Spectrum of ascending aortic aneurysms at a peri-urban tertiary hospital: an echocardiography-based study.

Introduction: Thoracic ascending aortic (TAA) aneurysms are an important cause of disability and death and require early detection for effective management. Currently, there is a paucity of data from Africa pertaining to TAA aneurysms. This study describes the spectrum of TAA aneurysms at a peri-urban tertiary hospital. Methods: A descriptive retrospective study based on clinical and echocardiographic imaging data of patients with TAA aneurysms from October 2017-October 2022. Advanced strain imaging was performed to measure left ventricular (LV) basal, apical, and global longitudinal strain as well as circumferential strain (CS) of the ascending aorta as a proxy measurement of aortic compliance. Results: The study comprised 139 cases of TAA aneurysms (52.5% females) with a mean age of 50 ± 14.8 years with 45 age and gender matched controls. Most cases (95%) were of African ethnicity. The main etiologies were hypertension (41.7%), HIV (36.6%), connective tissue disease (10.7%), congenital (2.2%) and mixed pathologies (8.6%). Two-thirds of patients (69.7%) presented in heart failure, 10% presented with aortic dissection. Thirty percent of the patients were classified as New York Heart Association (NYHA) class I, 59.7% NYHA II, 8.6% NYHA III and two patients NYHA class IV. Echocardiography revealed enlarged aortic dimensions compared to controls (P < 0.001). TAA aneurysms were complicated by severe aortic regurgitation (AR) in half (50.3%) of patients, moderate AR in 25.8%, and mild AR in 14.3%. The mean LV ejection fraction (46.9 ± 12.7%) was reduced compared to controls (P < 0.001). Aortic CS was reduced compared to controls [4.4 (3.2-6.2) % vs. 9.0 (7.1-13.4) %, P < 0.001]. Aortic stiffness was higher in the aortic aneurysm group compared to controls (15.39 ± 20.65 vs. 5.04 ± 2.09, P = 0.001). LV longitudinal strain (-13.9 ± 3.9% vs. 18.1 ± 6.7%), basal CS (-13.9 ± 5.6% vs. -17.9 ± 5.8%) and apical CS (-8.7 ± 8.5% vs. -30.6 ± 3.8%) were reduced compared to controls (P < 0.001). Most patients were on diuretic and anti-remodeling therapy. Surgery was performed in 29.4% and overall mortality was 7.9%. Mortality for acute aortic dissection was 40%. Conclusion: TAA aneurysms associated with hypertension and HIV are common in this predominantly African female population and are associated with considerable morbidity and mortality. Two-dimensional echocardiography and advanced strain imaging are potential tools for detecting and risk stratifying TAA aneurysms.

Right atrial strain in a normal adult African population according to age.

BACKGROUND: Right atrial longitudinal strain (RALS) is a useful parameter to define right atrial (RA) subclinical dysfunction prior to changes in RA dimension and volume. We sought to establish normal values for RALS in a sub-Saharan African population. METHODS: This was a retrospective, cross-sectional study from 2017 to 2019 of 100 normal individuals. All echocardiographic measurements were done as per the standard guidelines. RESULTS: Mean RALS was 32.7 ± 10.5%. The mean RA volume indexed to body surface area was 19.5 ± 5.7 ml/m2. There was a negative correlation between RALS and age but it was not statistically significant (r = -0.15, p = 0.129). Males had a tendency towards higher RA volume indexed and RALS measurements compared to females (20.8 ± 6.3 and 18.7 ± 5.2 ml/m2, p = 0.07; 34.6 ± 9.6 and 31.4 ± 10.9%, p = 0.141, respectively). Body mass index was an independent predictor of RALS (r = -0.43, p = 0.003). CONCLUSION: We have provided normative data for RALS in an African population. This study provides a platform for future larger studies on RALS.

A cross-sectional study of the spectrum, aetiology and clinical characteristics of adult mitral valve disease at Chris Hani Baragwanath Academic Hospital.

BACKGROUND: Valvular heart disease constitutes a considerable amount of cardiovascular morbidity and mortality worldwide. There is a scarcity of data from Africa. METHODS: In this descriptive, cross-sectional study, we documented the demographic, clinical and echocardiographic features of current patients with adult mitral valve disease (MVD) at Chris Hani Baragwanath Academic Hospital from December 2018 to March 2019. RESULTS: The study included 134 patients (mean age 50 ± 13.3 years) and 77% were female. The majority were of African ethnicity (96%). Mitral regurgitation (39%), followed by mixed MVD (38%) were the dominant lesions. Mitral stenosis was found in 23% of the patients. The main aetiologies were rheumatic heart disease (80%), mitral valve prolapse (11%), myxomatous degeneration (6%) and infective endocarditis (3%). Hypertension (30%) and HIV (12%) were the main co-morbidities. Heart failure was present in 78% of the patients at index hospitalisation. The main complications were pulmonary hypertension (28%) and atrial fibrillation (14%). CONCLUSION: The patients with MVD tended to be older African females with co-morbidities who had predominant rheumatic mitral regurgitation.

Non-typhoid Salmonella endocarditis complicated by cardiac failure and acute limb ischaemia in a person living with HIV and hepatitis C: A case report and literature review.

Salmonella infections are responsible for a large burden of disease worldwide. Non-typhoidal Salmonella (NTS) species cause a myriad of disease manifestations, particularly amongst severely immunocompromised individuals. We present a rare case of endocarditis caused by the NTS species Salmonella Enteritidis in an individual living with HIV and hepatitis C. In this case, endocarditis was complicated by embolization and acute arterial occlusion of the left arm, as well as mitral valve perforation resulting in cardiac failure. A review of the available literature shows few cases of NTS causing endocarditis in people living with HIV, with the earliest reported case in 1983. Our case demonstrates the potential complications of NTS endocarditis and highlights the importance of evaluating patients with NTS-associated blood stream infection for cardiovascular involvement. Prompt surgical intervention in addition to appropriate antimicrobial therapy is essential to reduce the high morbidity and mortality associated with NTS endocarditis.

Two-dimensional echocardiographic and strain values of the proximal thoracic aorta in a normal sub-Saharan African population.

BACKGROUND: There is limited data regarding reference ranges for aortic dimensions in African populations. This study aims to establish normal reference ranges for echocardiographic dimensions and circumferential strain (CS) of the proximal thoracic aorta in a healthy sub-Saharan African population. METHODS: This was a secondary analysis of data from a prospective cross-sectional study of 88 participants conducted at Chris Hani Baragwanath Hospital (2017-2019). Aortic measurements were obtained as per the 2015 American Society of Echocardiography guidelines using a Philips iE33 system. Circumferential Strain was measured using Philips QLAB version 11.0 software offline semi-automated analysis of speckle-based strain 2-D speckle-tracking software (Amsterdam, The Netherlands). RESULTS: Mean age was 37.22 ± 10.79 years (41% male). The mean diameter at the aortic annulus, sinuses, sino-tubular junction (STJ) and ascending aorta (AAO) were 19.11 ± 2.38 mm, 27.40 ± 6.11 mm, 25.32 ± 3.52 mm and 25.36 ± 3.38 mm, respectively. Males had larger absolute and indexed aortic diameters at all levels when compared to females. The mean aorta CS was 11.97 ± 5.05%. There was no significant difference in CS based on gender (12.19 ± 5.04% vs 11.51 ± 5.02%, P = 0.267). On multivariate linear regression analysis, male sex was the most significant predictor of increased diameter at the level of the aortic annulus (r = 0.17, P = 0.014), body surface area was the most significant predictor at the sinuses (r = 0.17, P = 0.014) and AAO (r = 0.30, P < 0.001), while age was the most significant predictor at the STJ (r = 0.27, P = 0.004). There was a negative correlation between age and aortic CS (r = - 0.12, P < 0.001). The most important predictor of aorta CS was age, on multivariate analysis (r = - 0.19, P = 0.024). CONCLUSIONS: This study provides normal reference ranges for dimensions of the proximal aorta and circumferential strain (CS) in a sub-Saharan African population according to age, sex, and body habitus. It serves as a platform for future larger studies and allows for risk stratification of cardiovascular disease in an African population.

An unusually large left ventricular thrombus complicating anterior myocardial infarction: the value of multimodality imaging.

Since the emergence of revascularisation for the treatment of myocardial infarction (MI), the incidence of left ventricular thrombus (LVT) has been declining. However, despite this, it is independently associated with increased morbidity and mortality rates. The mainstay of treatment is vitamin K antagonists, although non-vitamin K antagonists have been shown to be effective. Imaging plays an important role in the surveillance of LVT subsequent to MI. Herein, we emphasise the utility of multimodality imaging of a case of anterior MI complicated by a large LVT, and detail its management.

Evaluation of aortic wall strength in human immunodeficiency virus associated thoracic ascending aortic aneurysm: a pilot study.

Background: Human immunodeficiency virus (HIV) associated aortopathy is associated with considerable morbidity and mortality. The pathophysiology of aortic wall strength in HIV thoracic aortic aneurysm has not been studied. Methods: The patients with HIV associated thoracic ascending aortic aneurysm (TAAA) were enrolled in the study and underwent surgery as part of their routine management. We compared collagen quantity in aneurysmal and non-aneurysmal aortic tissue in TAAA with regards to hydroxyproline concentration as a surrogate measure for collagen content and sent aneurysmal aorta for routine clinical histological assessment. This data was analysed to identify potential relations between aortic aneurysm formation and the collagen content of the aortic wall. Results: The study included 12 patients with HIV aortopathy (9 females, median age 49 years). In total 33 tissue samples were investigated (14 aneurysmal, 13 non-aneurysmal aortic tissue and 6 aortic leaflets). There was no difference in hydroxyproline concentration of aneurysmal aortic tissue and seemingly normal tissue [19.40 (15.19-22.98) vs. 20.85 (15.55-25.83) µg/mg; P=0.82]. No difference was noted in hydroxyproline concentration among aneurysmal, seemingly normal aortic tissue and aortic valve leaflets [19.40 (15.19-22.98) vs. 20.85 (15.55-25.83) vs. 19.09 (13.94-22.00) µg/mg; P=0.86]. Histology showed fragmentation of elastin fibres in 50% of the cases. Conclusions: No difference in collagen concentration in the aneurysmal and non-aneurysmal aortic tissue was noted. However, most of the aneurysmal tissue had fragmentation of elastin fibres.

Assessment of pacemaker lead-related infective endocarditis with three-dimensional echocardiography and cardiac computed tomography.

Pacemaker endocarditis is rare and symptoms may be misleading. If missed, it carries significant morbidity and mortality, particularly in the elderly. Advances in multi-modality imaging in recent years have emphasised its role in clinical decision making. This case highlights the ability of multi-modality imaging techniques to individualise diagnosis, management and prognosis in patients with suspected cardiovascular implantable electronic device (CIED) endocarditis.

Focal myocarditis in a young male with SARS-CoV-2 infection.

A 31-year- old male with no comorbidities presented with chest discomfort and shortness of breath following SARS-CoV-2 infection. Primary viral myocarditis was confirmed with the aid of cardiac biomarkers and cardiac magnetic resonance (CMR) imaging. Herein, we detail his clinical presentation, management and highlight the role of CMR in viral myocarditis.

Electrocardiographic and echocardiographic abnormalities in urban African people living with HIV in South Africa.

BACKGROUND: Studies from high income countries report that HIV-positive people have an impaired systolic and diastolic cardiac function compared to HIV-negative people. It is unclear if results can be translated directly to the Sub-Saharan Africa context. This study assesses electro- and echocardiographic characteristics in an urban African population, comparing HIV-positive people (treated and not yet treated) with HIV-negative controls. METHODS: We conducted a cross-sectional study in Johannesburg, South Africa. We enrolled HIV-positive participants from three randomized controlled trials that had recruited participants from routine HIV testing programs. HIV-negative controls were recruited from the community. Data were collected on demographics, cardiovascular risk factors, medical history and electrocardiographic and echocardiographic characteristics. RESULTS: In total, 394 HIV-positive participants and 153 controls were enrolled. The mean age of HIV-positive participants was 40±9 years (controls: 35±10 years), and 34% were male (controls: 50%). Of HIV-positive participants 36% were overweight or obese (controls: 44%), 23% had hypertension (controls: 28%) and 12% were current smoker (controls: 37%). Median time since HIV diagnosis was 6.0 years (IQR 2.3-10.0) and median treatment duration was 4.0 years (IQR 0.0-8.0), 50% had undetectable viral load. The frequency of anatomical cardiac abnormalities was low and did not differ between people with and without HIV. We observed no relation between HIV or anti-retroviral therapy (ART) and systolic or diastolic heart function. There was an association between ART use and corrected QT interval: +11.8 ms compared to HIV-negative controls (p<0.01) and +18.9 ms compared to ART-naïve participants (p = 0.01). We also observed a higher left ventricular mass index in participants on ART (+7.8 g/m2, p<0.01), but this association disappeared after adjusting for CD4 cell count, viral load and HIV-duration. CONCLUSION: The low number of major cardiac abnormalities in this relatively young, well managed urban African HIV-positive population is reassuring. The increase in corrected QT interval and left ventricular mass may contribute to higher cardiac mortality and morbidity in people living with HIV in the long term.

Demographic, clinical, electrocardiographic and echocardiographic characteristics of patients hospitalized with COVID-19 and cardiac disease at a tertiary hospital, South Africa.

BACKGROUND: Coronavirus associated disease 2019 (COVID-19) is associated with higher morbidity and mortality in patients with cardiovascular disease. There is a paucity of data regarding COVID-19 and cardiac disease from Africa. We aimed to describe the demographic, clinical, electrocardiographic and echocardiographic characteristics of patients with COVID-19 and cardiac disease at a tertiary hospital in South Africa. METHODS: This was a retrospective cross-sectional descriptive study (Aug 2020 to March 2021) of 200 patients with COVID-19 and confirmed cardiac disease, conducted at Chris Hani Baragwanath. Demographic, clinical, electrocardiographic and echocardiographic characteristics were systematically collected. RESULTS: Majority (86%) of patients were Africans with mean age 56.4±15.6 years (57.5% females). Fifty three percent were unemployed and 28% were pensioners. Main comorbidities were hypertension (69.5%), diabetes mellitus (31.5%) and human immunodeficiency virus (HIV) (22.5%). Majority of the patients were overweight or obese (65.5%). All except 8 patients were on chronic medication. Dyspnoea on admission was noted in 88.5% of patients. Seventy nine percent of patients had abnormal chest X-Ray. Frequently documented electrocardiography findings were sinus tachycardia (63%) and atrial fibrillation, noted in 7% of patients. The most common indication for echocardiography was heart failure (30%). Severe left ventricular dysfunction was noted in 21.5%. Features of pulmonary hypertension were present in 45.5%. The right ventricle was enlarged in 59% of patients, and functional tricuspid regurgitation was noted in 54.5%. The most common diagnoses were hypertensive heart disease with preserved ejection fraction (35.8%), cardiomyopathies (20%), cor pulmonale (15.7%), acute coronary syndrome (6.5%), infective endocarditis (5.5%) and valvular heart disease (2.5%). Echocardiography modified management in 53% of cases. An in-hospital mortality of 17.5% was noted. On multivariate logistic regression analysis sinus tachycardia was the most important independent predictor of mortality (odds ratio, OR: 2.52, 95% confidence interval, CI: 1.08-5.85, P=0.03). CONCLUSIONS: Most patients were obese females with underlying hypertension. Echocardiography altered management in about half the patients. Mortality amongst this cohort of patients was high and were predominantly males.

Atrial-ventricular function in rheumatic mitral regurgitation using strain imaging.

BACKGROUND: Chronic mitral regurgitation (MR) historically has been shown to primarily affect left ventricular (LV) function. The impact of increased left atrial (LA) volume in MR on morbidity and mortality has been highlighted recently, yet the LA does not feature as prominently in the current guidelines as the LV. Thus, we aimed to study LA and LV function in chronic rheumatic MR using traditional volumetric parameters and strain imaging. METHODS: Seventy-seven patients with isolated moderate or severe chronic rheumatic MR and 40 controls underwent echocardiographic examination. LV and LA function were assessed with conventional echocardiography and 2D strain imaging. RESULTS: LA stiffness index was greater in chronic rheumatic MR than controls (0.95 ± 1.89 vs 0.16 ± 0.13, P = 0.009). LA dysfunction was noted in the reservoir, conduit, and contractile phases compared with controls (P < 0.05). LA peak reservoir strain (ƐR), LA peak contractile strain, and LV peak systolic strain were decreased in chronic rheumatic MR compared with controls (P < 0.05). Eighty-six percent of patients had decreased LA ƐR and 58% had depressed LV peak systolic strain. Decreased ƐR and normal LV peak systolic strain were noted in 42%. Thirteen percent had normal ƐR and LV peak systolic strain. One patient had normal ƐR with decreased LV peak systolic strain. CONCLUSIONS: In chronic rheumatic MR, there is LA dysfunction in the reservoir, conduit, and contractile phases. In this study, LA dysfunction with or without LV dysfunction was the predominant finding, and thus, LA dysfunction may be an earlier marker of decompensation in chronic rheumatic MR.

A Case of Severe Tricuspid Regurgitation Related to Traumatic Papillary Muscle Rupture.

A 25-year-old male presented after a motor vehicle accident with tricuspid valve (TV) regurgitation, due to a flail TV secondary to papillary muscle rupture. We highlight the importance of three-dimensional echocardiographic imaging of the tricuspid valve and its utility in aiding a successful surgical repair.

Echocardiographic Indices of the Left and Right Heart in a Normal Black African Population.

BACKGROUND: It is unknown whether ethnic differences occur with regard to right heart echocardiographic parameters. The aim of this study therefore was to establish normative values of left and right heart parameters in a black African population and to evaluate the effect of age and body mass index (BMI) on specific right ventricle (RV) parameters. METHODS: Two hundred fifty-three normal subjects were prospectively studied. A standardized echocardiographic examination was conducted with the RV focused view used to derive RV measurements. All left and right heart measurements were made in accordance with the American Society of Echocardiography 2015 chamber guideline recommendations. Right ventricle free wall strain was assessed using an RV focused apical four-chamber view. RESULTS: The average age was 36.3 ± 12.2 years, and 59% of patients were female. The mean left ventricular ejection fraction was 62.3% ± 5.7%. The RV linear measurements (RV base, 31.0 ± 4.5 mm; midcavity, 26.3 ± 5.8 mm) were not associated with sex, age, or BMI except for the RV length (64.6 ± 8.9 mm), which was greater in male patients. Tricuspid annular plane systolic excursion (TAPSE) was 21.7 ± 2.8 mm, fractional area change was 42.1% ± 5.5%, tricuspid annular peak systolic velocity RV S' was 12.1 ± 1.9 m/sec, and RV free wall strain was -31.5% ± 8.6%. Age and BMI were not associated with right atrial (RA) volumetric measurements, RV linear measurements, or any RV functional parameters except TAPSE and RV A', which increased with BMI. CONCLUSIONS: This study establishes normal left and right heart parameters in a black African population. Aging was not associated with RA or RV parameters except for RV E' and A'. BMI does not affect RA/RV measurements but may cause variability in TAPSE and RV A'.

Hydatid disease of the interventricular septum: Echocardiographic and computed tomography findings.

Hydatid disease (HD) is prevalent in South Africa, with cardiac HD being a rare but important manifestation to recognise and diagnose. An incidental finding on computed tomography (CT) of the chest in a patient with pulmonary HD prompted further multimodality imaging, which confirmed the presence of cardiac HD involving the interventricular septum. This case report focuses on imaging findings related to cardiac HD, as demonstrated by the CT of the chest and two- and three-dimensional transoesophageal echocardiography. Multimodality imaging is essential to assist in making a diagnosis and providing a detailed assessment of patients with cardiac HD.

Course of Disease and Clinical Outcome of Infective Endocarditis in HIV-infected Individuals: A Systematic Review and Meta-analysis.

Infective endocarditis (IE) causes substantial morbidity and mortality if untreated. The clinical course of IE might be different in HIV-positive patients as a result of immune dysfunction. This systematic review investigates the clinical course of IE in HIV-positive compared to HIV-negative patients. A systematic search was performed in PubMed, EMBASE, and Cochrane Library and registered in PROSPERO (CRD42016048649). All articles from 1996 and onward addressing the clinical outcome of HIV-positive adults suffering from IE were reviewed and included based on predefined inclusion and exclusion criteria. A meta-analysis was performed for the outcome mortality. Twenty-three articles were included of which eight included HIVpositive patients only, and 15 compared HIV-positive to HIV-negative patients. Two studies included patients on antiretroviral therapy (ART). HIV and intravenous drug use (IVDU) were closely related. Mortality was higher in HIV-positive patients with a CD4 count below 200 cells/µl than in HIV-positive patients with a higher CD4 count, while mortality was similar for HIV-positive compared to HIV-negative patients (risk ratio = 0.86 [95% confidence interval: 0.53-1.40]). No difference was found in length of hospital stay or rehospitalization. Clinical outcomes were strongly related to the right- or left-sided endocarditis. The clinical course of IE is not different for patients with and without HIV. Clinical outcomes were mainly associated with other factors, such as IVDU and side of cardiac involvement, rather than HIV status.

Cross-sectional study of the health of southern African truck drivers.

OBJECTIVES: Lifestyle and working conditions of truck drivers predisposes them to risk-factors associated with communicable and non-communicable diseases, but little is known about the health status of African truck driver. This study aims to assess a cross-section of truckers in South Africa to describe their health information. SETTING: The study took place across three truck-stop rest areas in the South African provinces of Free State and Gauteng. PARTICIPANTS: Eligibility criteria included being males aged 18 years and older, full-time employment as a long-distance truck driver. A total of 614 male truck drivers participated; 384 (63%) were Zimbabwean and 325 (55%) completed high-school. PRIMARY AND SECONDARY OUTCOME MEASURES: The trucker survey explored demographics; working conditions; sexual, eating and sleeping behaviours; mental health status, medical history and cardiac risk-factors. Medical assessments included physical measurements, glucose and lipid measurements, ECG, carotid intima-media thickness (CIMT) and cardiac ultrasound. RESULTS: In the previous month, 554 (91%) participants were sexually active; 522 (86%) had sex with a regular partner; 174 (27%) with a casual partner; 87 (14%) with a sex worker. Average time driving was 10 hours/day, 20 days/month, 302 (50%) never worked night shifts and 74 (12%) worked nights approximately four times per week. 112 (18%) experienced daytime sleepiness and 59 (10%) were ever hospitalised from an accident. Forty-seven (8%, 95% CI 5.3 to 9.5) were HIV-positive, with half taking antiretrovirals. Forty-eight (8%) truckers had some moderate depression, while 21 (4%) suffered from post-traumatic stress disorder. Reported tuberculosis, myocardial infarction, and diabetes were <3%. Prominent cardiac risk-factors included smoking (n=63, 11%), consuming alcohol (>15 drinks/week) (n=54, 9%), overweight/obesity (n=417, 69%), and hypertension (n=220, 36%,95% CI 32.1 to 39.7). ECG results showed 23 (4.9%) and 29 (5.3%) drivers had left ventricular hypertrophy using the Cornell criterion and product, respectively. CIMT measurements indicated nine (4.2%) drivers had a carotid atherosclerotic plaque. CONCLUSION: This first holistic assessment of health among southern African male truck drivers demonstrates substantial addressable cardiovascular risk factors, mental health issues and sexual risk behaviours.

Traumatic aorto-pulmonary artery fistula: a case report.

BACKGROUND: Aorta-pulmonary (A-P) artery fistula following a stab wound to the chest with superimposed infective endocarditis (IE) is a rare, often unrecognized presentation. Herein, we report a case of A-P fistula due to stab chest assessed by two- and three-dimensional (3D) imaging. CASE SUMMARY: A 30-year-old man presented with a history of being stabbed in the chest with a screwdriver. The chest wall laceration was sutured, an intercostal drain inserted for a haemopneumothorax, and he was subsequently discharged. He presented 3 weeks later with exertional dyspnoea, fever, rigours, and loss of weight. On examination, he had a wide pulse pressure and a harsh continuous murmur in the 2nd left intercostal space associated with a palpable thrill. Blood tests revealed raised infective markers and anaemia. All blood cultures were sterile. On echocardiography, the aortic and pulmonary valve was severely damaged, with suspicion of superimposed vegetations secondary to IE. There was severe aortic and pulmonary valve regurgitation. A fistulous connection was noted between the aorta and main pulmonary artery, just below the commissure adjoining the right and left coronary sinus of the aortic valve. On 3D imaging, the defect was quantified. The patient was subsequently referred for aortic and pulmonary valve replacement and closure of the A-P fistula. The presence of multiple vegetations was confirmed intraoperatively. He also received a 6-week course of intravenous antibiotics. DISCUSSION: We have described a rare case of an A-P fistula due to a stab wound to the chest complicated by IE. In a patient with stab wound to the chest, a high index of suspicion of cardiac involvement must be maintained, and a careful search for intracardiac shunts must be made on echocardiography, prior to discharge. Furthermore, in addition to two-dimensional imaging, 3D imaging proved useful in providing a comprehensive assessment of the morphology of the lesion prior to surgery.