Süleyman Kalaycı

Assessment of the severity of aortic regurgitation with pulsed wave Doppler velocity profile in the descending aorta

OBJECTIVE The quantitative parameters which are used to assess the severity of aortic regurgitation (AR) provide the most accurate information whereas these parameters are difficult and time-consuming. The aim of this study was to get a practical parameter to use in daily practice for assessing the severity of aortic regurgitation. METHODS The study was an observational cohort study on diagnostic accuracy of severity of aortic regurgitation. Thirty-seven patients with aortic regurgitation determined by quantitative parameters (18 patients with severe aortic regurgitation and 19 patients with moderate aortic regurgitation) were included in this study. Each patients diastolic flow pattern in the descending aorta was examined by pulsed wave Doppler. Systolic and diastolic flow time-velocity integral (TVI), TVI time, systolic and diastolic TVI ratio in the descending aorta were evaluated. In addition to these parameters, dP/dt, peak acceleration time and end-diastolic flow velocity in the diastolic flow were determined. We investigated whether there a significant difference between two groups or not. Receiver operating characteristic (ROC) analysis was used to determine the optimal cut-off values of echocardiographic parameters which were used to identify the severity of aortic regurgitation. RESULTS The study population was composed of 16 female and 21 male patients. Their mean age was 46.5 years. The mean diastolic flow TVI of patients who had moderate and severe aortic regurgitation was found 10.1 cm and 18.6 cm, respectively (p<0.001). In the ROC curve analysis, the values of diastolic flow TVI above 13.5 cm was found to have 83% sensitivity and 90% specifity to predict the severity of aortic regurgitation (AUC: 0.91, 95% CI 0.80-1.0, p<0.001). Also we investigated the other parameters like systolic flow TVI, the ratio of systolic and diastolic flow TVI, mean diastolic flow time, mean systolic flow time, the ratio of systolic and diastolic flow time, end-diastolic velocity, peak acceleration time, dP/dt values in evaluation of diastolic flow in the descending aorta. These parameters were found statistically significant in assessing the severity of aortic regurgitation but their statistical power was weak. CONCLUSION TVI of diastolic flow which is measured with pulsed wave Doppler in descending aorta could be a practical parameter in assessing the severity of aortic regurgitation.

Association between fractional flow reserve and Duke Treadmill Score in patients with single-vessel disease

BACKGROUND Duke treadmill score (DTS) is an index that provides prognostic information calculated at exercise stress test. Fractional flow reserve (FFR) is an invasive method used to evaluate intermediate coronary stenosis. The direct relation of DTS and FFR has not been studied to date. AIM The present study aims to investigate the relationship between the DTS and FFR. METHODS The study population consisted of a total of 106 patients with single-vessel disease, as confirmed by coronary angiography performed following EST, and whose FFRs were measured. The patients were separated into three groups according to the DTS values: low risk (DTS ≥ +5), intermediate risk (-10 ≤ DTS ≤ +4), and high risk (DTS ≤ -11). According to the FFR values, the patients were separated into two groups: FFR < 0.80 and FFR ≥ 0.80. RESULTS Angina symptoms and chronic heart failure were more frequent in the group with FFR < 0.80 than the group with FFR ≥ 0.80; respectively, 95% vs. 69.8%, p = 0.020 and 15% vs. 3.5%, p = 0.045. The mean DTS value was lower in the group with FFR < 0.80 than the group with FFR ≥ 0.80 (1.60 vs. 5.07; p = 0.011). However, there were no statistically significant differences in the DTS risk groups among the FFR groups (p = 0.070). A weak positive correlation was found between the numerical DTS and FFR values (r = 0.139; p = 0.156). When the patients with high-risk were excluded, a statistically significant relationship was determined between the FFR and in the groups with low- and intermediate-risk in terms of the DTS values (p = 0.029). CONCLUSION In conclusion, our study results showed an association with FFR and in the groups with low and intermediate risk in terms of the DTS values. DTS levels can be useful to determine patients who require invasive management.

Case images: Absence of posterior mitral valve leaflet detected in late adulthood.

A 62-year-old woman suffering from dyspnea and palpitation was referred. Electrocardiography (ECG) revealed left bundle branch block and atrial fibrillation. Transthoracic echocardiography revealed absence of posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (Figure A, Video 1*). Posterior myocardial wall replacement of the posterior leaflet had proceeded to coaptation line of the mitral valve (Figure B, Video 2*). Chordae tendineae and papillary muscles were attached to the tip of posterior myocardial wall. Coronary sinus was dilated. However, contrast echocardiography was normal during agitated saline injection into right and left upper extremity intravenous line. Ejection fraction was 40%, measured by Simpson’s rule. Subsequent transesophageal echocardiography (TEE) confirmed transthoracic echocardiography findings (Figure C; arrow: absent PMVL; Video 3*; all midesophageal views; 87°). Color Doppler examination revealed mild mitral regurgitation in TEE examination (Figure D). Coronary arteries were near normal on angiography. Medical follow-up was decided upon. Congenital malformations of the posterior mitral leaflet are extremely rare and present with a wide spectrum. Hypoplasia of the posterior mitral valve leaflet has been reported, and a few cases of absent PMVL have been described. Absence of the PMVL is usually symptomatic, due to severe mitral regurgitation and coexisting abnormalities such as intracardiac shunt. The present patient was asymptomatic until late adulthood, and no other cardiac anomaly was present. Absent PMVL may be more prevalent in asymptomatic adults than is known. 275

Biventricular noncompaction cardiomyopathy with severe systolic and diastolic dysfunction in a systemic sclerosis patient.

Non-compaction cardiomyopathy (NCM) is a rare congenital cardiomyopathy characterized by deep increased trabeculation in one or more segments of the ventricle. The apical segment of the left ventricle is most commonly affected, but left ventricular basal segment, biventricular involvement or right ventricle predominance have also been described. While some neuromuscular anomalies and myopathies had been described in systemic sclerosis patients, coexistence of chronic inflammatory disorders and NCM is unclear. This paper presents a case of biventricular NCM with severe systolic and diastolic dysfunction in a 40-year-old female diffuse cutaneous systemic sclerosis patient.

Temporary pacemaker with left bundle branch block image in ECG

When we made a detailed examination with TTE, we saw that the transvenous temporary pacing was not in the jugular vein. The suprasternal view showed the lead of the pacemaker in the arcus aorta (Fig. 3A). The localization of the pacemaker lead was seen in the right ventricle by fluoroscopy in the RAO. But, we were sure the localization of lead in the left ventricle when we was seen by fluoroscopy image in LAO projection at 28°. The lead of pace was inserted via the right common carotid artery. The tip of the lead was placed in the left ventricular septum in our patient. The patient did not consent to a coronary angiography. We had inserted a permanent VDD pacemaker via the left subclavian vein. We recorded a fluoroscopy image after inserting the permanent pacemaker in the LAO projection at 26° (Fig. 3B). The day after, we removed the temporary pacemaker with cardiovascular backup in the anticoagulant treatment. There was no neurological deficit after removal of the pacemaker. The followup was uneventful until 5 days later. Because of LBBB and the image in the anterior-posterior chest radiography, we may think that the pacemaker lead was in the right ventricle. However, the fluoroscopy and echocardiography showed that the tip of the pacemaker lead was in the left ventricle. A pacemaker lead may be implanted in the left ventricle via right jugular vein presence of atrial septal defect, ventricular septal defect, and patent foramen ovale. However, suprasternal images showed the lead of pacemaker in the arcus aorta. Generally, a pacemaker is inserted by ECG guidance in the emergency room. But, some dangerous complications may occur without fluoroscopic guidance. Malposition of pacemaker leads has been described in several different locations, including the left ventricle, pulmonary outflow tract, the atria, the coronary sinus, and other cardiac veins (1). Misimplantation of a temporary pacemaker lead in the aortic sinus via the femoral artery and left subclavian vein was reported previously (2, 3). In the presence of LBBB in ECG was the main tricky situation in our patient. Likewise, the tip of the pacemaker lead was seen in the right ventricle by anterior-posterior chest radiography. Transthoracic echocardiography and fluoroscopy images helped us to determine the localization of the pacemaker lead.