Levoatrial Cardinal Vein: In two siblings with normal heart morphology

Levoatrial cardinal vein (LACV) is anomalous connection between the left atrium or pulmonary veins and any systemic vein which is derived from cardinal venous system. Presence of the levoatrial cardinal vein without a cardiac anomaly is a very rare congenital anomaly of the systemic venous return. In the literature, no LACV anomaly was found in two siblings who were asymptomatic and did not have an additional cardiac anomaly. Therefore, we present two cases ( two siblings ) the symptoms, diagnosis (the echocardiographic finding, computed tomography (CT) and aniographic images ) and treatment modalities of isolated levoatrial cardinal vein.

ILLUMINATION OF SPONTANEOUS ECHO CONTRAST WITH HEMORHEOLOGY AND ECHOCARDIOGRAPHY IN MITRAL STENOSIS

Backround: Spontaneous echo contrast (SEC) is an echocardiographic finding particularly found in left atrium of patients with mitral stenosis (MS) and known as a risk factor for stroke. However, its pathophysiology is not fully understood. Methods: Forty-eight patients with MS scheduled for percutaneous mitral valvuloplasty were included in the study. Blood samples were taken from the aorta and left atrium (LA) during the procedure. Whole blood viscosity (WBV), plasma viscosity (PV) and peripheral blood smears were obtained and analysed separately from these sites. All participants underwent transthoracic and transesophageal echocardiography prior to the procedure Results: Severe SEC (grade 3-4) was found in 23 patients, remaining 25 patients had mild to moderate SEC (grade 0-1-2). Patients with severe SEC had increased LA diameter, area and PV. However, ejection fraction, left atrial appendage (LAA) filling and emptying velocities, LAA lateral wall late systolic velocity, LAA fractional area change and pulmonary vein (PVe) systolic velocity were found to be significantly reduced in patients with severe SEC compared to mild to moderate SEC. On multiple linear regression analysis, atrial fibrillation, left atrium PV and diameter were strongly correlated with SEC grade (Respectively p=0,011, p=0,013, p=0,030). Conclusion: We have shown that AF, systolic dysfunction of LAA and left ventricule, reduced PVe flow velocity, increased LA dimensions and left atrial PV were related with the severity of SEC in patients with mitral stenosis. We demonstrated the relationship between the increase left atrial PV and SEC in addition to impaired hemodynamic determinants in patients with mitral stenosis.

An echocardiographic finding mimicking tricuspid atresia in a neonate with dilated cardiomyopathy

We report a neonate with dilated cardiomyopathy and have echocardiographic findings consistent with “functional” tricuspid atresia. There was an echo-bright, plate-like tissue at the tricuspid valve position with no forward flow across it. This report underscores the role of right ventricle intracavitary haemodynamic influence on the tricuspid valve leaflet excursion and demonstrates a phenomenon of “pseudo or functional tricuspid atresia” mimicking tricuspid atresia in a patient with acute presentation of cardiomyopathy.

Elevated Pulmonary Pressure Noted on Echocardiogram: A Simplified Approach to Next Steps

An elevated right ventricular/pulmonary artery systolic pressure suggestive of pulmonary hypertension (PH) is a common finding noted on echocardiography and is considered a marker for poor clinical outcomes, regardless of the cause. Even mild elevation of pulmonary pressure can be considered a modifiable risk factor, informing the trajectory of patients' clinical outcome. Although guidelines have been published detailing diagnostic and management algorithms, this echocardiographic finding is often underappreciated or not acted upon. Hence, patients with PH are often diagnosed in clinical practice when hemodynamic abnormalities are already moderate or severe. This results in delayed initiation of potentially effective therapies, referral to PH centers, and greater patient morbidity and mortality. This mini‐review presents a succinct, simplified case‐based approach to the “next steps” in the work‐up of PH, once elevated pulmonary pressures have been noted on an echocardiogram. Our goal is for clinicians to develop a good overview of diagnostic approach to PH and recognition of high‐risk features that may require early referral.

Atrial septal aneurysm in Sub-Saharan Africa: From an asymptomatic incidental echocardiographic finding to a potential cause of cardio embolic stroke

Atrial Septal Aneurysm (ASA) is an abnormality of the interatrial septum that has continued to generate interest because of its rarity, asymptomatic presentation and possibility to cause cardioembolic stroke. There are many published accounts of atrial septal aneurysm in USA, Europe and Asia but very few published reports from sub-Saharan Africa. Our first case is a 48 years old female patient with type 1 ASA presented as an incidental finding during echocardiographic investigative procedures for other cardiac diagnosis. The second case is a 58 years old female with type 2L ASA, who presented with transient loss of consciousness lasting for 5 minutes. Our third case is a 25 years old male with type 5 ASA with heart failure who presented with exertional dyspnoea for 3 years. In this presentation, we ask questions about the reason for rare presentations and or publications of atrial septal aneurysm from Africa. We also re-examined the different associations of ASA as well as clinical presentations. ASA is an often asymptomatic but treatable cause of cardiovascular disease that includes cardioembolic stroke. A high index of suspicion is required to make the diagnosis during routine trans thoracic echocardiography and the availability of transesophageal echocardiography will definitely improve diagnosis and management of cases in sub-Saharan Africa.

‘The bubble heart’: an unusual natural history told by multimodality imaging- a case report

Background Intracardiac thrombosis is a relatively common pathological condition. Often, it is diagnosed at echocardiography during the subacute or chronic phase. In the very acute phase, tissue composition can make thrombus appearance very different from that usually seen. Fresh thrombosis has been previously found also in peripartum cardiomyopathy (PPC), but with imaging features different from our case. Case summary A 27-year-old woman was referred to our hospital for PPC, with echocardiographic finding of intraventricular masses, resembling big bubbles. Cardiac magnetic resonance (CMR) allowed definitively diagnosing intracardiac ‘very acute’ thrombosis, which is rarely detected. Discussion Our case provides a practical lesson about management of an unusual presentation of a common problem. When early echocardiography does not allow making a certain diagnosis, CMR can be helpful and decisive, due to its unique ability to provide characterization of intracardiac masses.

Abstract 15167: Short-term Sequalae of Children With Paediatric Inflammatory Multisystem Syndrome Temporarily Associated With Sars-cov-2 Infection (pims-ts) Assessed by Cardiovascular Magnetic Resonance

Introduction: Children with paediatric inflammatory multisystem syndrome temporally associated with SARS CoV2 infection (PIMS-TS) present with evidence of multiorgan dysfunction. Cardiac features include partial or typical Kawasaki disease symptoms or ventricular impairment. The aim of this study was to assess short term sequelae of cardiac involvement in patients with PIMS-TS. Methods: 17 consecutive paediatric patients with PIMS-TS were referred for CMR at our institution. The referring criteria were: Echocardiographic finding of LV dysfunction at presentation (53%), dilated coronary arteries (27%) and high cardiac markers without LV dysfunction (20%). 16 patients completed the scan and were included into the analysis. Results: Age of the patients was 17 months-12 years (mean 6.4 years), 12 (80%) were male. Six (40%) patients required general anaesthesia. The time between the onset of the symptoms and the scan was 12-72 days. All patients had SARS CoV2 PCR negative at the time of scan, 2 patients were previously positive and 12 (80%) had positive IgG. CMR indexed volumes (ml/m2) were in normal range: LVEDV 65±11, LVESV 24±7, RVEDV 67±12, RVESV 27±7. LV mass index were normal 45±8 gr/m2. No overt areas of myocardial oedema or acute inflammation on STIR (short tau inversion recovery) images were found. Mildly reduced LV ejection fraction was found in 1 patient with subtle linear late gadolinium enhancement (LGE) in the midventricular midmyocardial interventricular septum with negative STIR images. Another patient was found to have LGE of the proximal parts of mitral valve papillary muscles, but no abnormalities in the LV ejection fraction or mitral valve function were found. Two patients had a small pericardial effusion. 3 patients had dilated neck and/or innominate veins, 2 of them with phlebectatic appearance. One patient had enlarged liver, another liver and spleen. Conclusion: in conclusion no significant myocardial sequelae have been found in most of the patients presenting with PIMS-TS short-term after onset of symptoms. This might indicate rapid recovery of the cardiac inflammation in most of the patients. More follow up is needed to clarify if there will be any potential sequelae from the acute episode as well as the outcome of phlebectasia.

Abstract 17256: Utility of Echocardiography in Acute and Recurrent Pericarditis

Background: Pericarditis usually presents with sharp chest pain, and other diagnostic features include pericardial rub, typical EKG changes (diffuse ST elevation and PR depression), and the presence of pericardial effusion (PEff). Echocardiography (ECHO) is the first-line imaging modality in pericarditis. It helps to identify PEff, constrictive physiology, and wall motion abnormalities. We sought to characterize ECHO features in a large cohort of patients with acute (AP) and recurrent pericarditis (RP). Methods: Data were collected retrospectively for patients with acute and recurrent pericarditis. Pericarditis was diagnosed based on the European Society of Cardiology pericardial disease guidelines. ECHOs were reviewed for relevant features and findings. Chi-square test statistics were used to compare AP and RP. Results: A total of 323 consecutive patients with RP (68%) and AP (32%) was identified from January 2015 to December 2018. The median age was 52 years 56% were female. Of the total patients, the most common finding on ECHO was PEff (42%). Of the patients having PEff, 65 (20%) had trivial, 42 (13%) small, 19 (6%) moderate, and 6 (2%) had large effusion. Other findings included constrictive physiology (20%), thickened pericardium (4%), and echo wall motion abnormality (3%). AP patients had higher number of PEff compared to RP (51% vs 38%; [X 2 =4.1, p=0.043]. Increased pericardial thickness was only found in patients with RP (6% in RP vs 0% in AP; [X 2 =6, p=0.014]. All the other findings were similar across RP and AP Conclusion: The most common echocardiographic finding in acute and recurrent pericarditis patients is pericardial effusion followed by constrictive physiology and thickened pericardium. Pericardial effusion appears to be more frequent in AP patients as compared to RP. These findings may be useful in the diagnostic workup of pericarditis.

Evaluation and Management of Primary Tricuspid Regurgitation

Tricuspid regurgitation (TR) is a highly prevalent echocardiographic finding in general population being present in almost 80% to 90% of them. However, TR is mild or functional rather than organic in majority of people. Significant TR was seen in 14.8% of adult men and 18.4% of adult women, respectively. Of all the significant TRs, approximately 8% to 10% are primary. Mild TR is benign but moderate-to-severe TR tends to progress and carries significant morbidity and mortality. Tricuspid valve disease is either primary or secondary (functional) in nature. Valve leaflets are predominantly diseased in primary TR, whereas annular dilatation is the main culprit in secondary TR. Of all the heart valves, tricuspid valve was the most neglected valve till a decade ago, though there was enough evidence to show that moderate to severe TR was not as benign as was assumed. With the availability of 2-dimensional echocardiography (2D echo) and transesophageal echocardiography, we are able to diagnose and determine the severity as well as etiology of TR. Although surgical therapy remains the gold standard for severe primary tricuspid valve disease, it continues to suffer from one of the highest morbidity and mortality rates among all cardiac valve-related surgeries even in the hands of experienced surgeons. For the same reason, majority of patients are not referred or subjected to surgical therapy. Therefore, there is an unmet need for less invasive and safer form of therapy to overcome this hurdle. So, several less-invasive and innovative technologies for treating patients with severe tricuspid valve disease at high surgical risk are being developed. Some of them have already been used for treatment of severe mitral regurgitation. They are being adopted for the treatment of severe TR. This review provides a comprehensive picture of newer guidelines and latest technologies and their impact on diagnosis and outcome of high-risk TV disease.