The vital role the ductus arteriosus plays in the fetal diagnosis of congenital heart disease: Evaluation by fetal echocardiography in combination with an innovative cardiovascular cast technology.

BACKGROUND: The ductus arteriosus (DA) is one of the most important vessels of the fetal circulation. A variety of fetal congenital heart disease (CHD) may greatly influence the structure and flow patterns of the DA. This study was to investigate the structural characteristics of the DA and its value in the diagnosis of fetal CHD using fetal echocardiography combined with cardiovascular casting technology. METHODS: Twenty-six cases of a normal fetus and 20 cases of a fetus with CHD (10 cases of right-sided obstructive CHD and 10 cases of left-sided obstructive CHD) were enrolled in this study. The three-vessel view and the long axis view of the DA arch were chosen to observe the fetal DA. The diameters of the ascending aorta (AO) and the pulmonary artery trunk (PA) were measured on the left ventricular outflow tract view and the three-vessel view separately, and AO/DA and PA/DA values were calculated separately. The flow direction of the DA was recorded, and the blood flow peak velocity was measured using color and spectral Doppler technology. Cardiovascular cast specimens were made for fetuses secured from induced labor to facilitate further observations of the true form and connections of the DA. At the same time, heart and great vessel deformities were also recorded through careful observation of the cardiovascular cast. RESULTS: The following DA anomalies were observed: ① abnormal diameter (6 cases of stenosis and 9 cases of dilatation); ② abnormal blood flow direction (reverse flow in 5 cases); ③ abnormal blood flow speed (12 cases); ④ abnormal connection site (right-sided DA in 2 cases and a DA connection between the left pulmonary artery and the left subclavian artery in one case); and ⑤ absence of the DA in 2 cases. Compared with the control group, the DA diameter in the right-sided obstructive group was obviously narrowed; by contrast, the diameter of the DA in the left-sided obstructive group was obviously dilated. These differences were statistically significant (p<0.05). Compared with the control group, the AO/DA values in the right- and left-sided obstructive groups were significantly increased and decreased, respectively. Finally, relative to the control group, the PA/DA values of the right- and left-sided obstructive groups were significantly reduced. CONCLUSIONS: DA enlargement was often associated with left-sided obstructive CHD, whereas a small DA and reverse blood flow often indicated the presence of right-sided obstructive CHD. DA connections can manifest with multiple anatomical variations. During fetal echocardiography, evaluation of the DA is very important; such analyses may help search for associated cardiac defects whenever a diagnosis of CHD is made.

The diagnostic value of transthoracic echocardiography for eosinophilic myocarditis: A single center experience from China.

The aim of this study is to explore the value of transthoracic echocardiography in the diagnosis of eosinophilic myocarditis. The echocardiographic characteristics of nine patients with eosinophilic myocarditis in our hospital between January 2004 and January 2012 were retrospectively reviewed. In our study, four of the nine patients were diagnosed to have small pericardial effusion. The obliteration of the apical cavity was observed in five of the nine patients. There were six patients with both mitral and tricuspid regurgitation, one patient with only mitral regurgitation, and one patient with only tricuspid regurgitation. Transthoracic echocardiography showed that the diameters of the left and right atria were both increased in eight of the nine patients. The diameter of the left ventricle was increased in five patients, and the right ventricular diameter was increased in four patients. The left ventricular ejection fraction was decreased in two of the nine patients. Five of the nine patients had pulmonary hypertension, and one patient had severe pulmonary hypertension. Transthoracic echocardiography is the primary method for the diagnosis of eosinophilic myocarditis and is also useful in follow-up of the disease.

Diagnostic Value of Transthoracic Echocardiography in Patients with Coarctation of Aorta: The Chinese Experience in 53 Patients Studied between 2008 and 2012 in One Major Medical Center.

Although aortography is well known as the "gold standard" for the diagnosis of coarctation of aorta (CoA), the method is invasive, expensive and not readily accepted by some patients. Ultrasound diagnosis for CoA is non-invasive, inexpensive, readily accepted by every patient, and can be repeated as frequently as necessary. The purpose of this presentation is to evaluate the applicability of transthoracic echocardiography for the diagnosis of CoA. The echocardiographic appearances of 53 patients with CoA who had undergone surgery during a 5-year period from January 2008 to October 2012 were analyzed retrospectively, and the results were compared with findings at surgery. Fifty-three patients with CoA include six with isolated CoA and 47 of CoA associated with other cardiac anomalies. Of the 53 operated patients, 48 were correctly diagnosed preoperatively by echocardiography, while two were misdiagnosed as interrupted aortic arch and the diagnosis were missed in three other patients. Thus the diagnostic accuracy rate was 90.6%, and the misdiagnosis rate was 9.4%. Preoperative echocardiographic evaluation offers very satisfactory anatomic assessment in most patients with CoA. It makes preoperative angiography unnecessary. Thus transthoracic echocardiography should be the first-line method for the diagnosis of coarctation of the aorta.

The value of transthoracic echocardiography in the diagnosis of anomalous origin of the right pulmonary artery from the ascending aorta: A single center experience from China.

BACKGROUND: Anomalous origin of pulmonary artery (AOPA) from the ascending aorta is a rare but serious congenital cardiac malformation, which frequently involves the right pulmonary artery (RPA). METHODS: We retrospectively analyzed the echocardiographic characteristics of 9 cases with anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) studied from 2007 to 2014 in our institution. The results were compared with the findings at surgery. RESULTS: The corrective surgery was performed in all 9 cases with AORPA. The diagnosis by transthoracic echocardiography (TTE) of 8 cases with AORPA was confirmed at surgery. The coincidence rate for TTE and surgical findings was 88.9%. One case was misdiagnosed as anomalous origin of the left pulmonary artery from the ascending aorta. The anomalous RPA in all cases had a proximal origin from the posterior or lateral part of the ascending aorta in our series. The mean distance from the aortic valve to the site of origin of pulmonary artery was 16.1 ± 6.6 mm (range: 7.0 mm-24.0 mm). The mean diameter of the anomalous pulmonary artery was 9.6 ± 4.5 mm (range: 4.5 mm-17.0 mm). In 4 of 9 (44.5%) cases there were associated aortopulmonary septal defect, intact ventricular septum, patent ductus arteriosus and interruption of aortic arch (Type A), also known as the Berry's syndrome. Other associated cardiovascular abnormalities included patent ductus arteriosus, ventricular septal defect and atrial septal defect. Severe pulmonary arterial hypertension was noted in all cases. CONCLUSIONS: TTE plays an important role in the non-invasive and accurate diagnosis of AORPA. TTE can clearly display its site of origin and course, as well as other associated malformations and hemodynamic changes. TTE also plays an important role in the preoperative diagnosis of AORPA.

WITHDRAWN: Hypertrophic cardiomyopathy: Genotype-positive, phenotype-"almost" negative. Diagnostic role of exercise in provocation of left ventricular outflow tract gradient.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.ijcard.2014.09.137. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

The effect of right ventricular myocardial remodeling on ventricular function as assessed by two-dimensional speckle tracking echocardiography in patients with tetralogy of Fallot: a single center experience from China.

BACKGROUND: Published correlations between histological abnormalities and right ventricular (RV) function, as evaluated by speckle tracking echocardiography (STE), are scarce in patients with tetralogy of Fallot (TOF). The purpose of the study is to assess age-associated differences in the effect of RV myocardial remodeling on ventricular function in patients with TOF. METHODS: Operatively resected crista supraventricularis muscle from 30 patients (median age 12months) undergoing intracardiac repair of TOF were studied by light microscopy. The patients were divided into younger (age at surgery ≤12months) and older (age at surgery >12months) subgroups. The RV global longitudinal peak systolic strain (GLS), strain rate (GLSRs) and early diastolic strain rate (GLSRe) were measured by two-dimensional STE before and 6months after repair. RESULTS: The histopathological data revealed hypertrophy of the cardiomyocytes, a thickened endocardium, and increased interstitial and perivascular collagen in RV, which were associated with older age at the time of repair. The RV global systolic and diastolic functions in patients with repaired TOF were increased compared with the preoperative values. The RV cardiomyocyte diameter and collagen volume fraction (CVF) correlated with the preoperative GLS, GLSRs and GLSRe, respectively, in the younger patients (r1=-0.566, P1=0.018; r2=-0.493, P2=0.004; r3=-0.504, P3=0.039). The RV cardiomyocyte diameter and CVF correlated with preoperative GLS, GLSRs and GLSRe, respectively, in the older patients (r1=-737, P1=0.004; r2=-0.588, P2=0.035; r3=-0.812, P3=0.001). The correlation of the RV cardiomyocyte diameter with the postoperative GLS and GLSRe (r1=-665, P1=0.036; r2=-0.787, P2=0.007) and the CVF with the postoperative GLSRs and GLSRe (r1=-762, P1=0.002; r2=-0.713, P2=0.004) were identified only in the older patients. Multivariate analysis indicated that the age at repair was an independent predictor of postoperative GLSRs and GLSRe in all of the patients (ß=-0.449, P=0.041; ß=-0.607, P=0.004). CONCLUSIONS: The effect of RV myocardial remodeling on preoperative RV function was more pronounced in the older patients with TOF than in the younger ones. Preoperative myocardial remodeling affected the postoperative RV function in the older but not in the younger patients. The age at the time of surgical repair was the independent determinant of the postoperative RV myocardial function.

Hypertrophic cardiomyopathy: genotype-positive, phenotype-"almost" negative. Diagnostic role of exercise in provocation of left ventricular outflow tract gradient.

It has been proposed to use exercise stress echocardiography in the upright position with left ventricular outflow tract gradient monitoring both during and after exercise as a marker of genotype-positive/phenotype negative hypertrophic cardiomyopathy (HCM). Doppler measurement of gradient has been a very helpful and diagnostic examination in several subgroups of subjects (especially in young persons, athletes). Recently, many noninvasive (bio)markers have been found to be very helpful in screening patients suspected of HCM before full expression of phenotype.

Coronary artery fistula: comparison of diagnostic accuracy by echocardiography versus coronary arteriography and surgery in 63 patients studied between 2002 and 2012 in a single medical center in China.

BACKGROUND: Coronary artery fistula (CAF) is a rare congenital anomaly, which is conventionally diagnosed by coronary arteriography; however, the relation of the coronary artery fistulas to other structures, their origin and course may not be always apparent. METHODS: The echocardiograms of 63 patients with coronary artery fistulas, who had undergone coronary arteriography and/or surgery from June 2002 to December 2012 at the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, were analyzed retrospectively, and the results were compared with findings by coronary arteriography and at surgery. RESULTS: Right CAFs were detected in 33 of the 63 patients (52.4%); 11 had drainage to the right atrium, 10 to the right ventricle, 2 to the left ventricle, 9 to the main pulmonary artery, and 1 to the coronary sinus. Left CAFs were detected in 29 patients (46.0%); 6 had drainage to the right atrium, 12 to the right ventricle, 1 to the left atrium, 2 to the left ventricle, 7 to the main pulmonary artery, and 1 to the coronary sinus. One patient (1.6%) had the origin of the fistula in both coronary arteries. The entry point of the fistula was most often a single orifice (96.8%) and rarely multi-orificial (3.2%). 57 patients (90.5%) had isolated coronary fistulas (90.5%); 6 patients (9.5%) had other congenital cardiac malformations. The ultrasonic diagnosis of 60 patients was in line with findings at surgery and/or coronary arteriography. The diagnostic accuracy rate for coronary artery fistula was 95.2%. Preoperative transthoracic echocardiography missed the diagnosis of coronary artery fistula in three patients (4.8%). There is no difference (P>0.05) in diagnostic accuracy between echocardiography and coronary arteriography and/or surgery. CONCLUSIONS: Transthoracic echocardiography, in comparison with coronary arteriography and/or surgery, is much simpler, easier, less expensive, safer, readily repeatable, and more convenient with equal accuracy, and should be the first-line method for the diagnosis of congenital coronary artery fistula.

Need for a standardized protocol for stress echocardiography in provoking subaortic and valvular gradient in various cardiac conditions.

(Semi) supine exercise testing has an established role in the evaluation of patients with valvular heart disease and can help clinical decision making. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. However, exercise-induced changes in valve hemodynamics, left ventricular outflow obstruction and pulmonary artery pressure depended on load variation. Changing position from supine to upright rapidly decreases load conditions for the ventricles. Therefore several cardiac centers have proposed exercise stress echocardiography in the upright position with gradient monitoring sometimes also in post-exercise recovery. Doppler measurement of subaortic gradient has been a very helpful and informative examination in several heart diseases (especially in hypertrophic cardiomyopathy, valve heart diseases, prosthesis dysfunction).