Association of ruptured sinus of Valsalva aneurysm and congenital ventricular septal defect: a case series.

BACKGROUND: Ruptured sinus of Valsalva aneurysm (RSOVA) is rare, and it is more common in Asians. Typically, the patient presents with acute/subacute shortness of breath (SOB) and chest pain. Echocardiography is the gold standard for diagnosis in most of these cases. Surgery has remained the first line of management. CASE SUMMARY: We present two cases of RSOVA in which the patients presented to the emergency department with SOB. Their preoperative echocardiography results showed RSOVA into the right ventricle. During surgical repair, ventricular septal defect (VSD) was also found. DISCUSSION: RSOVA is frequently associated with other congenital anomalies, and most often with VSD. In our cases, we believe that VSDs were missed preoperatively because either the large aneurysmal sacs covered the VSD or there was overlap between the two shunts. Additionally, in the first case, right ventricular pressure was high approaching systemic pressure, which probably reduced the shunt across the VSD. Early intervention is recommended to prevent endocarditis or enlargement of the ruptured aneurysm; long-term results were excellent after surgical repair. Most patients undergo surgery between 20 and 40 years of age, and the reported survival rate is 95% at 20 years. If left untreated, patients typically die of heart failure or endocarditis within 1 year after onset of symptoms.

Importance of Systematic Right Ventricular Assessment in Cardiac Resynchronization Therapy Candidates: A Machine Learning Approach.

BACKGROUND: Despite all having systolic heart failure and broad QRS intervals, patients screened for cardiac resynchronization therapy (CRT) are highly heterogeneous, and it remains extremely challenging to predict the impact of CRT devices on left ventricular function and outcomes. The aim of this study was to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular remodeling and prognosis of CRT candidates by the application of machine learning approaches. METHODS: One hundred ninety-three patients with systolic heart failure receiving CRT according to current recommendations were prospectively included in this multicenter study. A combination of the Boruta algorithm and random forest methods was used to identify features predicting both CRT volumetric response and prognosis. Model performance was tested using the area under the receiver operating characteristic curve. The k-medoid method was also applied to identify clusters of phenotypically similar patients. RESULTS: From 28 clinical, electrocardiographic, and echocardiographic variables, 16 features were predictive of CRT response, and 11 features were predictive of prognosis. Among the predictors of CRT response, eight variables (50%) pertained to right ventricular size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with particularly good prediction of both CRT response (area under the curve, 0.81; 95% CI, 0.74-0.87) and outcomes (area under the curve, 0.84; 95% CI, 0.75-0.93). An unsupervised machine learning approach allowed the identification of two phenogroups of patients who differed significantly in clinical variables and parameters of biventricular size and right ventricular function. The two phenogroups had significantly different prognosis (hazard ratio, 4.70; 95% CI, 2.1-10.0; P < .0001; log-rank P < .0001). CONCLUSIONS: Machine learning can reliably identify clinical and echocardiographic features associated with CRT response and prognosis. The evaluation of both right ventricular size and functional parameters has pivotal importance for the risk stratification of CRT candidates and should be systematically performed in patients undergoing CRT.

Ruptured Sinus Of Valsalva Into The Right Ventricle A New Management Strategy.

We present 2 cases presented to the emergency department with shortness of breath (SOB). Their preoperative echocardiographies showed ruptured right sinus of Valsalva (RSOV) into the right ventricle (RV). Ventricular septal defect (VSD) was diagnosed only intraoperatively.

A Teaching Intervention Increases the Performance of Handheld Ultrasound Devices for Assessment of Left Ventricular Ejection Fraction.

BACKGROUND: Few studies have demonstrated the utility of a teaching program for evaluation of left ventricular ejection fraction (LVEF) of echocardiographic images acquired with high-end machines. No study to date explored the value of similar programs when a handheld ultrasound device is used. The aim of this study was to determine whether a teaching intervention could improve the accuracy and the reliability of LVEF visual assessment of echocardiographic images acquired with HUD. MATERIALS AND METHODS: Twenty echocardiograms acquired with a hand-held ultrasound device with a spectrum of LVEF were presented to 26 participants with varying experience in echocardiography (range 2-12 years) for single-point LVEF visual estimates. After this baseline assessment, participants underwent three training sessions which included analysis of the individual baseline results and review and interpretation of additional 60 cases from the same platform. After 2 months, 20 new echocardiograms were presented to the same 26 participants for visual LVEF assessment. For each participant, the visual LVEF for each case was compared with the reference LVEF (quantitative measurements by experts), and a difference of > ±5% was considered a misclassification. RESULTS: The misclassification rate was 61% preintervention and decreased to 41% after intervention (P < 0.0001). The mean absolute differences in LVEF between visual estimates and reference before and after intervention for all readers were -7.9 ± 9.6 and -1.2 ± 7.8, respectively (P < 0.0001). Inter-rater repeatability analysis was performed using the intraclass correlation coefficient. The intraclass correlation coefficient for inter-rater reliability was fair preintervention (0.65, 95% confidence interval [CI] 0.59 0.71) and good after intervention (0.80, 95% CI 0.73 0.87), and there were no differences when categorized according to the level of experience. CONCLUSIONS: A teaching intervention can improve the accuracy and the reliability in the visual LVEF assessment of images acquired with handheld ultrasound device.

Late Complication After Transcatheter Closure of Patent Ductus Arteriosus.

We describe the case of a 32-year-old man with history of patent ductus arteriosus (PDA) closed with an Amplatzer device 12 years earlier. Imaging investigations revealed a persistent large PDA and the device migrated in the right pulmonary artery. A new transcatheter PDA occlusion was attempted with optimal post-procedural results. (Level of Difficulty: Advanced.).

Hypertrophic Cardiomyopathy: Prevalence, Hypertrophy Patterns, and Their Clinical and ECG Findings in a Hospital at Qatar.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is a genetic disease associated with risk of morbidity and sudden cardiac death. The prevalence, hypertrophy patterns, mode of presentations, and different ECG findings vary in different regions of the world. To date, no data is present regarding these variables in Qatar. PATIENTS AND METHODS: A retrospective, cross sectional, descriptive analysis of all patients referred for echocardiography study at Hamad General Hospital, Qatar. The study period was from January 2008 till December 2010. AIMS: To study 1) the prevalence of HCM, 2) the different patterns of hypertrophy, and 3) the clinical and ECG presentations in this population. RESULTS: Out of the 29,286 cases evaluated, 38 patients were found to have HCM (0.13%). Their clinical, ECG, and echocardiography findings were analyzed. Mean age was 47 y, 35 males (92%) and 3 females (8%). Four patterns of hypertrophy were described; 17 (44.7%) had septal hypertrophy alone, 6 (15.8%) had septal and other segments hypertrophy but sparing the apex, 10 (26.3%) had apical segments along with any other segment hypertrophy, and 5 (13.2%) had apical hypertrophy alone. No obstruction was found in 19 (50%), left ventricular outflow (LVO) tract obstruction was found in 13 (34%), and mid cavity obstruction (MCO) in 6 (16%). Twenty one (55.3%) patients were referred because of chest pain, 15 (39.5%) with palpitations, 15 (39.5%) with shortness of breath, and 5 (13.2%) with syncope. Nine patients (23.7%) were asymptomatic and were referred because of cardiac murmur during routine examination. ECG evidence of LV hypertrophy was found in 29 (76.3%). CONCLUSION: The prevalence of HCM in our population group is 0.13% with a male predominance (12:1). There was a diversity of clinical presentation, ECG abnormalities and patterns of LV hypertrophy among HCM patients.