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   Table of Contents - Current issue
May-August 2022
Volume 6 | Issue 2
Page Nos. 89-163

Online since Tuesday, August 23, 2022

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Pilot Study Analyzing Combination of Point-of-Care Echocardiography and Clinical Correlation in Unveiling Cryptic Multi-Inflammatory Syndrome in Neonates during Coronavirus Disease 2019 Pandemic p. 89
Maitri Chaudhuri, Munesh Tomar, Seema Gaonkar, Anuj Rastogi, Arvind Shenoi
Introduction: Coronavirus disease 2019 (COVID-19), an extremely contagious pandemic, caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), originated from Wuhan, Hubei province, in China in December 2019. From April 2020, pediatric epicenters in Europe and the USA reported a new clinical spectrum called “pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2” or “multisystem inflammatory syndrome in children,” respectively. The unique feature was immune-mediated multiorgan dysfunction in response to previous COVID exposure. This case series aims to prospectively analyze the incidence, severity, and patterns of cardiac involvement in sick neonates exposed to perinatal SARS-CoV-2 in India. Methods: Twelve neonates presenting with very early-onset multi-inflammatory syndrome in neonates (MIS-N) at two tertiary care centers in India were included. Their clinical profiles, echocardiography findings, and treatment details were recorded. Results: Clinical presentations varied from loss of fetal movement, perinatal depression, prematurity, unusual respiratory distress syndrome, cardiogenic shock, arrhythmias, and multi-organ dysfunction. Echocardiographic markers were severe pulmonary hypertension, significant valvular regurgitation, cardiomegaly, biventricular dysfunction, neonatal coronary artery aneurysms, intracardiac thrombus, pericardial effusion, and arrhythmias. All babies, except one, had positive COVID IgG antibody and high inflammatory markers. Two mothers had antenatal primary contact with COVID patients 4–6 weeks prior to delivery, while 3 (25%) had documented mild COVID infection. All neonates were started on immunosuppressive therapy. Clinical stabilization and declining inflammatory markers were observed within 48–96 h of targeted therapy. All neonates (except one) recovered and were discharged in a stable condition. Follow-up available up to 9 months demonstrated persistent clinical, laboratory, and echocardiographic recovery in all survivors. Conclusion: Infection of pregnant mothers during community transmission during the two COVID-19 waves in India appears to have caused significant immune dysregulation and cardiac damage in neonates. Echocardiography detected significant damage to coronary arteries, pulmonary arterial hypertension, intracardiac thrombus, ventricular dysfunction, and incompetence of valve apparatus in MIS-N. Aggressive immunomodulators with antiplatelet drugs proved lifesaving. Echocardiography is an inexpensive, readily available imaging modality. It should be utilized to save this fragile, extremely special cohort.
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Echocardiographic Assessment of Right Ventricular Systolic Function in Postoperative Tetralogy of Fallot Patients with Special Emphasis on Right Ventricular-Global Longitudinal Strain p. 100
Mohammad Moaaz Kidwai, Sushil Azad, Sitaraman Radhakrishnan, Ankit Garg, Shashikapoor Yadav, Amit Kumar
Background: Limitations of echocardiography have long been known for the assessment of right ventricular (RV) systolic function in postoperative tetralogy of Fallot (TOF) patients. In this study, we evaluated the role of RV-global longitudinal strain (GLS) for the assessment of RV systolic function. Materials and Methods: It was a single institution prospective observational study of ninety postoperative TOF patients. Detailed 2-dimensional echocardiography along with RV-GLS using speckle tracing imaging was done at baseline and after 1 year. The children were divided into three groups based on duration since total correction, i.e., group A (6 months to 5 years), group B (6–10 years), and group C (>10 years) to assess the differences in RV systolic function. Furthermore, correlation of RV-GLS with RV-fractional area change (FAC), tricuspid annular plane systolic excursion, and tricuspid valve tissue Doppler imaging s' velocity was done. Results: In group A patients, a statistically significant increase in RV systolic function was seen over a period of 1 year. However, in group B and C patients, no significant change was seen. There was a strong positive correlation of RV-GLS only with RV-FAC during the first follow-up (r = 0.41, P < 0.01) and second follow-up periods (r = 0.67, P < 0.01). Conclusion: RV-GLS has a strong positive correlation with RV-FAC, and it detects preclinical regional myocardial dysfunction even when the RV-FAC is normal and thus must be included in the evaluation of postoperative TOF children.
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Echocardiographic Evaluation of Right Ventricular Function in Patients Presenting with Acute ST-Elevation Myocardial Infarction p. 108
Rajeev Kumar Gupta, Ram Gopal Singh Shahi, Rajneesh Kumar Calton
Background: To evaluate the effect of different infarction sites on the right ventricular (RV) function by echocardiography in patients presenting with acute ST-elevation myocardial infarction (STEMI) and to correlate it with in-hospital morbidity and mortality. Materials and Methods: The present study was a descriptive cross-sectional study conducted in a tertiary care hospital involving 55 patients of anterior wall myocardial infarction (AWMI), 25 patients of inferior wall myocardial infarction (IWMI), and 20 patients of IWMI + RVMI. Among them, 55% of patients were males with a M: F ratio of 1.22:1. M-mode, two-dimensional, and Doppler echocardiographic evaluation of both RV and left ventricular (LV) function (tricuspid annular plane systolic excursion/RV fractional area change/right ventricular index of myocardial performance and LV ejection fraction [LVEF]) were done in all patients within 48 h of admission along with the assessment of arrhythmias, heart failure (HF), cardiogenic shock (CS), and complete heart block (CHB). All the four echocardiographic parameters were deranged in 30 (54.5%) patients of AWMI and 14 (70%) patients of IWMI with RVMI. However, derangement in at least one echocardiographic parameter of RV dysfunction was observed in 50 (90.9%) patients of AWMI, 11 (44%) patients of IWMI, and 20 (100%) patients of IWMI+RVMI, respectively. LVEF was significantly reduced in patients with AWMI (40.4 ± 11.2%) as compared to patients with IWMI and IWMI+RVMI, respectively (46.4 ± 10.3% and 46.5 ± 7.6%). Cardiovascular complications (ventricular tachycardia, ventricular fibrillation, atrial fibrillation, CS, and HF) were more in the AWMI patients with RV dysfunction. HF was specifically more in the patients of AWMI (81.8%) than IWMI (28%) and IWMI+RVMI (20%). CHB was frequently seen in IWMI (20%) and IWMI+RVMI (20%) patients. Conclusion: RV dysfunction is not only common in RVMI but also in AWMI and IWMI, and complications of STEMI are also more frequently seen in patients with RV dysfunction.
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Diverse Radiologic Presentations of Common Pathology: Role of Cardiac Magnetic Resonance in the Workup of Intracardiac Thrombi and Mimics- A Pictorial Review p. 116
Amol Anil Kulkarni, Rajeshkannan Ramiah, Priya Darshan Chudgar, Nitin J Burkule
Thrombus represents the most common cardiac mass compared to primary or secondary cardiac tumors. It has variable size, shape, location, and imaging features. Differentiating the cardiac mass as a tumor, thrombus, or vegetation is clinically important due to their different therapeutic implications and prognostic outcomes. Thrombi carry an inherent risk of systemic and pulmonary embolism and warrant appropriate anticoagulation. For over two decades, echocardiography (transthoracic as well as transesophageal) has been the gold standard investigation to detect intracardiac thrombi. However, recent advances in cardiac magnetic resonance imaging allow higher sensitivity and specificity in the detection of thrombi and the assessment of the age of the thrombi by characterization of their contents. The objective of this review is to demonstrate different imaging presentations of cardiac thrombi and how imaging can help differentiate it from other mimics.
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A Rare Case of the Right Atrial Diverticulum Encroaching the Left Ventricle p. 129
Usha Mandikal Kodandarama, Arnab Ghosh Chaudhury, Prabhavathi Bhat, Manjunath Cholenahally Nanjappa
Single diverticulum of the right atrium is a rare congenital malformation. We describe echocardiographic and computed tomography scan findings of a congenital right atrial diverticulum and its successful surgical resection in a 5-year-old boy. A review of available literature is also done discussing the possible etiology and management of this disease entity.
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The Utility of Three-Dimensional Echocardiography in the Assessment of Pulmonary Valve Function in a Novel “Hand-Made” Pulmonary Valve Conduit p. 132
Mani Ram Krishna, Vijayakumar Raju
The right ventricle to pulmonary artery valved conduit is a key component of surgeries to rehabilitate the right ventricular outflow tract in children with congenital heart disease. Evaluation of the conduit valve function forms a key part of follow-up evaluation of these children. We report the utility of three-dimensional transthoracic echocardiography to evaluate the conduit valve function in these children.
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Multimodality Imaging Clues for Restrictive Cardiomyopathy p. 134
Srilakshmi M Adhyapak, Grace A Thomas, Anuraag Gupta, Jabraan U Shaikh, Tivlin Jose, Harshith Kramadhari, Kiron Varghese
Restrictive cardiomyopathy is an entity that can be mistaken for several mimicking conditions, including hypertrophic cardiomyopathy. These patients present with heart failure, which is essentially due to left ventricular diastolic dysfunction, with preserved left ventricular ejection fraction. Conditions associated with hypereosinophilia and diastolic dysfunction with restrictive heart disease are called Loeffler's syndrome. There is also associated left ventricular thrombus formation and fibrosis. Here, we present a case of restrictive cardiomyopathy associated with rheumatoid arthritis presenting clinically with heart failure. The clues pointing toward hypereosinophilic endocarditis were a high absolute eosinophil count and a large left ventricular thrombus. We discuss the multimodality imaging findings to differentiate the different types of restrictive cardiomyopathy.
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Intracardiac Thrombus in Community-Acquired Klebsiella pneumonia – An Unprecedented Complication p. 138
Ashish Kumar, Rohit Tandon, Bishav Mohan, Narender Pal Jain
Left ventricular thrombi commonly occur in the presence of left ventricular systolic dysfunction. Their occurrence in the presence of preserved left ventricular systolic function is extremely rare. Here we present a case of a diabetic lady with community acquired Klebsiella pneumonia who also had large intraventricular thrombi which were managed conservatively.
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Multimodal Imaging of an Atherosclerotic Splenic Artery Aneurysm Enables Endovascular Treatment of a Potentially Lethal Entity p. 142
Kothandam Sivakumar, Sandeep Mohanty
Splenic artery aneurysms (SAAs) are the third most frequent site of intraabdominal aneurysm and the most frequent splanchnic artery aneurysm. Surgery may be morbid and may include splenectomy and distal pancreatectomy. True aneurysm needs differentiation from a pseudoaneurysm caused by pancreatic enzymatic destruction. A giant SAA was diagnosed in an elderly atherosclerotic male with chronic calcific pancreatitis. Layered thrombus on multimodal imaging ruled out enzyme action and excluded possibility of a pseudoaneurysm. The distal splenic artery beyond the aneurysm was collateralized by left gastric artery. The aneurysm was closed with multiple coils and a vascular plug. Imaging after 6 months confirmed complete closure. Endovascular closure of SAA needs strategies to avoid an endoleak from the distal splenic artery. Pseudoaneurysm of splenic artery should be excluded, as they do not respond to the same strategies applied for true atherosclerotic aneurysms.
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A Rare Case of Giant Unruptured Sinus of Valsalva Aneurysm p. 146
Biswaranjan Mishra, Harsha Pattnaik
Sinus of Valsalva aneurysm is a rare congenital disorder that usually presents with rupture of the aneurysm into adjacent cardiac structures. It usually arises from the right sinus of Valsalva which ruptures into the right ventricle or right atrium (RA). Aneurysms may also arise from the noncoronary cusp that rupture into RA. Rarely, an unruptured aneurysm may compress or dissect into the adjacent structures and produce obstruction to either left or right ventricular outflow or produce conduction blocks. It may also intrude upon valves affecting valvular function. Here is a case of an unruptured giant aneurysm arising from the right sinus of Valsalva burrowing into the interventricular septum (IVS) causing conduction defect in the form of left bundle branch block with first degree atrioventricular block. Through IVS, it protruded into the left ventricular (LV) outflow tract (LVOT) giving rise to a cystic appearance causing mild LVOT obstruction and mild-to-moderate aortic regurgitation. The aneurysm also affected mitral valve function causing severe mitral regurgitation (MR) including characteristic diastolic MR due to prolonged PR interval. There was no regional wall motion abnormality indicating the absence of coronary arterial obstruction by the aneurysm. Left atrial and LV dilatation was present along with LV systolic dysfunction. Pulmonary arterial systolic pressure was approximately 48 mmHg as calculated from tricuspid regurgitation (TR) gradient. Like MR, TR also showed diastolic TR.
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Clinical Presentation of Acute Ruptured Sinus of Valsalva Aneurysm as a Mimic of Acute Coronary Syndrome p. 151
Gaurav Jain, Kothandam Sivakumar, Zeeshan Ahmed Mumtaz
Acute ruptured sinus of Valsalva aneurysm may present with chest pain and rapidly worsening dyspnea. A 41-year-old male without known atherosclerotic risk factors presented with ST-segment elevation in leads aVR and V1 on electrocardiogram and elevated cardiac troponins and was diagnosed as acute coronary syndrome. After antiplatelet loading, statin, and heparin, he was referred due to worsening hypotension and tachycardia. Clinical examination and echocardiogram was challenging in the acutely dyspneic restless patient. Transesophageal echocardiography delineated the ruptured aneurysm and assisted in its management. Importance of physical examination and echocardiography in the emergency room is highlighted as manifestations may be varied.
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Interarterial Pseudoaneurysm: A Potential Nightmare p. 155
Shantanu Singhal, Chandrakant Bhagwat Chavan, Ravi Kalra
Femoral artery pseudoaneurysm (FAP) is one of the most troublesome complications related to femoral artery access site after cardiovascular catheterization procedures and occurs in 0.8%–2.2% of the cases of cardiovascular interventional procedures. Management is by ultrasound-guided compression repair (UGCR). A 75-year-old male presented with anterior wall ST-elevation myocardial infarction and after percutaneous transluminal coronary angioplasty, developed FAP. This pseudoaneurysm had an interarterial communication between superficial femoral artery and deep femoral artery. It is unusual to have communication of pseudoaneurysm with two branches of femoral artery. Diagnosis was made using vascular sonography and Doppler study. Closure of this aneurysm was done by simple pressure with Doppler probe at both the narrow ends of the aneurysm. Arterial color Doppler is the mainstay for diagnosing FAPs. This case describes an interarterial pseudoaneurysm which is a rare entity to witness and the different modalities for its management, the most common one being UGCR.
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Interesting Arrhythmogenic Right Ventricular Cardiomyopathy: A Diagnosis beyond Criteria? p. 158
Srilakshmi M Adhyapak, Anuraag Gupta, Jabraan U Shaikh, Harshith Kramadhari, Kiron Varghese
A normotensive, euglycemic 24-year-old male presented with presyncope. There was no history of similar episodes or loss of consciousness. No similar family history was noted. General clinical and cardiovascular examination was unremarkable. Electrocardiogram done showed wide complex tachycardia with a left bundle branch block morphology suggestive of ventricular tachycardia. The tachycardia spontaneously reverted to normal sinus rhythm. The patient subsequently had sinus bradycardia with a heart rate of 58/min and demonstrated an epsilon wave in the inferior and right-sided chest leads. His cardiac magnetic resonance imaging showed a dilated right atrium and ventricle with no fibrofatty infiltration. This patient did not fulfil the criteria for arrhythmogenic right ventricular cardiomyopathy (ARVC) according to the 2020 criteria. He qualified for suspected ARVC. However, according to the Heart Rhythm Society guidelines of 2019, he qualified as ARVC as he met two major criteria. We report this case as we feel that the criteria for diagnosis of ARVC may not warrant strict adherence. A strong clinical suspicion is required in addition for diagnosis.
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Small Ventricular Septal Defect Presenting in an Adult as Quadruple Valve Infective Endocarditis Highly accessed article p. 162
Vikas Kataria, Pritam Kitey, Abhishek Gupta, Vipul Malpani, Mohan Nair
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