ABSTRACT. Imaging morphology and function of the right heart is of paramount importance in patients with adult congenital heart disease, since right ventricular dysfunction is associated with adverse cardiac events. Cardiac MRI has been shown to be a powerful tool for the non-invasive precise assessment of right ventricular and valvular dysfunction. Differential diagnoses of congenital heart disease characterised by, or combined with, right heart dilatation are diverse and necessitate a systematic approach.
Background Echocardiography is one of the main diagnostic tools for the diagnostic workup of stroke and is already well integrated into the clinical workup. However, the value of transthoracic vs. transesophageal echocardiography (TTE/TEE) in stroke patients is still a matter of debate. Aim of this study was to characterize relevant findings of TTE and TEE in the management of stroke patients and to correlate them with subsequent clinical decisions and therapies. Methods We evaluated n = 107 patients admitted with an ischemic stroke or transient ischemic attack to our stroke unit of our university medical center. They underwent TTE and TEE examination by different blinded investigators. Results Major cardiac risk factors were found in 8 of 98 (8.2%) patients and minor cardiac risk factors for stroke were found in 108 cases. We found a change in therapeutic regime after TTE or TEE in 22 (22.5%) cases, in 5 (5%) cases TEE leads to the change of therapeutic regime, in 4 (4%) TTE and in 13 cases (13.3%) TTE and TEE lead to the same change in therapeutic regime. The major therapy change was the indication to close a patent foramen ovale (PFO) in 9 (9.2%) patients with TTE and in 10 (10.2%) patients with TEE (p = 1.000). Conclusion Major finding with clinical impact on therapy change is the detection of PFO. But for the detection of PFO, TTE is non inferior to TEE, implicating that TTE serves as a good screening tool for detection of PFO, especially in young age patients. Trial registration The trial was registered and approved prior to inclusion by our local ethics committee (1/3/17).
SummaryA case of aortic valve stenosis is reported with progressive left ventricular dysfunction demonstrated by radionuclide angiography. A gradient of 120 mmHg was present across the aortic valve. At the time of surgery, the patient was in severe cardiac failure with a left ventricular ejection fraction of 22%.Two months postoperatively,the patient was asymptomatic, and repeat radionuclide anglography demonstrated an ejection fraction of 93%. The reversible nature of this patient's ventricular dysfunction suggests that the cardiac failure was related to 'afterload mismatch' caused by the stenotic valve, rather than due to depressed contractility. The encouraging result in this patient reinforces the view that surgical intervention is warranted in some patients with critical aortic stenosis and extreme impairment of left ventricular function, and that the close relation between ejection fraction and operative survival may not hold true in aortic stenosis.
Background and aims Neurovascular ultrasound (nvUS) of the epiaortic arteries is an integral part of the etiologic workup in patients with ischemic stroke. Aortic valve disease shares similar vascular risk profiles and therefore not only presents a common comorbidity, but also an etiologic entity. The aim of this study is to investigate the predictive value of specific Doppler curve flow characteristics in epiaortic arteries and the presence of aortic valve disease. Methods Retrospective, single-center analysis of ischemic stroke patients, both receiving full nvUS of the extracranial common- (CCA), internal- (ICA) and external carotid artery (ECA) and echocardiography (TTE/TEE) during their inpatient stay. A rater blinded for the TTE/TEE results investigated Doppler flow curves for the following characteristics: ‘pulsus tardus et parvus’ for aortic valve stenosis (AS) and ‘bisferious pulse’, ‘diastolic reversal’, ‘zero diastole’ and ‘no dicrotic notch’ for aortic valve regurgitation (AR). Predictive value of these Doppler flow characteristics was investigated using multivariate logistic regression models. Results Of 1320 patients with complete examination of Doppler flow curves and TTE/TEE, 75 (5.7%) showed an AS and 482 (36.5%) showed an AR. Sixty-one (4.6%) patients at least showed a moderate-to-severe AS and 100 (7.6%) at least showed a moderate-to-severe AR. After adjustment for age, coronary artery disease, arterial hypertension, diabetes mellitus, smoking, peripheral arterial disease, renal failure and atrial fibrillation, the following flow pattern predicted aortic valve disease: ‘pulsus tardus et parvus’ in the CCA and ICA was highly predictive for a moderate-to-severe AS (OR 1158.5, 95% CI 364.2–3684.8, p < 0.001). ‘No dicrotic notch’ (OR 102.1, 95% CI 12.4–839.4, p < 0.001), a ‘bisferious pulse’ (OR 10.8, 95% CI 3.2–33.9, p < 0.001) and a ‘diastolic reversal’ (OR 15.4, 95% CI 3.2–74.6, p < 0.001) in the CCA and ICA predicted a moderate-to-severe AR. The inclusion of Doppler flow characteristics of the ECA did not increase predictive value. Conclusions Well defined, qualitative Doppler flow characteristics detectable in the CCA and ICA are highly predictive for aortic valve disease. The consideration of these flow characteristics can be useful to streamline diagnostic and therapeutic measures, especially in the outpatient setting.
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