Giant coronary fistula aneurysm presenting as a progressing left-sided asymptomatic mediastinal mass with systolic dominant Doppler flow: a case report

Background Cases of giant coronary artery aneurysms associated with coronary fistula are rarely reported, and they present with various symptoms, including coronary steal syndrome. We report an uncommon case of an asymptomatic giant coronary fistula aneurysm presenting as a progressing left-sided mediastinal mass that has been tracked for years. Case summary A 67-year-old healthy asymptomatic woman was referred to our hospital because of an abnormal shadow on her chest radiography revealing a left-sided mediastinal mass that had progressed in size over the past 4 years. Computed tomography revealed mass progression from 4 cm to 5 cm in diameter within 2 years. Coronary computed tomography and coronary angiography identified a giant coronary artery aneurysm in a coronary fistula originating in the left anterior descending artery and draining into the main pulmonary artery. Transthoracic Doppler echocardiography revealed a unique systolic-dominant flow. She underwent coronary artery aneurysmectomy and fistula ligation. The patient has been in good health without any events for 10 months since her discharge. Discussion A giant coronary artery aneurysm in a coronary fistula can present as an asymptomatic left-sided mediastinal mass that has progressed in size for years in older adults. Echocardiography can provide clues of the steal phenomenon in coronary artery fistula. A close investigation of mediastinal abnormalities can facilitate the detection of coronary aneurysms.

Coronary Flow Velocity Reserve Using Dobutamine Test for Noninvasive Functional Assessment of Myocardial Bridging

Background: It has been shown that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during dobutamine (DOB) provocation provides a more accurate functional evaluation of myocardial bridging (MB) compared to adenosine. However; the cut-off value of CFVR during DOB for identification of MB associated with myocardial ischemia has not been fully clarified. Purpose: This prospective study aimed to determine the cut-off value of TTDE-CFVR during DOB in patients with isolated-MB, as compared with stress-induced wall motion abnormalities (VMA) during exercise stress-echocardiography (SE) as reference. Methods: Eighty-one symptomatic patients (55 males [68%], mean age 56 ± 10 years; range: 27–74 years) with the existence of isolated-MB on the left anterior descending artery (LAD) and systolic MB-compression ≥50% diameter stenosis (DS) were eligible to participate in the study. Each patient underwent treadmill exercise-SE, invasive coronary angiography, and TTDE-CFVR measurements in the distal segment of LAD during DOB infusion (DOB: 10–40 μg/kg/min). Using quantitative coronary angiography, both minimal luminal diameter (MLD) and percent DS at MB-site at end-systole and end-diastole were determined. Results: Stress-induced myocardial ischemia with the occurrence of WMA was found in 23 patients (28%). CFVR during peak DOB was significantly lower in the SE-positive group compared with the SE-negative group (1.94 ± 0.16 vs. 2.78 ± 0.53; p < 0.001). ROC analyses identified the optimal CFVR cut-off value ≤ 2.1 obtained during high-dose dobutamine (>20 µg/kg/min) for the identification of MB associated with stress-induced WMA, with a sensitivity, specificity, positive and negative predictive value of 96%, 95%, 88%, and 98%, respectively (AUC 0.986; 95% CI: 0.967–1.000; p < 0.001). Multivariate logistic regression analysis revealed that MLD and percent DS, both at end-diastole, were the only independent predictors of ischemic CFVR values ≤2.1 (OR: 0.023; 95% CI: 0.001–0.534; p = 0.019; OR: 1.147; 95% CI: 1.042–1.263; p = 0.005; respectively). Conclusions: Noninvasive CFVR during dobutamine provocation appears to be an additional and important noninvasive tool to determine the functional severity of isolated-MB. A transthoracic CFVR cut-off ≤2.1 measured at a high-dobutamine dose may be adequate for detecting myocardial ischemia in patients with isolated-MB.

709 Non-invasive assessment of myocardial work: an useful tool for predicting LV remodelling after myocardial infarction?

Aims Left ventricular function recovery (LV-REC) or left ventricular adverse remodelling (LV-REM) after acute myocardial infarction (AMI) play an important role for identifying patients at risk of heart failure. In this study we aim to evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV-REC or LV-REM after AMI. Methods and results Fifty patients with AMI (mean age, 63.8 ± 13.4 years), treated by primary percutaneous coronary intervention (PCI), were prospectively enrolled. They underwent a baseline transthoracic Doppler echocardiography (TTE) within 48 h after PCI and a second TTE after a median of 31 days during the follow-up. MW was derived from the strain-pressure loops, integrating in its calculation the non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. LV-REC was defined as an absolute improvement of left ventricular ejection fraction (LVEF) ≥ 5% from LVEF at baseline, whereas LV-REM was defined as an increase of ≥ 20% of the LV end diastolic volume (LVEDV) at 1 month follow-up. We overall found a significant improvement from baseline to one-month follow-up for values of LVEF (49.8 ± 9.5% vs. 52.8 ± 9.3%, P = 0.001), global longitudinal strain (GLS) (−13.4 ± 3.9% vs. −18.7 ± 5.4%, P = 0.016), global work index (GWI) (1368.6 ± 435.2 vs. 1788 ± 493 mmHg/%, P = 0.0001), global work efficiency (GWE) (89.96 ± 9.3% vs. 91.3 ± 6.4%, P = 0.001), global constructive work (GCW) (1619.16 ± 497.9 mmHg/% vs. 2008.6 ± 535.3 mmHg/%, P = 0.0001), global wasted work (GWW) (188.8 ± 19.8 mmHg/% vs. 149.2 ± 16.5 mmHg/%). However, LV-REC at 1 month of follow-up was observed only in 36% of the population enrolled, whereas LV-REM was described in 18% of cases. Using ROC curve analysis, we identified a cut off value of 202 mmHg/% for baseline GWW (sensitivity 75%, specificity 62%, AUC 0.6667, CI 95%: 0.51618–0.81715, P = 0.0001) to identify patients with LV-REM at 1 month. With regards to conventional echo parameters, patients with LV-REC showed lower baseline wall motion score index (WMSI) than those without LV-REC (1.73 vs. 1.38, P = 0.007). Conclusions Among standard and advanced TTE parameters, only baseline GWW is able to predict early LV-REM at 1 month after primary PCI. Therefore, it could be used during baseline evaluation of AMI patients for a more accurate stratification of those at higher risk of heart failure. However, further larger scale studies are needed to validate these findings.

767 Correlations between myocardial work parameters and pulse wave velocity

Aims The myocardial work (MW) is a new echocardiographic method, based on the pressure–strain loop, which allows to quantify the cardiac performance. On the other hand, the pulse wave velocity (PWV) evaluates arterial stiffness, knowing that as the stiffness of an artery increases, the transmission velocity of the anterograde and the retrograde sphygmic wave increase. The aim of the study is to evaluate the correlation between MW and PWV parameters. Methods and results We enrolled 32 healthy patients (mean age: 39 ± 17 years), who underwent transthoracic Doppler echocardiography (TTE). The MW parameters was derived from the strain–pressure loop, including in its calculation the measurement non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. The PWV measurement was obtained by tonometry at the level of the common carotid artery and the common femoral artery. None of the parameters measured was pathological according to the normality studies considered. It was found a linear correlation between PWV and global wasted work (GWW) (linear R2: 0.603; P = 0.001) and an inverse linear correlation between PWC and global work efficiency (GWE) (linear R2: −0.307; P = 0.032). Conclusions The study highlights the possibility of PWV to predict pre-clinical myocardial changes, given the correlation with GWW and the linear inverse correlation with GWE.

Characteristics of coronary flow velocity reserve on transthoracic Doppler echocardiography in patients with a history of Kawasaki disease

Whether the acute inflammation caused by Kawasaki disease will have an effect on the endothelial function of coronary arteries in the future is unknown. Methods: The coronary flow velocity reserve of the left anterior descending artery was examined by transthoracic Doppler echocardiography in 189 patients (male 125, female 64) with a history of Kawasaki disease and 10 volunteers (control). Their ages ranged from 6 to 40 years (median 22 years). The patients were divided into nine groups based on the left anterior descending artery lesions. The coronary flow velocity reserve was measured by intravenous administration of adenosine triphosphate (0.15 mg/kg/minute) while fasting. The coronary flow velocity reserve was calculated as the ratio of hyperaemic to basal mean diastolic flow velocities. The respective groups were as follows: control, no coronary artery lesions (n = 39), no coronary artery lesions in the right coronary artery (n = 29), regression (n = 11), aneurysm at the bifurcation of the left coronary artery (n = 26), aneurysm of the left anterior descending artery (n = 15), localised stenosis <75% (n = 12), localised stenosis ≥75% (n = 17), segmental stenosis (n = 5) and coronary artery bypass grafting (n = 36). One-factor ANOVA followed by Tukey’s test was used to compare the coronary flow velocity reserve among the groups. Results: The coronary flow velocity reserve was significantly lower in the localised stenosis ≥75%, segmental stenosis and coronary artery grafting groups than in the other groups (p < 0.05). Conclusions: The endothelial function in the epicoronary artery was preserved in patients with a history of Kawasaki disease and dilated coronary artery lesions.

Analysis of risk factors for venous air embolism in the semisitting position and its impact on outcome in a consecutive series of 740 patients

OBJECTIVE Routine use of the semisitting position, which offers several advantages, remains a matter of debate. Venous air embolism (VAE) is a potentially serious complication associated with the semisitting position. In this study, the authors aimed to investigate the safety of the semisitting position by analyzing data over a 20-year period. METHODS The incidence of VAE and its perioperative management were analyzed retrospectively in a consecutive series of 740 patients who underwent surgery between 1996 and 2016. The occurrence of VAE was defined by detection of bubbles on transthoracic Doppler echocardiography (TTDE) or transesophageal echocardiography (TEE) studies, a decrease of end-tidal CO2 (ETCO2) by 4 mm Hg or more, and/or an unexplained drop in systolic arterial blood pressure (≥ 10 mm Hg). From 1996 until 2013 TTDE was used, and from 2013 on TEE was used. The possible risk factors for VAE and its impact on surgical performance were analyzed. RESULTS There were 404 women and 336 men with a mean age at surgery of 49 years (range 1–87 years). Surgery was performed for infratentorial lesions in 709 patients (95.8%), supratentorial lesions in 17 (2.3%), and cervical lesions in 14 (1.9%). The most frequent pathology was vestibular schwannoma. TEE had a higher sensitivity than TTDE. While TEE detected VAE in 40.5% of patients, TTDE had a detection rate of 11.8%. Overall, VAE was detected in 119 patients (16.1%) intraoperatively. In all of these patients, VAE was apparent on TTDE or TEE. Of those, 23 patients also had a decrease of ETCO2, 18 had a drop in blood pressure, and 23 had combined decreases in ETCO2 and blood pressure. VAE was detected in 24% of patients during craniotomy before opening the dura mater, in 67% during tumor resection, and in 9% during wound closure. No risk factors were identified for the occurrence of VAE. Two patients had serious complications due to VAE. Surgical performance in vestibular schwannoma surgery was not affected by the presence of VAE. CONCLUSIONS This study shows that the semisitting position is overall safe and that VAE can be managed effectively. Persistent morbidity is very rare. The authors suggest that the semisitting position should continue to have a place in the standard armamentarium of neurological surgery.

Prognostic Value of Transthoracic Doppler Echocardiography Coronary Flow Velocity Reserve in Patients With Asymmetric Hypertrophic Cardiomyopathy

Background Microvascular dysfunction might be a major determinant of clinical deterioration and outcome in patients with hypertrophic cardiomyopathy (HCM). However, long‐term prognostic value of transthoracic Doppler echocardiography (TDE) coronary flow velocity reserve (CFVR) on clinical outcome is uncertain in HCM patients. Therefore, the aim of our study was to assess long‐term prognostic value of CFVR on clinical outcome in HCM population. Methods and Results We prospectively included 150 HCM patients (82 women; mean age 48±15 years). Patients’ clinical characteristics, echocardiographic and CFVR findings (both for left anterior descending [LAD] and posterior descending artery [PD]), were assessed in all patients. The primary outcome was a composite of: HCM related death, heart failure requiring hospitalization, sustained ventricular tachycardia and ischemic stroke. Patients were stratified into 2 subgroups depending on CFVR LAD value: Group 1 (CFVR LAD>2, [n=87]) and Group 2 (CFVR LAD≤2, [n=63]). During a median follow‐up of 88 months, 41/150 (27.3%) patients had adverse cardiac events. In Group 1, there were 8/87 (9.2%), whereas in Group 2 there were 33/63 (52.4%, P <0.001 vs. Group 1) adverse cardiac events. By Kaplan‐Meier analysis, patients with preserved CFVR LAD had significantly higher cumulative event‐free survival rate compared to patients with impaired CFVR LAD (96.4% and 90.9% versus 66.9% and 40.0%, at 5 and 8 years, respectively: log‐rank 37.2, P <0.001). Multivariable analysis identified only CFVR LAD≤2 as an independent predictor for adverse cardiac outcome (HR 6.54; 95% CI 2.83–16.30, P <0.001), while CFVR PD was not significantly associated with outcome. Conclusions In patients with HCM, impaired CFVR LAD (≤2) is a strong, independent predictor of adverse cardiac outcome. When the aim of testing is HCM risk stratification and CFVR LAD data are available, the evaluation of CFVR PD is redundant.

Cut-off value of coronary flow velocity reserve obtained by transthoracic Doppler echocardiography during intravenous infusion of dobutamine for diagnosis of functional significant myocardial bridging

Background Recent studies showed that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during inotropic stimulation with dobutamine (DOB), in comparison to vasodilation with adenosine, provides more reliable functional evaluation of myocardial bridging (MB). However, the adequate cut-off value of CFVR during DOB for diagnosing functional significant MB has not been fully established. Purpose The purpose of the study was to evaluate the adequate cut-off value of TTDE- CFVR during DOB for diagnosis of functional significant MB. Methods This prospective study included 79 patients (54 males, mean age 55±10 years) with angiographic evidence of isolated MB on the left anterior descending artery (LAD) and systolic compression ≥50% diameter stenosis. Exercise stress-echocardiography test (ExSE) and TTDE-CFVR in the distal segment of LAD during DOB infusion (DOB: 10–40μg/kg/min) were performed in all patients. Percent diameter stenosis (DS) of MB at end-systole and end-diastole were analyzed using quantitative coronary angiography. Results Exercise-SE was positive for myocardial ischemia in 22/79 (28%). CFVR during peak DOB was significantly lower in SE-positive group in comparison to SE-negative group (1.94±0.16 vs. 2.78±0.53, p&lt;0.001). ROC analysis identifies the optimal CFVR during peak DOB cut-off value &lt;2.1 (AUC 0.985, 95% CI: 0.965–1.000, p&lt;0.001), with a sensitivity of 96% and specificity of 95%, positive predictive value of 88%, and negative predictive value of 98%, for identifying functionally significant MB associated with stress-induced myocardial ischemia. The categorical agreement between TTDE-CFVR at peak DOB and ExSE was high (kappa value = 0.877, p&lt;0.001). Multivariate logistic regression analysis showed that percent DS at end-diastole was the only independent predictor of ischemic CFVR value &lt;2.1 (OR: 1.136, 95% CI: 1.045–1.235, p=0.003). Conclusion A cut-off value &lt;2.1 of CFVR during DOB infusion obtained by TTDE may adequate discriminate functional significant MB that induce myocardial ischemia which is caused by an incomplete diastolic MB-decompression. FUNDunding Acknowledgement Type of funding sources: None.

Arrhythmias in repaired pediatric and adolescent Fallot tetralogy, correlation with cardiac MRI parameters

Background Tetralogy of Fallot (TOF) is a common congenital cyanotic heart disease in which arrhythmias could develop even after successful operative repair. Pulmonary regurgitation and right ventricular dilatation develop in many cases. The relation between arrhythmias and right ventricular dilatation is not established. Our aim is to assess the relation in between the degree of right ventricular volume affection and the severity of the pulmonary regurgitation, associated arrhythmias and the need for pulmonary valve repair in Egyptian pediatric and adolescent cases after successful TOF repair. Results A cross sectional descriptive study was conducted on 32 cases after successful surgical repair. Transthoracic Doppler echocardiography, 24 h Holter monitoring and cardiac MRI for assessment of pulmonary regurgitation fraction (PRF), ventricular volumes and function were measured. Cases were classified according to right ventricular end diastolic volume index (RVEDVI) into 2 groups with cut off value 150 ml/m2. Mean age of the studied cases was (12.96 ± 3.384) years, mean age at time of surgical repair was (34.23 ± 22.1) months, and mean duration postoperatively was (121.72 ± 41.028) months. Eighteen cases (56%) had RVEDVI ≥ 150 ml/m2, PRF was significantly higher in cases with increased RVEDVI (p value 0.007), with positive significant correlation between RVEDVI and PRF (p value = 0.0001, r = 0.61). Arrhythmias were detected in 18 cases (56%), the most common of which was infrequent supraventricular ectopy. No significant difference in incidence of arrhythmias between the 2 groups (p value = 1) with also no significant correlation between arrhythmias and increased RVEDVI (p value = 0.76, r = 0.05). No difference between cases with and without arrhythmias regarding RVEDVI (p value = 0.56) or PRF (p value = 0.5). Conclusion Holter detected arrhythmias after successful surgical repair of TOF were significantly associated with increased postoperative duration but not with PRF or RVEDVI.

Early effect of percutaneous coronary intervention of non-left anterior descending artery on coronary flow velocity reserve of left anterior descending artery assessed by transthoracic Doppler echocardiography

Background Limited data are available regarding the influence of percutaneous coronary intervention (PCI) of non-totally occluded lesions (non-CTO) on the coronary flow of non-target vessels. We sought to investigate the short-term impact of the non-left anterior descending artery (non-LAD) PCI on the coronary flow physiology of LAD using transthoracic Doppler echocardiography (TDE). Methods and results We consecutively studied 50 patients who underwent successful PCI of non-LAD and non-CTO lesions and a coronary flow velocity assessment of LAD at rest and maximal hyperemia before and at 2 days after the procedure by TDE. Coronary flow velocity reserve (CFVR) was calculated as the ratio of hyperemic to resting diastolic peak velocity (hDPV/bDPV). We evaluated the changes in LAD coronary flow characteristics after PCI of non-LAD and explored the determinants of the change in LAD-CFVR. The median fractional flow reserve (FFR) of the culprit lesion and the LAD quantitative flow ratio (QFR) were 0.67 and 0.88, respectively. After non-LAD PCI, LAD-CFVR was decreased in 33 patients (66.0%). LAD-CFVR significantly decreased (pre-PCI: 2.41, post-PCI: 2.03, p = 0.001) due to a significant decrease in LAD-hDPV (P = 0.007). The prevalence of impaired LAD-CFVR (≤2.0) significantly increased (pre: 30%, post: 48%, P = 0.027). Multivariable linear regression analysis showed that pre-PCI LAD-CFVR was independent predictor of the change in LAD-CFVR after PCI. Conclusions LAD-CFVR significantly decreased after successful non-LAD PCI due to the postprocedural reduction of coronary flow assessed by LAD-hDPV.