Correlation of coronary artery calcium score and carotid artery intima-media thickness with severity of coronary artery disease.

Introduction: Coronary artery calcium score (CACS) and carotid artery intima-media thickness (CIMT) are the markers of atherosclerosis. An association between CACS and CIMT with presence of atherosclerotic coronary artery disease (CAD) is well established. However relationship between severity of CAD with CACS and CIMT is less clear. This study aimed to investigate the correlation between severity of CAD assessed by SYNTAX and Gensini scores with CACS and CIMT. Methods: This prospective study was conducted on 351 patients with CAD between June 2015 to December 2016. CACS was obtained using AGATSTON algorithm with 128 slice multidetector computer tomography (MDCT) before conventional coronary angiography (CCA). CIMT was measured by using Philips IE33 Echo machine. The severity of CAD was assessed by SYNTAX score (SS) and Gensini score on CCA. Correlation between severity of CAD with CACS and CIMT was analysed. Results: Mean CACS was 241.5±463.7, and this was positively correlated with over all SS (r=0.417, P <0.0001) and Gensini score (r=0.405, P<0.0001). Mean CIMT was 0.80±0.18 mm and this was also significantly correlated with SS (r=0.450, P<0.0001) and Gensini score (r=0.459,<0.0001). Multivariate analysis showed that CACS was independently associated with diabetes mellitus (ß:0.11, P=0.021), SS (ß:0.251, P =0.010) and mean CIMT (ß:0.128, P =0.028). Receiver-operating characteristic (ROC) curve analysis revealed a cut off CACS of >493 for SS≥33 (high-SS tertile). Conclusion: Our study confirmed a significant correlation between CACS and CIMT with the severity of CAD assessed by SS and Gensini scores. CACS and CIMT may be considered as important noninvasive diagnostic modalities in the assessment of the severity of CAD.

Novel single nucleotide mutations in exon-10 of human coagulation Factor V gene in patients with pulmonary thromboembolism.

Introduction: Acute pulmonary thromboembolism (PTE) presents with wide spectrum and has variable prognosis. Factor V Leiden (FVL) is the most common inherited thrombophilia, with a prevalence of 3%-7% in the general US population, approximately 5% in Whites, 2.2% in Hispanics and 1.2% in Blacks. PTE most commonly originates from venous thrombosis. The occurrence of venous thromboembolism is a culmination of environmental and genetic risk factors. The current study was sought to identify the mutations in exon-10 of FV gene in patients with PTE. Methods: Sixty cases diagnosed with PTE and 50 healthy controls were enrolled in the present study. Mutation studies in exon-10 of Factor V gene included PCR-DNA sequencing method. Results: Of 60 patients, we found two novel transition type point mutations: c.1538 G>A and c.1601 G>A in exon-10 of Factor V which is responsible for the cleavage site for aPC. These point mutations resulted in single amino acid change in protein sequence at p.Arg513Lys and p.Arg534Gln respectively. These mutations prevent efficient inactivation of Factor V and Factor V remains active which facilitates over production of thrombin leading to generation of excess fibrin and excess coagulation which results in deep vein thrombosis and PTE. Conclusion: We report two novel point mutations (c.1538 G>A and c.1601 G>A) in exon-10 of Factor V gene in Indian patients with PTE.

Assessment of immediate effects of percutaneous balloon mitral valvuloplasty on right ventricular and pulmonary functions in severe rheumatic mitral stenosis patients using speckle tracking echocardiography and spirometry.

Introduction: The current study was sought to assess the immediate effect of percutaneous balloonmitral valvuloplasty (PBMV) on right ventricular (RV) and pulmonary functions using speckle tracking echocardiography (STE) and spirometry respectively. Methods: Two-dimensional speckle tracking and doppler studies for strain and strain rate imaging of RV were performed before PBMV, after 48h and 15 days of PBMV using echocardiography and spirometry. Mitral valve area, peak and mean mitral valve transannular pressure gradients, late filling velocities,Wilkins score, Systolic pulmonary artery pressure, TAPSE, RV end-diastolic and end-systolic areas,RV fractional area change and Tei index were measured. Results: There was a significant rise in peak RV global longitudinal strain (GLS) from baseline to48h post PBMV and at 15 days post PBMV. Segmental RV strain at basal septum, mid septum,apical septum and basal RV free wall showed considerable improvement from baseline to 48h post PBMV and 15 days post PBMV. RV longitudinal strain rate parameters did not show significant improvement after PBMV and remained low at follow-up. Post PBMV all patients showed restrictive features on pulmonary function test. The mean FEV1 (% predicted), mean FVC (% predicted), mean PEFR improved from baseline to 48h PBMV and 15 days post PBMV. Though the mean FEV1/FVC increased post PBMV at 15 days follow-up, but it was statistically insignificant. Conclusion: RV performance in MS was decreased mainly due to increase in RV after load which improves after PBMV. Patients with severe MS have impaired pulmonary function which is of restrictive type and successful PBMV improves pulmonary function.

Spontaneous left atrial echo contrast, mitral annular systolic velocity, and left atrial appendage late emptying velocity in predicting improvement of left atrial function after percutaneous balloon mitral valvuloplasty.

BACKGROUND: Thromboembolic events are the major cause of morbidity and mortality in patients with mitral stenosis (MS). This study aims to investigate left atrial spontaneous echo contrast (LA SEC), mitral annular systolic velocity (Sa-wave), left atrial appendage (LAA) late emptying velocity (LAAEV), LAA filling velocity (LAAFV) pre- and postpercutaneous balloon mitral valvuloplasty (PBMV) for MS. This also aims to study the association of LA SEC with inflammatory marker, high-sensitivity C-reactive protein (hs-CRP) in MS. METHODS: The study population consisted of 100 patients with symptomatic MS with sinus rhythm who underwent PBMV. Transthoracic echo (TTE), tissue Doppler imaging (TDI), and transesophageal echo (TEE) examinations were carried out before and 14 days following PBMV. High-sensitivity C-reactive protein (hs-CRP) was measured at the time of admission. RESULTS: The mean age was 33.2 ± 10.3 years with female preponderance (71%). There was a decrease in SEC grading, (pre-PBMV 2.8 ± 0.9 and post-PBMV 0.4 ± 0.1; P < .01), increase in LAAEV (pre-PBMV 23.0 ± 7.9 cm/s and post-PBMV 40.9 ± 8.4 cm/s; P < .01), and LAAFV (pre-PBMV 31.8 ± 9.3 cm/s and post-PBMV 51.2 ± 8.7 cm/s; P < .01).A significant positive correlation was present between LAAEV and Sa-wave (r = .52, P < .01). Correlation between hs-CRP and SEC was positive and significant (r = .33, P < .01). Optimal cutoff value of hs-CRP for prediction of moderate to dense SEC was >2.3 mg/dL, the cutoff value of Sa-wave was≤ 5.5 cm/s for prediction of the presence of inactive LAA (LAAEV < 25 cm/s). CONCLUSION: Mitral annular systolic velocity (Sa-wave) is an independent predictor of inactive LAA and a useful parameter in estimating inactive LAA in MS. Sa-wave and hs-CRP are independent predictors for SEC. PBMV improves LAA function in patients with MS.

New integrated approach to percutaneous mitral valvuloplasty combining Wilkins score with commissural calcium score and commissural area ratio.

BACKGROUND: Present echocardiographic scoring systems for percutaneous mitral valvuloplasty (PMV) have limitations, and no scoring system is significant determinant of procedural outcome. In this study, we assess the relationship between various echocardiographic parameters and scoring systems with immediate outcomes and test an integrated approach by combining Wilkins score with other parameters. METHODS: One hundred two patients who had undergone PMV were included in this prospective observational study. Preprocedural mitral valve morphology was assessed and categorized using Wilkins score, Sutaria scoring system, and Nunes quantitative scoring system. RESULTS: Optimal PMV results were obtained in 84 patients (82.35%), and suboptimal PMV results were obtained in 18 patients (17.65%). Using Nunes scoring system, suboptimal PMV results were obtained in 9 (37.5%) patients of high-risk group (n=24), 8 (13.8%) of intermediate-risk group (n=58), and one (5%) patient of low-risk group (n=20). Using Wilkins scoring system, in patients having score>8 (n=16) suboptimal results were obtained in 5 (31.7%) and in patients having score<8 (n=86) suboptimal results were obtained in 13 (15.1%). Using Sutaria scoring system, in patients having score 3 to 4 (low risk, n=68) suboptimal results were obtained in 6 (8.8%), and in patients having score 0-2 (high risk, n=34) suboptimal results were obtained in 12 (35.3%) patients. CONCLUSION: All echocardiographic scores have significant limitations, and an integrative approach is mandatory. Combining traditional Wilkins score with Sutaria score and commissural area ratio better predicts procedural outcomes.

Right Ventricle before and after Atrial Septal Defect Device Closure.

BACKGROUND: Percutaneous atrial septal defect (ASD) device closure is a safe and effective means of reducing or eliminating interatrial shunting. The response of the right heart to device closure is incompletely understood. AIM: To evaluate the effects of transcatheter closure of secundum ASD on right ventricle size and function, that is, both systolic and diastolic by transthoracic echocardiography (TTE) over a 6-month period. METHODS: Seventy-three patients had 73 device implantations. The patients were assessed with echocardiography before and at 1 and 6 months after procedure. RESULTS: Mean age was 26 ± 17 years. Mean ASD size indexed to body surface area (BSA) was 19.1 ± 8.6 mm/m(2) . The device size ranged from 12 to 42 mm. One month after closure, there were statistically significant decreases in right ventricular (RV) basal diameter (3.5 ± 0.7 cm vs. 4.2 ± 0.8 cm), RV/LV end-diastolic diameter ratio (0.9 ± 0.1 vs. 1.2 ± 0.2), left ventricular eccentricity index (LVEI) (1.0 ± 0.1 vs. 1.2 ± 0.2), right atrial (RA) major dimension (4.4 ± 0.8 cm vs. 4.8 ± 1.0 cm), RA end-systolic area (13.2 ± 4.6 cm(2) vs. 18.5 ± 6.7 cm(2) ), tricuspid annular plane systolic excursion (TAPSE) (2.2 ± 1.8 cm vs. 2.8 ± 0.5 cm), tricuspid annular systolic velocity (TASV or S') (13.1 ± 3.0 cm/sec vs. 16.0 ± 2.8 cm/sec), E/A (1.4 ± 0.3 vs. 1.7 ± 0.5), and E/e' (5.9 ± 5.0 vs. 7.2 ± 2.0) in comparison with baseline. Six months after closure, there were statistically significant decreases in RV major dimension (5.9 ± 1.1 cm vs. 6.3 ± 1.0 cm), RV/LV end-diastolic diameter ratio (0.8 ± 0.1 vs. 0.9 ± 0.1), RA major dimension (4.1 ± 0.8 cm vs. 4.4 ± 0.8 cm), and RA end-systolic area (11.4 ± 3.8 cm(2) vs. 13.2 ± 4.6 cm(2) ) in comparison with 1 month post-device closure. After 6 months, there was a statistically insignificant increase in both TASV (13.7 ± 2.8 cm/sec vs. 13.1 ± 3.0 cm/sec) and TAPSE (2.5 ± 1.6 cm/sec vs. 2.2 ± 1.8 cm/sec). There was no significant change in tissue Doppler MPI at baseline, 1 month, and 6 months after closure (0.38 ± 0.19 vs. 0.35 ± 0.15 vs. 0.38 ± 0.13). There was significant decrease in E/e' from baseline to 1 month and 1 month to 6 months after closure (7.2 ± 2.0 vs. 5.9 ± 5.0 vs. 4.7 ± 1.5). CONCLUSION: RV volumes decreased significantly in the first month after ASD device closure and continued up to 6 months. There was no change in global right ventricular systolic function but a high basal RV systolic function decreased after closure. Some patients had impaired diastolic function before closure of defect, which reversed to normal within 6 months after closure. Diastolic dysfunction in older age-group may be a cause for long duration taken by right heart chambers to regress and deserves further investigation.

Predictive Value of D-Dimer Levels and Tissue Doppler Mitral Annular Systolic Velocity for Detection of Left Atrial Appendage Thrombus in Patients with Mitral Stenosis in Sinus Rhythm.

BACKGROUND: Transesophageal echocardiogram (TEE) is a gold standard test for diagnosis of left atrial (LA) thrombus, but it has limited sensitivity for identification of small thrombi within side lobes. Thus, the absence of visualizing a left atrial appendage (LAA) thrombus does not equate with the absence of a LAA thrombus. AIM: To assess the predictive value of mitral annular systolic velocity (Sa) and D-dimer for the detection of LA thrombus and spontaneous echocardiographic contrast (SEC) in mitral stenosis (MS) patients with sinus rhythm (SR). METHODS: Transthoracic echocardiogram, TEE, and D-dimer analysis were performed in 104 severe MS patients and divided them into three groups: Group I:no LA thrombus or SEC; Group II:LA SEC only; and Group III:LA thrombus. RESULTS: Group III had more severe New York Heart Association (NYHA) class (III-IV) dyspnea and lower Sa (6.9 ± 0.7 vs.10.0 ± 1.2 cm/sec), lower LAA late emptying velocity (17.7 ± 2.1 vs. 24.4 ± 4.2 cm/sec), larger LA transverse dimension, and LAA area (LAAA) than group I+II. Mean D-dimer levels were higher in groups III and II than in group I. In multivariate analysis Sa, D-dimer levels, LAAA, and NYHA class were independent predictors of LA thrombus. ROC curve analysis revealed that higher Sa >8 cm/sec and lower D-dimer levels <370 µg/L predict the absence of LA thrombus and lower Sa <8 cm/sec and higher D-dimer levels >510 µg/L predict the presence of LA thrombus. CONCLUSION: Measurement of Sa and D-dimer levels is necessary for better assessment of LA thrombus and SEC, for identification of patients who are at high risk for LA thrombus formation and for initiation of prophylactic anticoagulation.

Real Time 3D Echocardiographic Evaluation of Iatrogenic Atrial Septal Defects After Percutaneous Transvenous Mitral Commissurotomy.

INTRODUCTION: Percutaneous transvenous mitral commissurotomy (PTMC) is a safe and effective procedure for relief of severe mitral stenosis. PTMC is being done widely and many transseptal procedures requiring large diameter catheters, sheaths are becoming popular. The knowledge of iatrogenic atrial septal defect (iASD) is vital. This study assessed the use of real-time 3D echocardiography (RT3DE) and incidence of iASD in a cohort of patients undergoing transseptal catheterization during PTMC. METHODS: One hundred ten patients underwent PTMC. The reliability and accuracy of RT3DE for iASD detection was determined, RT3DE was compared with 2D echocardiography (2DE) for iASD occurrence, influencing variables analyzed and followed up for 1 year. RESULTS: RT3DE is more reliable and accurate for the study of iASD than 2DE. Color RT3DE detected iASD in 94 (85.5%), with 2DE iASD was detected in 74 (67.3%) (P < .0001).On follow up 85% had iASD post procedure, 56% at 6 months, 19% at 1 year follow up. The mean iASD diameter was 5.41 ± 3.12 mm and area 6.57 ± 3.81 mm(2). iASD correlated with patient height, Wilkins score, pre-PTMC LA 'v', and post-PTMC LVEDP. CONCLUSION: RT3DE imaging is superior in accuracy to traditional 2DE techniques. All the modes of RT3DE are useful in the assessment of iASD. iASD measured by RT3DE correlates with several patient, procedural and echocardiographic variables.

Reliability of Doppler-Based Measurement of Pulmonary Vascular Resistance in Congenital Heart Disease with Left-to-Right Shunt Lesions.

BACKGROUND: Pulmonary vascular resistance (PVR) is a crucial parameter in the management of patients with left-to-right shunt lesions. Cardiac catheterization (Cath) is the gold standard test to assess PVR (PVRcath ), but it is invasive and hence, risky in children with pulmonary arterial hypertension (PAH). A noninvasive tool to assess PVR is desirable. Ratio of tricuspid regurgitation velocity (TRV) and time-velocity integral of right ventricular outflow tract (TVIRVOT ) by Doppler was previously shown to be a reliable noninvasive method for estimation of PVR in acquired PAH. METHODS: Peak TR velocity and TVIRVOT were recorded from 63 prospective patients with various congenital shunt lesions. Subsequently, the patients were subjected to cath in less than 2 hours. The patients were subdivided into four subsets based on age and pulmonary arterial mean pressure (PAMP). A regression equation was developed for calculation of PVR from TRV/TVIRVOT (PVREcho ) which was indexed for BSA (PVRIEcho ). Bland-Altman analysis was done for agreement between PVRIcath and PVRIEcho . Receiver operating characteristic (ROC) curves were plotted to test the identity of the two methods and also the applicability of PVRIEcho across a wide range of Wood units. RESULTS: Receiver operating characteristic curve plotted between the two methods showed good identity. Bland-Altman analysis showed excellent agreement between the two methods with negligible bias. ROC curves showed that PVRIEcho was accurate in distinguishing different cutoff values of PVR in each of the 4 groups. CONCLUSION: Noninvasive Doppler estimation of PVR is reliable in patients with shunt lesions over a wide range of PVR.