Echocardiography & Cardiovascular Imaging

Effect of General Endotracheal Anesthesia and Mechanical Ventilation on the Echocardiographic Measurements in Severe Aortic Stenosis Muralidhar Kanchi, Rudresh Manjunath, Pooja Natarajan, Kumar Belani Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):227-231 Introduction: We measured the peak pressure gradient (pPG) and mean pressure gradient (mPG) obtained by transesophageal echocardiography (TEE) after induction of anesthesia and compared it with the preoperative pPG and mPG by transthoracic echocardiography (TTE) in adults with aortic stenosis (AS). We also compared the aortic valve area (AVA) measurements as obtained preoperatively by TTE versus those by TEE following induction of general endotracheal anesthesia (GETA) during the inspiratory phase, expiratory phase of the ventilatory cycle and with incremental increases in tidal volume. Materials and Methods: All patients had preoperative TTE within 1 month of surgery and was reviewed 1 day before the surgery. After anesthetic induction, precardiopulmonary bypass (CPB) TEE evaluation was done to measure mPG and pPG across AV, under steady-state conditions. Three different controlled tidal volumes: 8 ml, 10 ml, and 12 ml per kg body weight were utilized during the TEE measurements. Results: A total of 90 adults underwent aortic valve replacement from 2017 to 2018. The preoperative pPG and mPG across the AV by TTE was 96.7 ± 23.27 mmHg and 60.7 ± 18.1 mmHg, respectively. Compared to preoperative TTE, pre-CPB TEE pressure gradient during both phases of ventilation under GETA was significantly lower. The pPG and mPG were higher during inspiration as compared to those in the expiratory cycle during mechanical ventilation under GETA (pPG during inspiration = 66.63 ± 22.15 mmHg; mPG during inspiration = 38.24 ± 13.65 mmHg; pPG during expiration = 52.49 ± 19.10 mmHg; mPG during expiration = 30.76 ± 12.66 mmHg). There were no significant changes in AVA between TTE/TEE and inspiration/expiration. Conclusions: The findings of this study demonstrate that the TEE pre-CPB PGs underestimated the severity of AS; hence, the severity of AS must be interpreted with caution during GETA and mechanical ventilation (MV). In addition, PGs must be done at similar points in the respiratory cycle.

Impact of Mitral Valve Replacement on the Right Ventricle Function in Mitral Stenosis N Swaminathan, Venkatesan S Sangareddi, G Ravishankar, Justin Paul, L Alen Binny Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):232-236 Background: In patients with mitral stenosis (MS), right ventricular (RV) function may be altered due to an increase in the left atrial pressure and/or changes in pulmonary arteriolar vasculature or may be affected by rheumatic process directly. Aims: In this study we have evaluated the recovery of RV function upto 3 months in patients undergoing mitral valve replacement (MVR) using two dimensional and tissue Doppler echocardiographic indices (TDI). Materials and Methods: A total of 30 patients who were advised MVR were enrolled prospectively. All patients underwent MVR successfully. RV function was assessed using conventional and TDI pre-operatively, 1 week, and 3 months after surgery. Results: New York Heart Association (NYHA) functional class improved significantly at the end of one week. Mean transmitral gradient reduced postoperatively. Tricuspid regurgitation severity reduced significantly. Significant RV reverse remodelling was noted at the end of 3 months. Global RV function parameters fractional area change and RV Tei index improved significantly at the end of 3 months. In patients with mild to moderate pulmonary hypertension (PH), global RV function improved significantly, RV remodelling was seen. In patients with severe PH, both global and longitudinal functions did not improve at the end of 3 months follow up, though RV remodelling was noticed. Conclusion: In patients with severe rheumatic MS whenever per-cutaneous trans-mitral commissurotomy is not feasible, MVR promotes RV remodelling and improvement in RV function along with significant improvement in NYHA functional status. But this improvement in RV function was noted only in patients with mild to moderate PH rather than in patients with severe PH.

Left Atrial ReModeling in Disease: Association with Clinical Markers Joel Quadros Piedade, Srilakshmi M Adhyapak, Pradyumna Muralidharan, John Michel Raj, Fabio Fantini, Kiron Varghese Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):237-242 Background: The role of left atrial (LA) enlargement has a significant and independent association with moderate and severe diastolic dysfunction, atrial fibrillation, and left ventricular (LV) end-diastolic volume. Clinical features of heart failure have shown a correlation with LV dilatation and LV ejection fraction (LV). Aims: Correlation of clinical features with substrates of cardiac remodeling, especially left atrial (LA) remodeling, has not been well-documented. We sought to determine the major clinical factors that are associated with LA enlargement in subjects with heart failure. Materials and Methods: We studied 200 patients who presented with breathlessness due to underlying cardiac disease. The association of clinical features of cardiac disease with LA remodeling was studied using three-dimensional echocardiography. Results: This was a cross-sectional study conducted between January 2016 and January 2017. We found that clinical features of heart failure such as breathlessness, elevated jugular venous pressure, dilated LV, diastolic dysfunction, severe mitral regurgitation, pulmonary hypertension, and abnormal tricuspid annular plane systolic excursion were significantly associated with LA enlargement. LA volume was significantly and independently associated with moderate and severe diastolic dysfunction, atrial fibrillation, lower hemoglobin levels, and LV diastolic size on echocardiography. The sensitivity and specificity of breathlessness with LA enlargement were not significant. Conclusions: Clinical features of heart failure, namely breathlessness, were significantly associated with LA enlargement. LA enlargement was not a sensitive or specific marker of breathlessness in heart failure.

Echo in Congenital Heart Disease Munesh Tomar Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):243-243

Sequential Segmental Approach to Congenital Heart Disease Samir Shakya, Palleti Rajashekar, Saurabh Kumar Gupta Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):244-252 The sequential segmental approach is essential for better understanding of cardiac anatomy in normal and malformed hearts. It is based on a detailed analysis of the three main cardiac segments, namely atria, ventricles, and great vessels, and the two connecting segments, namely atrioventricular and ventriculoarterial connections. Each segment is systematically defined based purely on its morphological characteristics. In most cases, echocardiography is sufficient, but some cases necessitate the use of other imaging modalities. Systematic identification of different segments, connections, and their abnormalities helps in making an accurate diagnosis of congenital heart disease (CHD). This review provides a brief description of the sequential segmental approach for detecting CHD on echocardiography.

Echocardiographic Evaluation of Atrial Septal Defect Sushil Azad Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):253-259 Atrial septal defect accounts for 8-10% of all congenital heart defects. Echocardiography is method of choice for assessment of patient with a known or suspected atrial septal defect. A Thorough knowledge and understanding of all echocardiographic view is essential for complete assessment of atrial septal defect , associated physiological status and assessment of neighbouring intracardiac structures. Complete evaluation is crucial for planning the modality of treatment whether it is suitable for catheter intervention or needs surgical intervention.

Ventricular Septal Defect: Echocardiography Evaluation Ravi Ranjan Tripathi Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):260-266 Ventricular septal defects (VSDs) are among the most common congenital heart defects. These defects may be isolated, associated with other defects, or occur as an intrinsic component of some complex heart defects. There is wide variation in size and location of VSD. Echocardiography plays an important role in evaluation of anatomy, hemodynamic significance, and planning of management of VSDs. With the emerging trends in transcatheter closure of VSD, echocardiography plays a crucial role in decision-making and intra- and postprocedure evaluation. A stepwise approach of echocardiography is necessary for accurate evaluation and management of VSDs.

Assessment of Atrioventricular Septal Defect on Echocardiography Munesh Tomar Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):267-275 Atrioventricular septal defect comprise of 1.4-2.9% of congenital cardiac defect and is most common congenital cardiac defect in Trisomy 21. This anomaly is characterized by a common atrioventricular junction coexisting with atrial and/or ventricular septal defect , cleft of left atrioventriocular valve along with left ventricular outflow tract abnormality. Due to cleft of left atrioventricular valve ,valve regurgitation is almost invariably present leading to early onset of congestive cardiac failure in these patients. Other associated structural heart defects are pulmonary stenosis,ductal arteriosus,aortic arch anomalies,pulmonary and systemic venous anomalies and unbalaned atrioventricular valve connection leading to univentricular physiology. Echocardiography plays very crucial role in defning the anomaly and planning management In this article, I am going to focus on role of echocardiography in atrioventricular septal defect.

Echocardiography to Evaluate Pulmonary Stenosis Smita Mishra, Praneet Lele Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):276-286 Congenital pulmonary stenosis (PS) is a common term for lesions causing right ventricular outflow obstruction. It can be further classified as the valvar, supravalvar, and infundibular PS. The PS may often present with other congenital heart diseases. In this article, echo imaging of isolated PS has been discussed. It is imperative to know that the guideline for intervention in isolated PS is totally based on echocardiography. Echocardiographic guidance is required for the selection of procedure, hardwares, evaluation of the outcome of the procedure, and long-term prognosis.

Left Ventricular Outflow Tract Anomalies: Echocardiographic Evaluation Tanuja Karande Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging 2020 4(3):287-294 The left ventricular outflow is divided into subvalvar area, the aortic valve and supra valvar region. There can occur a number of anomalies in the outflow tract, most commonly of which are obstructive lesions, which can exist in isolation or as a part of association with other defects such as ventricular septal defects or interrupted arch. The following chapter highlights on echocardiography imaging of the left ventricular outflow tract and its anomalies.

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