relies on detecting reduced cusp mobility and the presence of thrombus, but the latter is more difficult to visualize. Here we present 2 cases of abnormal bioprosthetic cusp mobility in

Incremental value of 3D over 2D echocardiography in a patient with multiple ICD leads in the right ventricle

A 65-year-old male with dyspnoea and oedema from severe tricuspid regurgitation was referred for tricuspid valve (TV) surgery. He had undergone placement of a dual-chamber implantable cardioverter defibrillator (ICD) 15 years prior for dilated cardiomyopathy that was upgraded to a biventricular system with placement of a new right ventricular lead 3 years ago. Intraoperative 2D …

Association Between Echocardiography Laboratory Accreditation and the Quality of Imaging and Reporting for Valvular Heart DiseaseCLINICAL PERSPECTIVE

Background— It is presumed that echocardiographic laboratory accreditation leads to improved quality, but there are few data. We sought to compare the quality of echocardiographic examinations performed at accredited versus nonaccredited laboratories for the evaluation of valvular heart disease. Methods and Results— We enrolled 335 consecutive valvular heart disease subjects who underwent echocardiography at our institution and an external accredited or nonaccredited institution within 6 months. Completeness and quality of echocardiographic reports and images were assessed by investigators blinded to the external laboratory accreditation status and echocardiographic results. Compared with nonaccredited laboratories, accredited sites more frequently reported patient sex (94% versus 78%; P<0.001), height and weight (96% versus 63%; P<0.001), blood pressure (86% versus 39%; P<0.001), left ventricular size (96% versus 83%; P<0.001), right ventricular size (94% versus 80%; P=0.001), and right ventricular function (87% versus 73%; P=0.006). Accredited laboratories had higher rates of complete and diagnostic color (58% versus 35%; P=0.002) and spectral Doppler imaging (45% versus 21%; P<0.0001). Concordance between external and internal grading of external studies was improved when diagnostic quantification was performed (85% versus 69%; P=0.003), and in patients with mitral regurgitation, reproducibility was improved with higher quality color Doppler imaging. Conclusions— Accredited echocardiographic laboratories had more complete reporting and better image quality, while echocardiographic quantification and color Doppler image quality were associated with improved concordance in grading valvular heart disease. Future quality improvement initiatives should highlight the importance of high-quality color Doppler imaging and echocardiographic quantification to improve the accuracy, reproducibility, and quality of echocardiographic studies for valvular heart disease.

Transthoracic and Transesophageal Echocardiography in Interventional Cardiovascular Catheter-Based Therapy

Transcatheter-based cardiovascular intervention for structural heart disease—and, with it, interventional echocardiography—is a rapidly evolving field. While historically these catheterization laboratory–based interventions were performed under fluoroscopy and angiography guidance, the increasing procedural complexities seen nowadays have necessitated precise periprocedural imaging guidance, as procedural mishaps often translate into devastating outcomes. With this realization, the use of echocardiography has become an integral part of today’s catheter-based interventions, from patient selection to intraprocedural monitoring to postprocedural follow-up. Undeniably, echocardiography represents the ideal technique for intraprocedural guidance, as it provides superior delineation of cardiac anatomy and pathology, allows real-time visualization of intracardiac structures and catheters, is portable, and permits a reduction in radiation exposure from fluoroscopy. It is important to recognize that echocardiography for guidance of transcatheter-based cardiovascular intervention poses different demands from those of routine evaluation of patients with structural heart disease. This chapter is therefore intended to provide practical guidance for echocardiographers participating in various catheter-based cardiovascular interventions, with particular emphasis on the utility of transthoracic and transesophageal echocardiography in guiding these procedures.

INTRACRANIAL ANEURYSMS IN PATIENTS WITH BICUSPID AORTIC VALVE: PREVALENCE AND PREDICTORS OF OCCURENCE

Background: There are limited data regarding intracranial aneurysm (IA) in patients with bicuspid aortic valve (BAV). Methods: Retrospective review of patients with BAV who underwent brain magnetic resonance angiography (MRA) at Mayo Clinic, 1994-2013. Study objective was to determine the

COMPARATIVE OUTCOME OF PARAVALVULAR LEAK FOLLOWING SURGICAL VERSUS TRANSCATHETER AORTIC VALVE REPLACEMENT

Background: Paravalvular leak (PVL) negatively impacts outcomes, but a direct comparison of its impact after transcatheter aortic valve replacement (TAVR) versus surgical replacement (SAVR) has not been previously reported. We reviewed our experience to better understand the impact of PVL on

NOVEL ECHOCARDIOGRAPHIC MEASUREMENTS DETECT INCREASED MYOCARDIAL STIFFNESS IN PATIENTS WITH SEVERE ORGANIC MITRAL REGURGITATION

Background: Chronic left ventricular (LV) volume overload in organic mitral regurgitation (MR) triggers altered contractile proteins and collagen synthesis leading to LV remodeling and ultimately LV dysfunction. Invasive studies demonstrated increased LV compliance but conflicting findings on

DIASTOLIC MYOCARDIAL STIFFNESS ESTIMATED BY ECHOCARDIOGRAPHY IN PATIENTS WITH AORTIC STENOSIS

Patients with aortic stenosis (AS) have chronic left ventricular (LV) pressure-overload, leading to LV hypertrophy, myocardial ischemia and fibrosis. These factors alter intrinsic tissue properties, reduce myocardial distensibility, increase filling pressures, and alter LV function. Thus,