Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography

Background Aortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden. Aim Rheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR. Material and methods 17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005–2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8–24 years) who met modified Jones’ criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR. Results In presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography. Conclusion Systolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.

Low cost calibrated mechanical noisemaker for hearing screening of neonates in resource constrained settings.

Background & objectives: There is a need to develop an affordable and reliable tool for hearing screening of neonates in resource constrained, medically underserved areas of developing nations. This study valuates a strategy of health worker based screening of neonates using a low cost mechanical calibrated noisemaker followed up with parental monitoring of age appropriate auditory milestones for detecting severe-profound hearing impairment in infants by 6 months of age. Methods: A trained health worker under the supervision of a qualified audiologist screened 425 neonates of whom 20 had confirmed severe-profound hearing impairment. Mechanical calibrated noisemakers of 50, 60, 70 and 80 dB (A) were used to elicit the behavioural responses. The parents of screened neonates were instructed to monitor the normal language and auditory milestones till 6 months of age. This strategy was validated against the reference standard consisting of a battery of tests - namely, auditory brain stem response (ABR), otoacoustic emissions (OAE) and behavioural assessment at 2 years of age. Bayesian prevalence weighted measures of screening were calculated. Results: The sensitivity and specificity was high with least false positive referrals for 70 and 80 dB (A) noisemakers. All the noisemakers had 100 per cent negative predictive value. 70 and 80 dB (A) noisemakers had high positive likelihood ratios of 19 and 34, respectively. The probability differences for pre- and post- test positive was 43 and 58 for 70 and 80 dB (A) noisemakers, respectively. Interpretation & conclusions: In a controlled setting, health workers with primary education can be trained to use a mechanical calibrated noisemaker made of locally available material to reliably screen for severe-profound hearing loss in neonates. The monitoring of auditory responses could be done by informed parents. Multi-centre field trials of this strategy need to be carried out to examine the feasibility of community health care workers using it in resource constrained settings of developing nations to implement an effective national neonatal hearing screening programme.

Management of hypertension in heart failure: striking lack of evidence for a common problem.

Arterial hypertension is common either as a concomitant or pathogenetic entity in patients with systolic heart failure and in those with heart failure and normal ejection fraction. In free-living communities, more than half of the patients of heart failure with normal ejection fraction (HFnEF) have hypertension somewhat more than that occurring in presence of systolic heart failure. In acute heart failure, co-existent hypertension is much more frequent. Separate guidelines exist for management of hypertension and systolic heart failure. There are no published guidelines for management of HFnEF. There are contradictory recommendations with regard to drug management of hypertension and systolic heart failure. This review examines the available literature on this common co-existing combination and suggests some new recommendations.

Aneurysmal deformity of the basal interventricular septum secondary to impinging turbulent transprosthetic eccentric flow jets.

Cases of aneurysm of basal muscular interventricular septum are very uncommon. This report describes a rare case of a young man in which aneurysmal deformity was an incidental finding during follow-up after thrombolysis of the obstructed mitral prosthesis.

World Health Assembly recommends exclusive breastfeeding for first six months.

Exclusive breastfeeding means that the infant receives only breast milk (from his or her mother or a wet nurse or expressed breast milk) and no other liquids or complementary foods with the exception of undiluted drops or syrups consisting of vitamin and mineral supplements or medicines. During this period water is not permitted. The resolution (WHA 54.2) urges Member States to support exclusive breastfeeding for first six months as a global public health recommendation and to provide safe and appropriate complementary foods, with continued breastfeeding for up to two years or beyond. Breastfeeding Promotion Network of India (BPNI) has issued guidelines for breastfeeding and complementary feeding.

Tissue Doppler echocardiography: principles and applications.

Tissue velocity imaging is an important development in the field of cardiac ultrasound that provides quantitative information for analysis of myocardial motion independent of the quality of gray-scale 2-D echocardiography data. It holds promise to reduce inter- and intraobserver variability in regional wall motion interpretation and is likely to improve the accuracy and reproducibility of stress echocardiography and myocardial viability assessment. It also enables regional diastolic function assessment independent of the loading conditions and offers a practical clinical tool to differentiate pathologic from physiologic myocardial hypertrophy, restrictive cardiomyopathy from constrictive pericarditis and for monitoring and selecting therapies in patients with advanced heart failure. The use of tissue velocity data for myocardial strain and strain rate imaging is likely to circumvent the limitations of tissue velocity in differentiating active and passive motion of a myocardial segment. However, its incremental utility and exact role in improving the diagnostic yield and clinical outcome needs to be addressed in future studies.

Left ventricle dynamics during pulsus alternans: insights from tissue velocity imaging.

A 34-year-old female patient with idiopathic dilated cardiomyopathy presented with hemodynamic pulsus alternans. Mitral annular tissue Doppler velocities showed reciprocal beat-to-beat alterations during systolic ejection and diastolic filling periods. Tissue velocity waves were unaltered during the isovolumic relaxation and contraction periods.