Victor Farah

Transapical valve-in-valve replacement of a stenosed prosthetic mitral valve in a critically ill patient with cardiogenic shock: a case report

The burden of managing dysfunctional mitral prosthetic valve disease in the elderly population is increasing for those who cannot tolerate a redo sternotomy along with their multiple comorbid conditions. We report a critically ill elderly patient with a high surgical risk, multiple comorbid conditions, longstanding chronic lung disease, hepatic dysfunction, coagulopathy, acute kidney injury, fluid overload and presenting with cardiogenic shock who was initially rescued with veno-arterial extracorporeal membrane oxygenation and then underwent successful transapical mitral valve-invalve replacement. She survived the procedure and was successfully extubated in the ICU on postoperative day 2. She died on day 5 due to a suspected thrombotic state.

An unprecedented case report of primary cardiac lymphoma exclusive to left ventricle: a diagnostic and therapeutic challenge

Abstract Introduction Primary cardiac lymphoma accounts for <2% of all primary cardiac tumours. It is uncommon in immunocompetent patients, often fatal and diagnosed at autopsy. Tumour usually involves the right heart chambers and pericardium. With advances in imaging, early diagnosis is possible and treatment including chemotherapy and surgery affords good prognosis. Case presentation We present a 50-year-old woman with abdominal pain and fevers for 5 days. Computed tomography of the abdomen showed splenic and renal infarcts but no mass or vegetation was noted on echocardiography. Thoracic computed tomography divulged a large left ventricular filling defect. Cardiac magnetic resonance imaging delineated a 3.5 × 4.5 cm anterobasal mass with frond-like projections and endocardial invasion without extracardiac involvement suggestive of a low-vascularity tumour. Echo-guided endomyocardial biopsy and minithoracotomy with needle biopsy were inconclusive. A sarcoid-protocol cardiac positron emission tomography-fluorodeoxyglucose scan showed focally elevated uptake in the basal anteroseptum without extracardiac uptake, supporting a malignant entity. This prompted open heart mass resection. Pathology revealed diffuse large B-cell lymphoma. Discussion Our case is a unique report of cardiac lymphoma isolated to the left ventricle. Location of the tumour and lack of specific imaging characteristics made it a diagnostic challenge. It underscores the importance of including lymphoma in the differential for intracardiac masses as it is responsive to chemotherapy. Additionally, it emphasizes the complementary role of imaging modalities and multidisciplinary team approach in diagnosis. Early diagnosis and therapy is the key to establishing successful outcomes.

Echocardiography and cardiovascular MRI entwined within the imaging domain; uniting the two. A compendium for the echocardiographer

A review of the unique and complementary roles echocardiography and cardiovascular MRI provide to the clinician. A focus on the physics of each modality as well as imaging of the left ventricle.

Physiologic left ventricular ejection efficiency assessed at the level of the aorta

Methods Vascular ejection efficiency (VEE) is proportional to the dimensionless ratio of aortic diameter to wavelength of the transmitted blood pulse. The wavelength of ejected blood is proportional to blood wave velocity divided by blood wave frequency measured using phase velocity mapping (PVM) applied to the ascending aorta. Left ventricular function and aortic PVM data were retrospectively obtained in 118 patients who underwent CMR scanning as a clinical routine. The LV end-diastolic and end-systolic volumes were measured using manually drawn contours for a contiguous stack of LV slices. The aortic area was measured from the PVM images along with the average velocity, taken as a measure of blood wave velocity (not to be confused with the more common pulse wave velocity), the end-systolic time was taken as the pulse length and aortic area instead of diameter to yield the VEE index: VEE = Aortic Area × End systolic time / Average blood velocity The VEE was calculated and plotted against the ventricular measures of EF and VVC.

Debt-free cardiac health

Background Predicting cardiac prognosis and outcome is important. As the heart progresses towards failure, it is known that the ventricular-vascular coupling (VVC) progresses from the optimal range (0.5 to 1.2) to values as high as 10 in severe failure. However, even hearts close to failure may exhibit a VVC in the normal range and thus its future predictive value is low. Here we consider the cardiac energy usage derived from cardiovascular magnetic resonance (CMR) to better utilize VVC data. To accomplish this we consider the difference between internal energy (EInternal) and external energy (EExternal) which we term energy debt (EDebt).

A model argument for accurate EF

Background CMR still suffers from several sources of inaccuracy in measuring LV volumes and EF. Typical standard deviations (SD) between readers for EF range from 4% 7.5% (Quantification of LV function: Suinesiaputra A, et al. J Cardiovasc Magn Reson. 2015 Jul 28;17(1):63). Further, since the data range of agreement for 95% of data is 4SD (i. e. 16% 30%), it is common practice to adjust EF based on a visual assessment. This presents several major problems in that there is no guarantee that visual EF is a good guide and that adjustments to EDV and ESV will result in the SV being adjusted correctly. Here we present a technique termed ‘Removing Endocardial Measured Overage Directionally using External Leverage’ (REMODEL) that accomplishes intuitive simultaneous corrections of EF and SV.