Aortic Valve Insufficiency – ABC CARDIOL

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Case Report

TAV-in-TAV for Acute Failure of a Transcatheter Aortic Valve in a High Surgical Risk Octogenarian Patient

Gustavo Carvalho et al. Maria Fernanda Miranda Carvalho Enio Eduardo Guérios Pedro Calegari … Cláudia Biondo Zanlorensi Fernando Silva Botelho Bruna O. Erbano Vinícius D. Vaz

Abstract

An 82-year-old patient with severe aortic valve stenosis and high risk for conventional surgery due to chronic renal dysfunction and restrictive lung disease underwent transfemoral transcatheter aortic valve implantation (TAVI) using a self-expanding Navitor^® prosthesis (Abbott). Immediately after implantation, valve dysfunction was observed, characterized by inversion of the right coronary leaflet, resulting in severe acute prosthetic regurgitation and hemodynamic instability. Therefore, a 21.5 mm balloon-expandable Myval^® prosthesis was also implanted (TAV-in-TAV). The critical condition was resolved with immediate hemodynamic recovery. This case demonstrates the efficacy and safety of TAV-in-TAV as a bailout intervention in acute prosthetic failure.

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Case Report

Asymptomatic Non-Bacterial Thrombotic Endocarditis Leading to a Diagnosis of Pancreatic Cancer

Diego Chemello et al. Patricia Chagas Daniel Marques Barreiro Camila Sales Fagundes … Rafael Coelho Marcelo Dantas Tavares de Melo

Introduction

Non-bacterial thrombotic endocarditis (NBTE) is a phenomenon associated with sterile vegetations composed of fibrin and platelets aggregating on healthy heart valves. Most cases are diagnosed after death or in patients experiencing systemic embolization. Diagnosis relies on clinical suspicion and a compatible echocardiographic image. The correct treatment is long-term systemic anticoagulation to avoid arterial embolization, which often presents as multiple and recurrent ischemic strokes.

The first antemortem report of NBTE as the initial presentation of underlying pancreatic cancer was published in 2008. However, incidental diagnosis of uncomplicated NBTE that leads to a subsequent discovery of carcinoma is rare.

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Case Report

ATTRwt Cardiac Amyloidosis and Aortic Regurgitation in a Patient with Acute Myelomonocytic Leukemia: an Unusual Combination

Diego Chemello et al. Patricia Chagas Camila Sales Fagundes Juliana Chiodelli Salvador Marcelo Tavares

Introduction

Systemic amyloidosis is a relatively rare multisystem disease caused by the deposition of misfolded protein in various tissues and organs. Cardiac amyloidosis (CA) is recognized as an underlying cause of left ventricular wall thickening, heart failure, and arrhythmia with variable clinical presentation. The clinical diagnosis of cardiac involvement in amyloidosis is challenging, requiring a patient-centered diagnostic work-up that ensures an appropriate diagnosis.^,

Although amyloidosis has been associated with multiple malignant disorders, its association with leukemia is rather uncommon.^– Also, there is a relationship between CA and valvular heart disease, particularly aortic stenosis (AS). The association of ATTRwt CA and aortic regurgitation (AR) in a patient with acute myelomonocytic leukemia (MML) is unique and has not been described so far.

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Original Article

Left Ventricular Longitudinal Linear Displacement Versus Global Longitudinal Strain on Cardiovascular Magnetic Resonance

Rafael Almeida Fonseca et al. Sergio Marrone Ribeiro Clerio Francisco de Azevedo Filho Roney Sampaio … Flávio Tarasoutchi Carlos Eduardo Rochitte

Abstract

Background

Left ventricular (LV) systolic diastolic function is prognostic in cardiovascular diseases and can be assessed via global longitudinal strain (GLS) on echocardiography and cardiac magnetic resonance (CMR). However, GLS by CMR requires the use of expensive software. Longitudinal linear displacement (LLD) may be a simple and inexpensive alternative to GLS, but the two have not been systematically compared.

Objective

To compare LLD with GLS and LV ejection fraction (LVEF) in aortic valve disease patients and controls.

Methods

We included 44 participants (26 with aortic valve disease, 19 controls). GLS was determined using CVI42 software (Circle Cardiovascular Imaging), while the LLD linear measurements of the distance between the base/apex of the LV included maximum displacement (MD), maximum velocity in early diastole (MVED), atrioventricular junction velocity in diastasis (VDS), and VDS/MVED ratio.

Results

DM and MVED were correlated with GLS (r=0.69 and r=0.65, respectively) and LVEF (r=0.47 and r=0.57, p<0.001 for both). DM and MVED showed areas under the receiver operating characteristic curve (AUC) of 0.88 and 0.91, and at the best cut-off point (-0.13 and 0.66), sensitivities of 72.43% and 57.14% and specificities of 80.65% and 87.10%, respectively, compared to GLS. Using LVEF as a reference, we obtained AUC of 0.70 and 0.82, and at the best cut-off point (-0.11 and 0.61), sensitivities of 75.00% and 50.00% and specificities of 72.97% and 78.38%, respectively.

Conclusion

LLD demonstrated similar performance to that of GLS. MD derived from LLD was the best parameter during systole, while MVED was the best during diastole. Our findings demonstrate the routine, quick, and inexpensive assessment of diastolic function on CMR.

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Editorial

Assessment of Aortic Valve Regurgitation by Echocardiography: Basic and New Concepts

Conclusion

Introducing new concepts or techniques that can help grading AR severity is a valuable resource. AR VTI is a promising concept that is physiologically sound and appears reproducible. Larger clinical trials will be needed to further assess its role and, more importantly, its prognostic value and correlation with clinical outcomes.

It is imperative, however, to keep in mind that it is very unlikely that we will find a single echocardiographic marker that will be a gold standard when assessing AR severity. The echocardiographist has to keep an open mind and integrate all available data to come to a final conclusion. This includes the following:

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Original Article

Longitudinal Shortening of the Left Ventricle by Cine-CMR for Assessment of Diastolic Function in Patients with Aortic Valve Disease

Sergio Marrone Ribeiro et al. Clerio Francisco de Azevedo Filho Roney Sampaio Flávio Tarasoutchi … Max Grinberg Roberto Kalil-Filho Carlos Eduardo Rochitte

Abstract

Background:

Diastolic dysfunction, commonly evaluated by echocardiography, is an important early finding in many cardiomyopathies. Cardiac magnetic resonance (CMR) often requires specialized sequences that extends the test time. Recently, feature-tracking imaging has been made available, but still requires expensive software and lacks clinical validation.

Objective:

To assess diastolic function in patients with aortic valve disease (AVD) and compare it with normal controls by evaluating left ventricular (LV) longitudinal displacement by CMR.

Methods:

We compared 26 AVD patients with 19 normal controls. Diastolic function was evaluated as LV longitudinal displacement in 4-chamber view cine-CMR images using steady state free precession (SSFP) sequence during the entire cardiac cycle with temporal resolution < 50 ms. The resulting plot of atrioventricular junction (AVJ) position versus time generated variables of AVJ motion. Significance level of p < 0.05 was used.

Results:

Maximum longitudinal displacement (0.12 vs. 0.17 cm), maximum velocity during early diastole (MVED, 0.6 vs. 1.4s^-1), slope of the best-fit line of displacement in diastasis (VDS, 0.22 vs. 0.03s^-1), and VDS/MVED ratio (0.35 vs. 0.02) were significantly reduced in AVD patients compared with controls, respectively. Aortic regurgitation showed significantly worse longitudinal LV shortening compared with aortic stenosis. Higher LV mass indicated worse diastolic dysfunction.

Conclusions:

A simple linear measurement detected significant differences on LV diastolic function between AVD patients and controls. LV mass was the only independent predictor of diastolic dysfunction in these patients. This method can help in the evaluation of diastolic dysfunction, improving cardiomyopathy detection by CMR, without prolonging exam time or depending on expensive software.

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Anatomopathological Correlation

Case 1/2019 – A 51-year-old Man with Arterial Hypertension, Aortic Dissection and Aortic Valve Regurgitation, in Addition to Heart Failure with Unchanged Clinical Course After Surgical Intervention

Desiderio Favarato et al. Vera Demarchi Aiello

Clinical aspects

This was a male patient, who presented with ascending aortic dissection, and who, even after surgery for dissection repair, developed a picture of severe heart failure and died.

The International Registry of Acute Aortic Dissection (IRAD) showed that patients with aortic dissection were older than our patient, 61 years; and a majority of males (63%). Regarding the diseases related to the dissection, they were: Marfan syndrome (6.7%), hypertension (69.3%), atherosclerosis (24.4%), previously known aortic aneurysm (12.4%), previous aortic dissection 3.9%) and diabetes mellitus (4.3%). Also, 15.9% had a history of previous cardiac surgery and iatrogenic cause in 4.8% (1.7% coronary angiography and 3.1% after cardiac surgery). The 2015 update of the same registry, with a ten-fold higher number of patients, showed an increase in hypertension (75.5%) and a decrease in the presence of Marfan syndrome (4.5%), (75.5%), atherosclerosis (19.6%) and previous cardiac surgery (10.6%).

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Image

Challenging Evaluation of Aortic Regurgitation: More Than a Quadricuspid Valve

Gonçalo Pestana et al. Carla Sousa Teresa Pinho Sara Maia M. Júlia Maciel

A 61-year-old female patient with chronic obstructive pulmonary disease, and no other comorbidities, was referred for cardiological assessment due to aggravated exertional dyspnea (New York Heart Association – NYHA class III) and atypical chest pain. Physical examination disclosed only a diastolic murmur in the second intercostal space in the right sternal border.

The transthoracic echocardiogram (TTE) showed aortic regurgitation (), with non-dilated cardiac chambers and preserved biventricular function. The acoustic window limited the evaluation of the valvular lesion severity and its importance in the context of the complaints, although the continuous Doppler spectrum suggested significant regurgitation (). The evaluation was further impaired by a systolic flow acceleration in the Left Ventricular Outflow Tract (LVOT), with no significant gradient and an undetermined cause. The aortic root had normal size, but it was not possible to carry out an adequate morphological and functional characterization of the valve.

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Partial Prosthetic Mitral Valve Dehiscence: Transapical Percutaneous Closure

Catarina Ruivo et al. José Ribeiro Alberto Rodrigues Luís Vouga Vasco Gama

An 80-year-old woman with a history of mitral and aortic prosthesis replacement with biological prostheses due to endocarditis presented worsening dyspnea. A transthoracic echocardiogram demonstrated a paravalvular regurgitation between the left ventricle and left atrial appendage. Given her high-risk surgery (EuroSCORE-II: 38%), a percutaneous approach was performed for definitive closure.

Transesophageal echocardiography (TEE) peri-procedure allowed the visualization of a partial dehiscence of the mitral prosthesis (Panel A, ). Through the 3D images, a tunneled defect with wall dissection measuring 12.5 mm of maximum diameter (Panel B, ) was observed. Using a transapical pathway and collecting three-dimensional (3D) images in real time, a 12 mm Amplatzer septal prosthesis was positioned, occluding the entire defect. The TEE 3D image demonstrated savings of adjacent structures and absence of pericardial effusion during closure. Coronary angiography demonstrated no arterial compromise. A slight residual flow was detected after device implantation (C-F Panels ).

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Anatomopathological Session

Case 4 – A 67 Year-Old Man with Aortic Regurgitation Who Presented Syncope Followed by Shock

Desiderio Favarato et al. Luiz Alberto Benvenuti

Clinical aspects

Patient with aortic insufficiency diagnosed at 57 years of age, presenting with several transient ischemic attacks simultaneous to atrial fibrillation. Presented with upper digestive bleeding and, finally, syncope followed by decreased consciousness and complex mixed shock with acute renal failure.

The patient showed normal aortic insufficiency clinical evolution, that is, progressive dilatation of the left ventricle with few cardiovascular symptoms. Generally, aortic insufficiency progression is slow and the left ventricle has time to dilate and handle high regurgitating volumes with normal filling pressure. This good compliance maintenance and low end-diastolic pressure has little repercussion on the left atrium and on the pulmonary venocapillary territory, thus there is no increase in liquid content in the lungs and dyspnea appears as a late symptom.

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Anatomopathological Session

Case 5: 40 year-old man, hypertensive, presented abdominal pain and shock

Diego R. Barbosa Pereira et al. Fabio Augusto Pinton Luiz Alberto Benvenuti

ANATOMOPATHOLOGICAL SESSION

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Case Report

Infectious endocarditis due to Streptococcus bovis in a patient with colon carcinoma

Alexandre Maulaz Barcelos et al. Marco Antônio Teixeira Lidianny Silva Alves Marcelo Antunes Vieira … Marcus Lima Bedim Noely A. Ribeiro

We report the case of a 66 year-old female patient with infectious endocarditis due to Streptococcus bovis and adenocarcinoma of the colon that developed acute aortic insufficiency. She was submitted to aortic valve replacement surgery and later to tumor resection (right hemicolectomy). It is important to emphasize the need for complementing the study of the colon, even in asymptomatic individuals, when infectious endocarditis due to S. bovis is diagnosed.

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Artigo Original

Dobutamine-stress echocardiography in asymptomatic patients with aortic regurgitation

Marcia M. Barbosa et al. Claudia M. V. Freire Lúcia M. A. Fenelon William A. M. Esteves … Gilmar Reis Maria do Carmo P. Nunes

BACKGROUND: Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE: To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHDOS: Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS: Mean age was 37.8±16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3±7.9% to 71.5±10.5% at a dobutamine dose of 20 µg/kg/min (p<0.001). The patients were followed-up for 36.6±20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION: Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.

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Artigo Original

Neurohormonal profile of rheumatic patients with significant chronic aortic regurgitation

Guilherme Sobreira Spina et al. Flávio Tarasoutchi Roney Orismar Sampaio Marcelo Luiz Campos Vieira … Célia Strunz Francisco Rafael Laurindo Max Grinberg

BACKGROUND: Neurohormones are involved in the physiopathology of heart failure, but little is known about its behavior in significant chronic aortic regurgitation (AR). We aimed at analyzing the behavior of these mediators in AF. OBJECTIVE: We aimed at analyzing the behavior of these mediators in AF. METHODS: We analyzed 89 patients with AF, whose mean age was 33.6±11.5 years and of whom 84.6% were males, 60% asymptomatic, all with rheumatic etiology. After the clinical and echocardiographic assessment, plasma measurements of tumor necrosis factor (TNF), soluble TNF receptor types I and II (sTNFRI e sTNFRII), interleukin-6 (IL-6), its soluble receptor (sIL6R), endothelin-1 and B-type natriuretic peptide (BNP) were carried out; 12 healthy individuals were used as controls. RESULTS: The mean values of the left ventricle diastolic diameter (LVDD) were 71.9±8.3mm, whereas the mean values of the LV systolic diameter (LVSD) were 50.4±9.3mm. The neurohormonal levels were elevated in patients with AF (TNF 92.65±110.24 pg/mL vs. 1.67±1.21 pg/ml in controls, p<0.001), (IL-6 7.17±7.78pg/ml vs. 0.81±0.38pg/mL in controls, p=0.0001) and TNFRI (894.75±348.87pg/mL vs. 521.42±395.13pg/ml, p=0.007). Except for the BNP levels, symptomatic and asymptomatic patients presented a similar neurohormonal profile. There was a correlation between TNFRII and LVDD (r=-0.329, p=0.038) and LVSD (r=-0.352, p=0.027). BNP levels were significantly higher in symptomatic patients and only in the latter it was possible to establish a correlation between BNP and ventricular diameters. CONCLUSION: Patients with significant chronic AF present high neurohormonal levels, with no correlation with the symptomatic status. The TNFRII and BNP levels could be correlated with ventricular diameters, but only the latter could be correlated with symptoms.

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Artigo Original

Myocardial fibrosis and ventricular remodeling in severe chronic aortic regurgitation

Nelson Elias et al. Flávio Tarasoutchi Guilherme Sobreira Spina Roney O. Sampaio … Pablo M. A. Pomerantzeff Francisco Rafael Laurindo Max Grinberg

BACKGROUND: Significant symptomatic chronic aortic regurgitation (AR) leads to considerable left ventricular remodeling at the expense of myocyte hypertrophy and extracellular matrix remodeling. The relevance of interstitial fibrosis concentration in these patients is unknown. We analyzed the degree of fibrosis in the left ventricle (LV) in symptomatic patients with AR submitted to surgical treatment, and its relationship with functional and anatomical characteristics. OBJECTIVE: To evaluate myocardical fibrosis in chronic severe aortic regurgitation. METHODS: Twenty-eight patients with chronic symptomatic AR (16 with normal LV function and 12 with LV dysfunction) were selected and assessed pre- and postoperatively by echocardiography. Functional capacity was measured using maximal oxygen consumption (VO2max) through the cardiopulmonary test. Myocardial fibrosis volume fraction (MFV) was quantified through endomyocardial biopsy performed in all patients during surgery. We compared the histopathologic results with a nine-patient control group. RESULTS: The mean age was 39 ± 12 years, 75% of the patients were male, and the rheumatic etiology accounted for 84% of the cases. Twenty-five patients remained in FC l and ll at the end of the study, and there was a significant reduction of the LV diameters between the preoperative and late postoperative timepoints. Three deaths occurred but they were not related to postoperative ventricular dysfunction. The parameters of the cardiopulmonary test were similar between pre- and postoperative timepoints. MFV in patients with AR was significantly higher than in the control group (3.47 ± 1.9% vs 0.82 ± 0.96%, respectively, p=0.001). There was no statistical correlation among LV fibrosis and LV diameters, LVEF and MVO2. CONCLUSION: In patients with significant symptomatic AR, the presence of limited myocardial fibrosis was not associated with clinical, echocardiographic or functional complications.

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Case Report

Quadricuspid aortic valve by transthoracic echocardiography

Erlon Oliveira de Abreu Silva et al. Alessandro Giralde Iglesias Erlon de Abreu Silva

A 55-year-old woman seeks medical attention with palpitations, atypical chest pain and dyspnea upon exertion, lasting for 12 months. ECG showed left ventricular hypertrophy. Transthoracic Doppler echocardiogram confirmed hypertrophy of the left chambers and showed a quadricuspid aortic valve, with equal-sized cusps, in addition to a moderate regurgitant central flow. Upon echocardiography, the quadricuspid valve is identified by its characteristic “X” form during diastole and rectangular aspect during systole. Heart failure symptoms are presumably caused by valve insufficiency due to abnormal leaflet coaptation. Considering the possibility of progressive regurgitation, follow up on the patient was performed with periodic echocardiographic control. Symptoms responded to treatment.

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