Unlocking insights in bicuspid aortic valve management in adult patients: the vital role of cardiac imaging.

The bicuspid aortic valve (BAV) presents a multifaceted clinical challenge due to its diverse morphologies and associated complications. This review aims to elucidate the critical role of cardiac imaging in guiding optimal management strategies for BAV patients. BAV, with a prevalence of 1-2%, has genetic underpinnings linked to the NOTCH1 gene mutation. Variability in BAV morphology necessitates tailored surgical approaches. The three primary types of BAV morphology - right-left cusp fusion, right-noncoronary cusp fusion, and left-noncoronary cusp fusion - demand nuanced considerations due to their distinct implications. Valvular dysfunction results in aortic stenosis or regurgitation, attributed to altered valve structure and turbulent hemodynamics. Cardiac imaging modalities, including echocardiography, magnetic resonance imaging, and computerized tomography, are instrumental in assessing valve function, aortic dimensions, and associated complications. Imaging helps predict potential complications, enabling informed treatment decisions. Regular follow-up is crucial to detecting alterations early and intervening promptly. Surgical management options encompass aortic valve repair or replacement, with patient-specific factors guiding the choice. Post-surgical surveillance plays a vital role in preventing complications and optimizing patient outcomes. The review underscores the significance of advanced cardiac imaging techniques in understanding BAV's complexities, facilitating personalized management strategies, and improving patient care. By harnessing the power of multimodal imaging, clinicians can tailor interventions, monitor disease progression, and ultimately enhance the prognosis and quality of life for individuals with BAV.

A native mitral valve mass beyond imagination.

The authors report a case of a patient with a history of IgA nephropathy that, during the admission for pneumonia, was found to have an incidental finding of a huge mitral valve (MV) mass on transthoracic echocardiography. The differential diagnosis was challenging because the clinical scenario raised the suspicion of possible infective endocarditis and the imaging features were suggestive of a myxoma or vegetation. The patient underwent urgent excision of the mass with MV replacement due to the high risk of embolism. Intraoperative findings were consistent with clot or vegetation. Pathology result of thrombus was beyond our imagination and at the best of our knowledge one case only has been reported. Awareness about native MV thrombosis and its etiologic factors, workup, and management is key for better medical and surgical management planning because this condition is extremely rare and challenging in the clinical and imaging arena.

Imaging in transcatheter native mitral valve replacement with Tendyne mitral valve system: echocardiographic pathway for the interventional imager.

The interaction between the implanter team and the imager team is critical to the success of transcatheter native mitral valve replacement (TMVR), a novel interventional procedure in the therapeutic arsenal for mitral regurgitation. This imaging scenario necessitates the addition of a new dedicated professional figure, dubbed "the interventional imager," with specific expertise in structural heart disease procedures. As its clinical application grows, knowledge of the various imaging modalities used in the TMVR procedure is required for the interventional imager and beneficial for the interventional implanter team. The purpose of this review is to describe the key steps of the procedural imaging pathway in TMVR using the Tendyne mitral valve system, with an emphasis on echocardiography. Pre-procedure cardiac multi-modality imaging screening and planning for TMVR can determine patient eligibility based on anatomic features and measurements, provide measurements for appropriate valve sizing, plan/simulate the access site, catheter/sheath trajectory, and pros- thesis positioning/orientation for correct deployment and predict the risks of potential procedural complications and their likelihood of success. Step-by-step echocardiographic TMVR intraoperative guidance includes: apical access assessment; support for catheter/sheath localization, trajectory and positioning, valve positioning and clocking; post deployment: correct clocking; hemodynamic assessment; detection of perivalvular leakage; obstruction of the left ventricular outlet tract; complications. Knowledge of the multimodality imaging pathway is essential for interventional imagers and critical to the procedure's success.

Percutaneous Coronary Intervention Vs Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Disease: G-LM Registry.

Coronary artery bypass surgery (CABG) has been the standard of care for revascularization for patients with obstructive unprotected left main coronary disease (ULMCA). There have been multiple randomized and registry data demonstrating the technical and clinical efficacy of PCI in certain patients with ULMCA. The purpose of this study is to evaluate clinical outcomes of ULMCA PCI as compared to CABG in patients requiring revascularization in three Gulf countries. All ULMCA cases treated by PCI with DES versus CABG were retrospectively identified from 14 centers in 3 Arab Gulf countries (KSA, UAE, and Bahrain) from January 2015 to December 2019. In total, 2138 patients were included: 1222 were treated with PCI versus 916 with CABG. Patients undergoing PCI were older, and had higher comorbidities and mean European System for Cardiac Operative Risk Evaluation (EuroSCORE). Aborted cardiac arrest and cardiogenic shock were reported more in the PCI group at hospital presentation. In addition, lower ejection fractions were reported in the PCI group. In hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) occurred more in patients undergoing CABG than PCI. At median follow-up of 15 months (interquartile range, 30), no difference was observed in freedom from revascularization, MACCE, or total mortality between those treated with PCI and CABG. While findings are similar to Western data registries, continued follow-up will be needed to ascertain whether this pattern continues into latter years.

Transcatheter mitral valve-in-valve implantation for failed bioprosthesis.

OBJECTIVE: This study is a report of clinical and echocardiographic outcomes of experience with transapical mitral valve-in-valve (VIV) replacement. METHODS: Eleven patients with a mean age of 63.7±13.0 years who underwent transapical mitral VIV implantation for a failed bioprosthesis at a single institution were enrolled. All of the patients were considered high-risk for surgical intervention, with a Society of Thoracic Surgery predicted risk of mortality of 14.2±17.6%, and a mean European System for Cardiac Operative Risk Evaluation (EuroSCORE II) of 10.5±6.1%. RESULTS: Transapical mitral VIV implantation was successful in all of the patients. Edwards, Sapien XT and Sapien 3 valves (Edwards Lifesciences Corp., Irvine, CA, USA) were used in 8 (73%), 2 (18%), and 1 (9%) patients, respectively. Size 26 valves were used in 6 (55%) patients while size 29 valves were used in 5 (45%) patients. All of the patients (11, 100%) had no or only trace mitral regurgitation at the end of the procedure. The mean length of hospital stay was 19±8.0 days. The survival was 100% at 14 days, and 90% at 30 days and at 4 years. One patient died as a result of multiorgan failure on day 16 of intensive care unit stay. The mean mitral valve gradient across the percutaneous valve was 2.26±1.047 mmHg, and the mean valve area was 2.20±0.14 cm2. Through the 4 years follow up, the New York Heart Association class of the 10 patients remaining improved to class II with no readmission for heart failure. All of the patients were on coumadin with a target international normalized ratio of 2-3. CONCLUSION: In high-risk patients, transapical mitral VIV implantation can be performed with a high success rate and considerable improvement in clinical status.

Door-to-balloon time in the treatment of ST segment elevation myocardial infarction in a tertiary care center in Saudi Arabia.

BACKGROUND: Atherosclerotic heart disease is still a leading cause of mortality despite improvements in cardiovascular care. Percutaneous coronary intervention (PCI) is the recommended reperfusion therapy in acute ST-elevation myocardial infarction (STEMI), and the international guideline is to achieve a door-to-balloon (D2B) time within 90 minutes of patient arrival to an emergency department (ED). OBJECTIVES: Describe interventions, data for the study period, challenges in ensuring 24/7 patient access to PCI and quality indicators. DESIGN: Retrospective observational study. SETTING: Tertiary care institution in Riyadh, Saudi Arabia. PATIENTS AND METHODS: We included all acute coronary syndrome patients from 2010-2018 who presented or were transferred to our ED from nearby non-PCI capable hospitals, and for whom a 'code heart' was activated. Electronic medical records and the patient care report from the ambulance services were accessed for data collection. MAIN OUTCOME MEASURES: D2B time, readmission and mortality rate. SAMPLE SIZE AND CHARACTERISTICS: 354 patients, mean age (standard deviation) 55.6 (12.6) years, males 84.5% (n=299). RESULTS: STEMI patients constituted 94% (n=334) of the study group; the others had non-STEMI or unstable angina. Hypertension (51%) was the most prevalent risk factor. Coronary artery stenting was the most frequent intervention (77.4%) followed by medical therapy (14.7%). The most common culprit artery was the left anterior descending (52.5%) followed by the right coronary artery (26.0%). A D2B time of within 90 minutes was achieved in over 85% of the patients in four of the years in the 278 patients who underwent PCI. The median D2B time (interquar-tile range) over 2010-2018 was 79 (31) minutes. CONCLUSION: Meeting the international benchmark of D2B time within 90 minutes for STEMI patients is achievable when the main stakeholders collaborate in patient-centric care. Our patient demographics represent regional trends. LIMITATIONS: Patient acceptance to our institution is based upon eligibility criteria. Transfer of 'code heart' patients from other institutions was carried out by our ambulance team. The credentials and experience of cardiologists, emergency physicians, and ambulance services are not standardized across the country. Therefore, the results may not be generalizable to other institutions. CONFLICT OF INTEREST: None.

Outcomes of Routine Coronary Angiography in Asymptomatic Patients With End-Stage Renal Disease Prior to Kidney Transplantation.

We report the prevalence of coronary artery disease (CAD) in asymptomatic patients with end-stage kidney disease (ESKD) on hemodialysis and explore the best revascularization strategies prior to kidney transplantation. This is a retrospective single-center study, which included all patients who were candidates for kidney transplantation and underwent coronary angiography between 2003 and 2018. All included patients underwent coronary angiography without noninvasive testing and were asymptomatic cardiac-wise. Out of the 368 patients with ESRD, 45% had coronary vessel disease, 17% had 3-vessel disease, 11% had 2-vessel disease, 5.2% had significant left main artery narrowing, and 17% had single-vessel disease. Patients with 3-vessel disease had the worst survival rate at 5 and 10 years. The patients with significant 3-vessel disease or left main artery involvement underwent revascularization; 19% underwent coronary artery bypass grafting, 5% had stenting of the coronary arteries, and 4.7% were on maximal medical therapy. The patients who underwent stenting had a better survival than those on medical therapy, but the difference was not significant (P = .445). Our findings reflect a high prevalence of CAD in patients with ESKD. There is a need for further studies to evaluate benefits of cardiovascular screening in this patient population.

Three dimensional transesophageal echocardiography: a missing link in infective endocarditis imaging?

The role of two dimensional (2D) echocardiography (ECHO) for the diagnosis and clinical decision making in infective endocarditis (IE) has been extensively studied and described in the medical literature. Some reports have demonstrated the incremental value of three dimensional (3D) transesophageal (TE) ECHO in the setting of IE. However, a systematic review focusing on the role of 3D imaging is lacking. In this manuscript, we examine the role of 3D TE ECHO in the diagnosis of IE. IE is a challenging disease in which 2D transthoracic (TT) and TE ECHO have complementary roles and are unequivocally the mainstay of diagnostic imaging. Still, 2D imaging has important limitations. Technological advances in 3D imaging allow for the reconstruction of real-time anatomical images of cardiac structure and function. 3D imaging has emerged as a diagnostic technique that overcame some of the limitations of 2D ECHO. Currently, both transthoracic and transesophageal echocardiography transducers are able to generate 3D images. However, 3D TE ECHO provides images of a higher quality in comparison to 3D TT ECHO, and is the best echocardiographic modality able to allow for a detailed anatomical imaging. 3D TE ECHO may represent the key adjunctive echocardiographic technique being able to positively impact on IE-related surgical planning and intervention and to facilitate the interaction between the surgeon and the imaging specialist. Importantly, 3D TE ECHO is not the recommended initial modality of choice for the diagnosis of IE; however, in highly specialized centers, it has become an important complementary technique when advanced surgical planning is required. Furthermore, anatomical imaging has become the link between the different techniques that play a role in IE imaging. In fact, both computed tomography and magnetic resonance allow three dimensional reconstruction. An important future goal should allow for the fusion among various imaging modalities. Our review highlights the role of 3D TE ECHO in IE imaging and emphasize where it offers incremental value.

Three-Dimensional Echocardiographic Imaging of a Gerbode Defect Complicating Transcatheter Aortic Valve Replacement.

We describe a case of a 77-year-old male who underwent transcatheter aortic valve implantation (TAVR) with Edwards SAPIEN XT size 26 mm for severe aortic stenosis. Postprocedural transesophageal echocardiography (TEE) showed left-to-right shunt between the left ventricular outflow tract just below the bioprosthesis and the right atrium across the atrioventricular septum (Gerbode defect). Three-dimensional echocardiography (3DE) allowed a detailed anatomical imaging of the shape and the location of a small, circular, atrioventricular defect that was a type II, direct, supravalvular, Gerbode-type defect. This is the third report of a Gerbode defect after TAVR whose diagnosis has important implications on clinical decision-making. TEE plays a key role; its diagnostic ability is enriched by the additional value of 3DE.

High prevalence of coronary artery calcification in Saudi patients with normal myocardial perfusion.

BACKGROUND: Normal single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has a high negative predictive value for ischemic heart disease. Thus, the presence of subclinical coronary atherosclerosis detected by coronary artery calcification (CAC) score in patients who have under-gone SPECT MPI is unknown. OBJECTIVES: Determine the prevalence of coronary artery calcification (CAC) in patients with normal SPECT MPI and examine the association of CAC with conventional coronary artery disease (CAD) risk factors. DESIGN: Cross-sectional analytical study using medical records from February 2010 to April 2016. SETTINGS: Single tertiary-care center. PATIENTS AND METHODS: We studied patients referred from the outpatient clinical services for clinically indicated noninvasive CAD diagnosis with MPI SPECT. CAC scoring was subsequently performed within 3 months after a normal MPI. We excluded patients with chest pain or decompensated heart failure or patients with a history of CAD. The study population was divided into three groups: patients with a CAC score of 0, a CAC score from 1 to 300, and a CAC score more than 300. The groups were analyzed by age and other demographic and clinical characteristics. MAIN OUTCOME MEASURE(S): Prevalence of CAC in patients with normal MPI. RESULTS: The prevalence of CAC was 55% (n=114) in 207 patients with a mean (SD) age of 57.1 (10.4) years. Twelve percent had severe coronary atherosclerosis (CAC score > 300). All patients had a normal MPI SPECT. CAC scores were 0 for 93 patients (45%), 1 to 300 for 89 (43%), and more than 300 for 24 (12%). There was a strong association between CAC score and age (P < .0001), male sex (P < .0001), and diabetes mellitus (P=.042), but no association between CAC score and hypertension (P=.153), family history of CAD (P=.23), obesity (P=.31), hypercholesterolemia (P=.071), or smoking (P=.308). CONCLUSIONS: The prevalence of CAC is high in this study population of patients with normal SPECT MPI. Age, male sex and diabetes were risk factors associated with CAC. LIMITATIONS: Single center and small study population.

Management of immediate partial bioresorbable vascular scaffold stent thrombosis.

Bioresorbable vascular scaffold (BVS) stents have been proposed recently as an elegant technique for treatment of coronary artery disease. However, perspective that these "dissolvable" stents will replace conventional metallic stents in broad spectrum of clinical conditions and patient categories in the near future has been moderated by non-negligible incidence of stent thrombosis (ST). Mechanical factors, such as strut thickness and malapposition have been implicated in increased risk of BVS ST. Presently described is case of immediate partial BVS ST in a young male related to technical procedural problem, rather than mechanical problem. Glycoprotein IIb/IIIa inhibitors associated with anticoagulation resulted in complete resolution of thrombus and facilitated successful patient outcome.

Non-Cardiovascular Computed Tomography Incidental Findings in Patients Who Underwent Transaortic Valve Implantation Procedure.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a new treatment option for patients with severe aortic stenosis. Pre-TAVI procedure workup includes computed tomography angiography (CTA) of the heart and aorta from aortic annulus to the iliofemoral arteries. Frequently, there are a number of incidental non-cardiac findings (INCFs) in pre-TAVI CTA. However, the frequency and clinical significance of these INCFs are unknown. The aim of our study was to investigate the prevalence of INCFs and their clinical significance. METHODS: This was a retrospective review of 67 patients who underwent dedicated pre-TAVI CTA from 2010 till 2015. Non-cardiovascular INCFs were classified according to their clinical significance into three categories. The first category includes findings that may require urgent treatment. The second category includes findings that need further follow-up. The third category includes incidental findings that require no further follow-up or recommendation. RESULTS: The total number of patients was 67, and the mean age was 73 ± 8 years. All patients had INCFs and the total number was 248. Of the patients, 69% had chest findings, 85% had abdominal findings, and 33% had musculoskeletal findings. Results based on categorical classification were as follows: 9%, 25%, and 66% of these 248 findings belong to the first category, the second category, and the third category, respectively. CONCLUSION: Non-cardiovascular INCFs are common in pre-TAVI CTA presumably due to increased age of such specific population. These findings have variable clinical significance and some of them might require acute treatment or additional evaluation, and should be managed properly taking into consideration patient's life expectancy and comorbidities.

Thrombolytic Therapy as the Management of Mitral Transcatheter Valve-in-Valve Implantation Early Thrombosis.

A 70-year-old male underwent mitral transcatheter valve-in-valve implantation for a failed bioprosthesis implanted 11 years earlier. In the first days following the procedure, he developed thrombosis of the new bioprosthesis with restricted cusp motion. The transmitral mean gradient increased significantly despite effective anticoagulation therapy using unfractionated heparin infusion. Low dose and slow infusion of alteplase resulted in resolution of the thrombus and normalisation of cusp motion. Thereafter long-term anticoagulation using a vitamin K antagonist was instituted and the patient remained asymptomatic.

Coronary artery calcium score in high-risk asymptomatic women in Saudi Arabia.

BACKGROUND AND OBJECTIVE: Coronary artery calcification (CAC) is indicated by calcium deposits in the coronary artery wall. Calcification is a component of atherosclerosis and coronary artery disease. Currently, there are no data on calcification in Saudi women at high risk of coronary artery disease. The aim of this study was to investigate the prevalence and percentiles of CAC score in high-risk asymptotic women in Saudi Arabia with comparison of age-specific CAC percentiles derived from large population-based published study in the United States. DESIGN AND SETTING: Retrospective analysis of CAC scores (CACS) at a single tertiary care center. METHODS: Between January 2011 and April 2015, women referred for CAC screening because of the presence of one or more CAD risk factors were enrolled in the study. CT scans were interpreted by an experienced radiographic technologist, and confirmed by a radiologist. RESULTS: The study sample consisted of 918 women, mean (SD) age of 55 (11) years. All patients were asymp.tomatic and referred by their primary care physician or cardiologist for CAC screening because presence of one or more CAD risks factors. CAD risk factors included diabetes, hypertension, hypercholesterolemia, family history of CAD, and obesity. Baseline CAD risk factors were remarkably higher than in the US comparator group. CACS for 25th, 50th, 75th, and 90th percentiles were calculated. The 75th and 90th CACS percentiles in Saudi women were significantly higher than the US percentiles. Age and diabetes are the most independent predictor of severity of CAC. LIMITATIONS: A potential bias due to sample collection because data was from a single tertiary care center, the study was retrospective and the sample size was small. CONCLUSION: There are significantly higher CACS percentiles in Saudi women compared with international data. Application of available published percentiles to a local population is not applicable and underestimates the severity of subclinical atherosclerosis. A large local population-based study is warranted to establish local CACS percentiles for a better understanding CAD screening, diagnosis, and treatment.

A patient with recent chest discomfort-ischemia or no ischemia? Postsystolic shortening comes to the rescue.

The diagnosis of myocardial ischemia in the emergency department can be challenging particularly in a patient in whom the chest discomfort has abated. Symptoms can be atypical, physical exam is often noncontributory, the electrocardiogram is usually nondiagnostic and cardiac enzymes remain normal. Thus, the decision for hospital admission or discharge can be quite difficult. Here, we describe such a patient in whom echocardiography with strain imaging identified the presence of postsystolic shortening (PSS) at the left ventricular apex. This suggested the likelihood of ischemic memory in the territory of the left anterior descending (LAD) artery. At coronary angiography a high grade stenosis was present in the proximal LAD artery. Our report highlights the role of echocardiography in the detection of myocardial ischemia and apical PSS as a marker of ischemic memory.

Immediate and intermediate results of intracoronary stand-alone bolus administration of eptifibatide during coronary intervention (ICE) study.

BACKGROUND: This study evaluated the immediate and intermediate results of intracoronary (i.c.) eptifibatide administration during percutaneous coronary intervention (PCI). Several studies tested intravenous (i.v.) bolus and continuous administration of eptifibatide during PCI. However, limited data are available regarding giving eptifibatide as i.c. bolus alone during PCI. METHODS: We studied clinical outcomes of 376 patients who received coronary stent(s) and eptifibatide by 3 applications during PCI and were followed up over 24 months. Group A (119 patients) had i.c. eptifibatide bolus only, group B (119 patients) had i.c. bolus and i.v. infusion, and group C (138 patients) had i.v. bolus and infusion. The standard 2 boluses of eptifibatide 180 microg/kg were given either via i.c. or i.v. route, and only groups B and C received i.v. infusion at 2 microcg x kg(-1) x min(-1) for 18 to 24 hours. RESULTS: There were 256 males and 120 females, with a mean age of 57 +/- 11 years. Among them, 52% were diabetic. The 6-, 12-, and 24-month cumulative composite end point of death and myocardial infraction was lower in group A (2.5%) compared with group C (10.8%, odds ratio [OR] 4.3, P = .029) and group B (5.8%, OR 2.6, P = .17). Compared with group A, target vessel revascularization was 3-fold in group C (OR 3.3, P = .001) and 2-fold in group B (OR 2.0, P = .061). Bleeding was significantly higher in group C (OR 5.4, P < .0001) and group B (OR 3.4, P = .007) compared with group A. Rehospitalization was significantly lower in group A (10.9%) compared with group B (16.8%) and group C (28%) (P = .0009). CONCLUSION: The i.c.-bolus-alone application of eptifibatide may be safer and superior to the i.v. route, and continuous infusion may not be necessary. Large-scale prospective randomized trials are needed to further validate these findings.

Long-term results (up to 16.5 years) of mitral balloon valvuloplasty in a series of 518 patients and predictors of long-term outcome.

OBJECTIVES: To assess the long-term results (up to 16.5 years) of mitral balloon valvuloplasty (MBV) and to identify predictors of restenosis and event-free survival. METHODS AND RESULTS: We report the immediate and long-term clinical and echocardiographic results in 518 patients, mean age 31 +/- 11 years, who underwent successful MBV for severe mitral stenosis (MS) and were followed up for 0.5-16.5 (mean 6 +/- 4.5) years. After MBV, mitral valve area (MVA) increased from 0.84 +/- 0.2 to 1.83 +/- 0.53 cm(2) (P < 0.0001) as measured by catheter and from 0.92 +/- 0.17 to 1.96 +/- 0.29 cm(2) (P < 0.0001) as measured by two-dimensional echo. Restenosis occurred in 111 patients (21%) and it was less frequent in patients with low echo score (11%). Actuarial freedom from restenosis at 5, 10, 15 years was 85 +/- 1%, 70 +/- 3%, and 44 +/- 5%, respectively, and was significantly higher in patients with low echo score. Event-free survival (death, redo MBV, mitral valve replacement, New York Heart Association [NYHA] functional class III or IV) at 5, 10, 15 years was 89 +/- 1%, 79 +/- 2%, 43 +/- 9%, respectively, and was significantly higher for patients with low echo score. Cox regression analysis identified mitral echocardiographic score (MES) > 8 (P < 0.0001), postprocedure mitral valve area (MVA) (P = 0.0015), and preprocedure functional class (P = 0.014) as predictors of restenosis and MES (P < 0.0001) and age (P < 0.0001) and postprocedure MVA (P = 0.015) as predictors of event-free survival. CONCLUSIONS: MBV provides excellent long-term results for selected patients with MS. The long-term outcome after this procedure can be predicted from baseline clinical and echocardiographic characteristics.