Tricuspid valve (TV) dysfunction can result from morphological alterations in the valve or from f... more Tricuspid valve (TV) dysfunction can result from morphological alterations in the valve or from functional aberrations of the myocardium. It can be classified as primary and secondary. Primary TV disease with intrinsic structural abnormality is less common than diseases of the aortic and mitral valves. The slow progression of the disease leads to delayed appearance of symptoms. The physical signs are often less impressive. Hence, it may go undetected until advanced stage results in hepatomegaly, ascites, and leg edema. The secondary form of TV disease is far more common and is often the result of annular dilatation with incomplete valve closure. The functional abnormalities may be in the form of pure or predominant tricuspid stenosis (TS), pure or predominant tricuspid regurgitation (TR), or mixed.
ABSTRACT Aortic valve stenosis (AS) is the most frequent form of valvular heart disease. The numb... more ABSTRACT Aortic valve stenosis (AS) is the most frequent form of valvular heart disease. The number of studies evaluating the effect of aortic valve replacement (AVR) for AS on aortic vascular function is limited. The aim of the present study was to examine alterations in aortic distensibility in patients with AS during a 1-year follow-up after AVR. Twelve patients with severe AS who underwent AVR were prospectively examined (mean age 65 +/- 11 years, 7 men). Systolic and diastolic ascending aortic diameters (SD and DD, respectively) were recorded in M mode 3 cm above the aortic valve from a parasternal long-axis view. The SD and DD were measured at the time of maximum anterior motion of the aorta and at the start of the QRS complex, respectively. Aortic stiffness index (beta) was defined as [ln(SBP/DBP)] x DD/deltaD, where ln is the natural logarithm, SBP and DBP are the systolic and diastolic blood pressure values, respectively, and deltaD = SD - DD. As expected, aortic stenosis severity and left ventricular mass decreased significantly after AVR. Aortic diameter changes (systolic minus diastolic dimensions) progressively increased and the aortic stiffness index progressively improved to levels comparable with those of age-, sex-, and risk factor-matched controls at the 1-year assessment. Aortic valve replacement in patients with AS is associated with a progressive improvement in aortic distensibility to 1-year values similar to those of controls.
Background: Behcet’s disease is an autoimmune disease characterized by diffuse vasculitis and ora... more Background: Behcet’s disease is an autoimmune disease characterized by diffuse vasculitis and oral and genital ulcers. Coronary vasculitis is a rare finding in Behcet’s disease and only reported in few cases. Case summary: A 47-year-old male patient was recently diagnosed as Behcet’s disease and admitted as inferior ST elevation myocardial infarction. Coronary angiogram revealed coronary aneurysm in posterior descending artery with TIMI III flow. The patient was managed medically with immunosuppressive therapy and he discharged after 5 days in a stable condition. Patient was seen in the clinic after one month and he was asymptomatic. Conclusion: Coronary involvement in patients with Behcet’s disease is rare; however, it can be associated with myocardial infarction. Medical management with steroid and immunosuppressive therapy is the mainstay of therapy. Coronary intervention might be required in some cases with ongoing ischemia.
Aim: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral sten... more Aim: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral stenosis using the three-dimensional (3D) scoring system. Methods: A two-staged study was conducted. The first stage was designed to select the best 3D images of MV leaflets and chordae through analysis of 471 images. The second stage was designed to organize the best 3D images into protocols for complete scoring of MV. It included 35 consecutive patients; 23 had sinus rhythm (SR) and 12 had atrial fibrillation (AF). Both single- and multi-beat 3D acquisition from apical and parasternal windows were focused on MV leaflets and chordae using all 3D modalities (live, zoom, and full volume). To propose the protocols, 1563 images were analyzed. Results: In SR with good apical window, 2 protocols were recommended for complete scoring of leaflets and chordae (4 zoom 3D images [1 image for leaflets and 3 images for chordae] and 1 full-volume 3D image) using single- and multi-beat acquisition. In AF, the same 2 protocols using single-beat acquisition were recommended. From parasternal window, complete scoring of leaflets was obtained by 3 recommended protocols (single- or multi-beat zoom 3D images from parasternal short axis [PSAX], multibeat live 3D images from PSAX, and single- or multi-beat full-volume 3D images from parasternal long axis) in SR and 1 protocol in AF (single-beat zoom 3D images from PSAX). Scoring of chordae was incomplete in all patients by all 3D modalities. Conclusions: The proposed 3D-transthoracic echocardiography protocols suit all patients regardless of echo window and heart rhythm and enabled complete MV scoring.
Tricuspid annulus (TA) evaluation continues to be a major problem in the surgical decision-making... more Tricuspid annulus (TA) evaluation continues to be a major problem in the surgical decision-making process. Obviously, 2-dimensional transthoracic echocardiography (2D TTE) is limited in TA visualization due to its complex 3D shape. The study aimed to determine TA morphology, size and function with real-time three-dimensional echocardiography (RT3DE) in 40 patients divided into two equal groups (I: normal TA and II: dilated). 2D TTE measurements included TA diameter (TAD) at apical 4-chamber (AP4CH) and parasternal short axis (PSAX) views. RT3DE measurements included TA area (TAA), major TAD and minor TAD. TA fractional shortening (TAFS), and TA fractional area change (TAFAC) were calculated from end-systolic and end-diastolic measurements. RT3DE allowed visualization and measurement of the entire oval-shaped TA in all patients irrespective of its size (normal or dilated). 2D TTE measurement of TAD at both AP4CH and at PSAX views was significantly smaller than the major TAD measured ...
# The Author(s) 2011. This article is published with open access at Springerlink.com Abstract Non... more # The Author(s) 2011. This article is published with open access at Springerlink.com Abstract Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheterbased balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by twodimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.
License, which permits unrestricted use, distribution, and reproduction in any medium, provided t... more License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aim of Study. To assess the feasibility of a new proposedmaneuver “RATLe-90 ” using real-time three-dimensional transesophageal echocardiography (RT-3DTEE) for anatomically oriented visualization of the interatrial septum (IAS) in guiding the transseptal puncture TSP.Methods. The study included 20 patients (mean age, 60.2 ± 6.7 years; 60 % males) who underwent TSP for different indications. RT-3DTEEwas used to guide TSP.The proposedmaneuver RATLe-90 (Rotate-Anticlockwise-Tilt-Left-90) was applied in all cases to have the anatomically oriented en face view of the IAS from the right atrial (RA) aspect. Having this anatomically oriented view, we guided the TSP catheter towards the proper puncture site according to the planned procedure. Results. Using the RATLe-90 maneuver, the anatomically oriented en face view of the IAS from the RA was obtained in all ...
Spectral pulsed-wave tissue Doppler imaging lateral-to-septal delay fails to predict clinical or ... more Spectral pulsed-wave tissue Doppler imaging lateral-to-septal delay fails to predict clinical or echocardiographic outcome after cardiac
Practical Manual of Tricuspid Valve Diseases, 2018
Tricuspid valve disease is common but often has less attention than in the left side of the heart... more Tricuspid valve disease is common but often has less attention than in the left side of the heart. Functional tricuspid regurgitation if left untreated is associated with unfavorable outcome. Moreover, tricuspid valve surgery is often associated with higher complications than for any other surgical valve intervention. Transthoracic echocardiography (TTE) is the gold standard imaging of choice in the assessment of tricuspid valve disease. TTE has many sub modalities such as the M-mode, 2D and 3D modes, the bi-plane mode and the recently introduced iRotate mode. Furthermore, Doppler interrogation of the tricuspid valve as well as blood flow over other cardiac valves, pulmonary, aortic, hepatic venous flow is the mainstay in hemodynamic assessment of patients with tricuspid valve disease. TTE role begins with screening for the presence or absence and type of tricuspid valve disease. Moreover, determination of the etiology, severity of the tricuspid lesion, associated other valvular problems and chamber quantification are part of an imaging protocol/approach, which required for full diagnosis of tricuspid valve disease. Pre-operative and pre-catheter interventional planning can be performed by TTE. Finally, post interventional outcome as well as follow-up is often determined via TTE. In this chapter, we will provide a comprehensive and state-of-the art overview of the use of TTE for the assessment of TV disease. Advantages as well as limitations of each TTE sub modality will be outlined. A perspective on the value of TTE in the era of percutaneous transcatheter TV interventions will also be highlighted.
Tricuspid valve (TV) dysfunction can result from morphological alterations in the valve or from f... more Tricuspid valve (TV) dysfunction can result from morphological alterations in the valve or from functional aberrations of the myocardium. It can be classified as primary and secondary. Primary TV disease with intrinsic structural abnormality is less common than diseases of the aortic and mitral valves. The slow progression of the disease leads to delayed appearance of symptoms. The physical signs are often less impressive. Hence, it may go undetected until advanced stage results in hepatomegaly, ascites, and leg edema. The secondary form of TV disease is far more common and is often the result of annular dilatation with incomplete valve closure. The functional abnormalities may be in the form of pure or predominant tricuspid stenosis (TS), pure or predominant tricuspid regurgitation (TR), or mixed.
ABSTRACT Aortic valve stenosis (AS) is the most frequent form of valvular heart disease. The numb... more ABSTRACT Aortic valve stenosis (AS) is the most frequent form of valvular heart disease. The number of studies evaluating the effect of aortic valve replacement (AVR) for AS on aortic vascular function is limited. The aim of the present study was to examine alterations in aortic distensibility in patients with AS during a 1-year follow-up after AVR. Twelve patients with severe AS who underwent AVR were prospectively examined (mean age 65 +/- 11 years, 7 men). Systolic and diastolic ascending aortic diameters (SD and DD, respectively) were recorded in M mode 3 cm above the aortic valve from a parasternal long-axis view. The SD and DD were measured at the time of maximum anterior motion of the aorta and at the start of the QRS complex, respectively. Aortic stiffness index (beta) was defined as [ln(SBP/DBP)] x DD/deltaD, where ln is the natural logarithm, SBP and DBP are the systolic and diastolic blood pressure values, respectively, and deltaD = SD - DD. As expected, aortic stenosis severity and left ventricular mass decreased significantly after AVR. Aortic diameter changes (systolic minus diastolic dimensions) progressively increased and the aortic stiffness index progressively improved to levels comparable with those of age-, sex-, and risk factor-matched controls at the 1-year assessment. Aortic valve replacement in patients with AS is associated with a progressive improvement in aortic distensibility to 1-year values similar to those of controls.
Background: Behcet’s disease is an autoimmune disease characterized by diffuse vasculitis and ora... more Background: Behcet’s disease is an autoimmune disease characterized by diffuse vasculitis and oral and genital ulcers. Coronary vasculitis is a rare finding in Behcet’s disease and only reported in few cases. Case summary: A 47-year-old male patient was recently diagnosed as Behcet’s disease and admitted as inferior ST elevation myocardial infarction. Coronary angiogram revealed coronary aneurysm in posterior descending artery with TIMI III flow. The patient was managed medically with immunosuppressive therapy and he discharged after 5 days in a stable condition. Patient was seen in the clinic after one month and he was asymptomatic. Conclusion: Coronary involvement in patients with Behcet’s disease is rare; however, it can be associated with myocardial infarction. Medical management with steroid and immunosuppressive therapy is the mainstay of therapy. Coronary intervention might be required in some cases with ongoing ischemia.
Aim: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral sten... more Aim: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral stenosis using the three-dimensional (3D) scoring system. Methods: A two-staged study was conducted. The first stage was designed to select the best 3D images of MV leaflets and chordae through analysis of 471 images. The second stage was designed to organize the best 3D images into protocols for complete scoring of MV. It included 35 consecutive patients; 23 had sinus rhythm (SR) and 12 had atrial fibrillation (AF). Both single- and multi-beat 3D acquisition from apical and parasternal windows were focused on MV leaflets and chordae using all 3D modalities (live, zoom, and full volume). To propose the protocols, 1563 images were analyzed. Results: In SR with good apical window, 2 protocols were recommended for complete scoring of leaflets and chordae (4 zoom 3D images [1 image for leaflets and 3 images for chordae] and 1 full-volume 3D image) using single- and multi-beat acquisition. In AF, the same 2 protocols using single-beat acquisition were recommended. From parasternal window, complete scoring of leaflets was obtained by 3 recommended protocols (single- or multi-beat zoom 3D images from parasternal short axis [PSAX], multibeat live 3D images from PSAX, and single- or multi-beat full-volume 3D images from parasternal long axis) in SR and 1 protocol in AF (single-beat zoom 3D images from PSAX). Scoring of chordae was incomplete in all patients by all 3D modalities. Conclusions: The proposed 3D-transthoracic echocardiography protocols suit all patients regardless of echo window and heart rhythm and enabled complete MV scoring.
Tricuspid annulus (TA) evaluation continues to be a major problem in the surgical decision-making... more Tricuspid annulus (TA) evaluation continues to be a major problem in the surgical decision-making process. Obviously, 2-dimensional transthoracic echocardiography (2D TTE) is limited in TA visualization due to its complex 3D shape. The study aimed to determine TA morphology, size and function with real-time three-dimensional echocardiography (RT3DE) in 40 patients divided into two equal groups (I: normal TA and II: dilated). 2D TTE measurements included TA diameter (TAD) at apical 4-chamber (AP4CH) and parasternal short axis (PSAX) views. RT3DE measurements included TA area (TAA), major TAD and minor TAD. TA fractional shortening (TAFS), and TA fractional area change (TAFAC) were calculated from end-systolic and end-diastolic measurements. RT3DE allowed visualization and measurement of the entire oval-shaped TA in all patients irrespective of its size (normal or dilated). 2D TTE measurement of TAD at both AP4CH and at PSAX views was significantly smaller than the major TAD measured ...
# The Author(s) 2011. This article is published with open access at Springerlink.com Abstract Non... more # The Author(s) 2011. This article is published with open access at Springerlink.com Abstract Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheterbased balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by twodimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.
License, which permits unrestricted use, distribution, and reproduction in any medium, provided t... more License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aim of Study. To assess the feasibility of a new proposedmaneuver “RATLe-90 ” using real-time three-dimensional transesophageal echocardiography (RT-3DTEE) for anatomically oriented visualization of the interatrial septum (IAS) in guiding the transseptal puncture TSP.Methods. The study included 20 patients (mean age, 60.2 ± 6.7 years; 60 % males) who underwent TSP for different indications. RT-3DTEEwas used to guide TSP.The proposedmaneuver RATLe-90 (Rotate-Anticlockwise-Tilt-Left-90) was applied in all cases to have the anatomically oriented en face view of the IAS from the right atrial (RA) aspect. Having this anatomically oriented view, we guided the TSP catheter towards the proper puncture site according to the planned procedure. Results. Using the RATLe-90 maneuver, the anatomically oriented en face view of the IAS from the RA was obtained in all ...
Spectral pulsed-wave tissue Doppler imaging lateral-to-septal delay fails to predict clinical or ... more Spectral pulsed-wave tissue Doppler imaging lateral-to-septal delay fails to predict clinical or echocardiographic outcome after cardiac
Practical Manual of Tricuspid Valve Diseases, 2018
Tricuspid valve disease is common but often has less attention than in the left side of the heart... more Tricuspid valve disease is common but often has less attention than in the left side of the heart. Functional tricuspid regurgitation if left untreated is associated with unfavorable outcome. Moreover, tricuspid valve surgery is often associated with higher complications than for any other surgical valve intervention. Transthoracic echocardiography (TTE) is the gold standard imaging of choice in the assessment of tricuspid valve disease. TTE has many sub modalities such as the M-mode, 2D and 3D modes, the bi-plane mode and the recently introduced iRotate mode. Furthermore, Doppler interrogation of the tricuspid valve as well as blood flow over other cardiac valves, pulmonary, aortic, hepatic venous flow is the mainstay in hemodynamic assessment of patients with tricuspid valve disease. TTE role begins with screening for the presence or absence and type of tricuspid valve disease. Moreover, determination of the etiology, severity of the tricuspid lesion, associated other valvular problems and chamber quantification are part of an imaging protocol/approach, which required for full diagnosis of tricuspid valve disease. Pre-operative and pre-catheter interventional planning can be performed by TTE. Finally, post interventional outcome as well as follow-up is often determined via TTE. In this chapter, we will provide a comprehensive and state-of-the art overview of the use of TTE for the assessment of TV disease. Advantages as well as limitations of each TTE sub modality will be outlined. A perspective on the value of TTE in the era of percutaneous transcatheter TV interventions will also be highlighted.
Uploads
Papers by Ashraf M Anwar