Publications by authors named "Domenico Galzerano"

36 Publications

Severe Rheumatic Mitral Stenosis, Worse Left Atrial Mechanics is Closely Associated with Echo Criteria for Intervention.

J Cardiovasc Echogr 2022 Jan-Mar;32(1):38-46. Epub 2022 Apr 20.

University of Glasgow, Adult Congenital Cardiac Service, Glasgow, Scotland.

Background: Rheumatic mitral valve (MV) stenosis is associated with progressive left atrial (LA) fibrosis and functional impairment, Pulmonary artery systolic pressure (PASP) and right ventricular (RV) dysfunction. The aims of the study were to determine in those patients with severe MV stenosis if LA mechanical function as assessed by speckle tracking echocardiography could identify those with increased PASP, atrial fibrillation (AFib), and RV dysfunction.

Subjects And Methods: Patients with severe MV stenosis were identified from the institutional echo database. Echocardiograms were read off line and measurements included atrial and ventricular strain. Patients were divided into tertiles of LA reservoir strain (LASr) values and data compared between the groups.

Results: Ninety-seven patients, 67 females, mean age 47.4 ± 11.9 years, had MV mean gradient of 8.3 ± 5.1 mmHg, MV area by pressure half time of 1.3 ± 0.3 cm and LASr of 11.18% ± 6.4%. Those patients in the lowest LASr tertile had more AFib (72%, = 0.0001), PASP >50 mm Hg (39%, = 0.005), and worst RV impairment. In multivariable logistic regression analysis, LASr, age, and mean MV gradient were the independent predictors of AFib and PASP >50 mm Hg. Cutoffs, determined by receiver operating characteristic curve analysis had high specificity for the composite outcome of Afib and PASP >50 mmHg (85% for LASr <7.7%).

Conclusion: In severe MV stenosis LASr, age and mean MV gradient, are independent predictors of Afib and PASP >50 mmHg. LASr <7.7% has high sensitivity and specificity in identifying those who meet ESC guideline 2017 criteria for valve intervention, suggesting its potentially helpful addendum to the surveillance of patients with MV stenosis.
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http://dx.doi.org/10.4103/jcecho.jcecho_80_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9164921PMC
April 2022

Right-sided infective endocarditis and pulmonary embolism: a multicenter study.

Monaldi Arch Chest Dis 2022 Apr 12. Epub 2022 Apr 12.

Cardiology Unit, Polyclinic Hospital, Bari.

The incidence of right-sided infective endocarditis (RSIE) is steadily increasing and it has been reported to be associated with high risk of embolic events (EE). Aim of our study was to identify the clinical characteristics of patients with RSIE complicated by PE. Indeed, the identification of patients at high risk of significant PE who will benefit from a more aggressive therapeutic strategy may improve the prognosis. From January 2015 to September 2020, 176 patients (Pts) in 6 centers were found to have definite RSIE complicated by PE. Advanced imaging for PE including computed tomography pulmonary angiography (CTPA) was performed in 28 pts (16%) who represent our study group (24 male, mean age 50.6 ±18.29 years). They all underwent transesophageal echocardiography (TEE), in 12 cases (43%) also three-dimensional (3D) TEE, and 27 patients (99%) had both TEE and transthoracic echocardiography (TTE). A total of 53 vegetations (V) were detected. In 18 pts (64%) two or more vegetations were found. Native tricuspid valve was the most frequently involved valve (38 V, 71.7%), followed by catheter (5 V, 9.4%), tricuspid valve prosthesis (4 V, 7.5%), chordae and papillary muscle (2 V, 3.8%) and one vegetation (9%) in each of the following: pulmonic valve, inferior vena cava, eustachian valve, and right atrium. The most common location for vegetations was the anterior leaflet of the tricuspid valve (19 V, 35.8 %) followed by the posterior leaflet (11 V, 20.8%). The most common vegetations morphology was raceme-like shaped (35.8%). Staphylococcus aureus (S. aureus) was the most common causative pathogen (14 pts, 50%). The incidence of PE was very high in patients with vegetation length above 1.5 cm (median 17.6±6.5 mm by TEE). Our results suggest that a routine CTPA should be advised in the presence of vegetations larger than 1.5 cm and with S. aureus infection. This behavior would identify patients at high risk of PE who will benefit from a more aggressive therapeutic strategy, leading to an improvement in the prognosis. Further prospective studies are required to better confirm our hypothesis.
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http://dx.doi.org/10.4081/monaldi.2022.2251DOI Listing
April 2022

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves.

Monaldi Arch Chest Dis 2021 Dec 3;92(2). Epub 2021 Dec 3.

Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh.

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.
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http://dx.doi.org/10.4081/monaldi.2021.2065DOI Listing
December 2021

Preoperative Assessment and Management of Cardiovascular Risk in Patients Undergoing Non-Cardiac Surgery: Implementing a Systematic Stepwise Approach during the COVID-19 Pandemic Era.

J Cardiovasc Dev Dis 2021 Oct 3;8(10). Epub 2021 Oct 3.

Orthopedic Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy.

Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.
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http://dx.doi.org/10.3390/jcdd8100126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8541645PMC
October 2021

Features and behavior of valvular abnormalities in adolescent and adult patients in mucopolysaccharidosis: an echocardiographic study.

Monaldi Arch Chest Dis 2021 Aug 9;91(4). Epub 2021 Aug 9.

Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua.

Mucopolysaccharidoses, a rare inherited disorder of lysosomal storage, account for less than 0.1% of all genetic diseases.  The penetrance is highly variable and clinically it varies from severe fetal-neonatal forms to attenuated diseases diagnosed in adult individuals. The majority of the patients have been reported to show cardiac abnormalities since pediatric age, however, there is a minority of patients with attenuated disease diagnosed in the adolescent and adult age. The haematopoietic stem cell transplantation and enzyme replacement therapy are the current therapies for these disorders. Thanks to these treatments, Mucopolysaccharidoses patients live longer than in the past. Even though enzyme replacement therapy has been demonstrated to reduce left ventricular mass in patients with cardiomyopathy, the efficacy on valve abnormalities has not been clearly demonstrate yet. Furthermore, thanks to the current therapy, to better understanding and to the advent on new technologies, an increasing number of adolescent and adult patients diagnosed with MPS are followed up in the adult echocardiographic laboratory. Indeed, a systematic descriptive study describing the echocardiographic features of valvular involvement and their evolution in adolescent and adult patients lacks of medical literature and this was the aim of our investigation. Our results showed that all the valves are affected, mainly the mitral valve with a higher prevalence compared to the pediatric age.  The echocardiographic features of MPS differs from other valvular disease of adolescent and adult age, and knowing them can avoid misdiagnosis. Our observations also suggest that the progression of cardiac involvement slows after the initiation of the therapy in our group of age. Further studies on larger population are required to confirm our results.
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http://dx.doi.org/10.4081/monaldi.2021.1767DOI Listing
August 2021

Giant Iatrogenic Pseudoaneurysm of Right Pulmonary Artery Compressing the Left Atrium.

JACC Case Rep 2020 Jun 17;2(6):870-872. Epub 2020 Jun 17.

The Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.

We describe a case of giant pseudoaneurysm of the right pulmonary artery compressing the left atrium after percutaneous pulmonary valve implantation and right pulmonary artery dilatation. Such a complication mimicking an intracavity left atrial mass and treated successfully by stent placement has never, to the best of our knowledge, been reported. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.03.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302032PMC
June 2020

Spectral Doppler Interrogation of the Pulmonary Veins for the Diagnosis of Cardiac Disorders: A Comprehensive Review.

J Am Soc Echocardiogr 2021 03 22;34(3):223-236. Epub 2020 Oct 22.

King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; Alfaisal University, Riyadh, Saudi Arabia; CHU Limoges, Limoges, France.

Data obtained from echocardiographic studies are used on a daily basis to guide clinical decision-making regarding patient management and the need for additional diagnostic investigations. Interrogation of blood flow in the pulmonary veins by spectral, most often pulsed-wave, Doppler is an important component of any comprehensive echocardiographic study. Whereas it is most often used to help assess left-sided filling pressure and quantify the severity of mitral regurgitation, the pulmonary vein Doppler profile provides added diagnostic insights into several disorders that affect heart function and allows assessment of their hemodynamic consequences on the heart. The aim of this review is to summarize current knowledge in the field of PV Doppler interrogation, highlight the physiological and pathological parameters that influence it, and delineate the manifestations of various cardiovascular disorders on the flow profile.
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http://dx.doi.org/10.1016/j.echo.2020.09.012DOI Listing
March 2021

Contrast transesophageal three dimensional echocardiographic imaging for patent foramen ovale: a needful role?

Monaldi Arch Chest Dis 2020 Oct 19;90(4). Epub 2020 Oct 19.

The Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh; College of Medicine, Alfaisal University, Riyadh.

We report a case of a 55-year-old male admitted for cardiogenic embolic ischemic stroke work up. A transesophageal (TE) echocardiography (E) with contrast study to rule out patent foramen ovale (PFO) was performed; two-dimensional (2D) analysis did not detect any bubbles passage during Valsalva manoeuvre in the standard 2D cross sectional planes; further real time three-dimensional (3D) TEE imaging revealed passage of bubbles in the left atrium (LA) by both real-time 3DTEE imaging and by the 2D unconventional cross-sectional planes allowed by 3DTEE imaging. Even though 2DTEE is considered to be the gold standard modality for diagnosing PFO, it has some limitations. It has never been reported about usefulness of 3DTEE in PFO imaging. Even in the presence of only a report, our case suggests that 3DE could have an additional value and will compliment 2D imaging in PFO assessment.
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http://dx.doi.org/10.4081/monaldi.2020.1278DOI Listing
October 2020

Beyond the Imagination: An Incredible Upside Down Flip.

Circ Cardiovasc Imaging 2020 10 25;13(10):e010998. Epub 2020 Sep 25.

The Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia (M.A., D.G., O.V., M.A.A., M.A., A.F.F.).

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http://dx.doi.org/10.1161/CIRCIMAGING.120.010998DOI Listing
October 2020

The validity of a daytime ambulatory blood pressure to diagnose masked hypertension.

Monaldi Arch Chest Dis 2020 Jul 29;90(3). Epub 2020 Jul 29.

Princess Noorah Oncology Centre; King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah.

Masked hypertension (MH) is traditionally diagnosed with 24-hour ambulatory blood pressure monitoring (24-ABPM). This is relatively costly and could cause discomfort during the night. We studied the validity of daytime ABP (DT-ABPM) in young National Guard soldiers and determined the prevalence in comparison to the standard 24-ABPM. A prospective study of 196 soldiers aged 21-50 years, without a history of hypertension or antihypertensive medication use. Each participant was fitted with a 12h-ABPM. Patients were diagnosed with MH if the office blood pressure (OBP) was <140/90 mmHg and the average DT-ABPM was ≥135/85 mmHg. By pairing the average OBP with the 12 h-ABPM, the prevalence of MH was estimated as 18/196 (9.2%), the SBP MH (systolic blood pressure) of 8.2% and the DPB MH (diastolic blood pressure) of 3.1%.  When we compared the daytime prevalence with the 24 h-ABPM, and the average OBP, the prevalence of MH was 29/196 (14.8%). No statistically significant difference was noted (kappa=0.74; 95% CI: 0.59 to 0.88). We conclude that DT-ABPM is a good method and convenient to detect MH, with no statistically significant difference when compared to the 24 h-ABPM. The prevalence of MH in young healthy soldiers was unexpectedly high.
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http://dx.doi.org/10.4081/monaldi.2020.1356DOI Listing
July 2020

The long term results of the Ross procedure: The importance of candidate selection.

Int J Cardiol 2020 Dec 15;320:35-41. Epub 2020 Jul 15.

The Heart Centre, King Faisal Specialist Hospital and research centre, Riyadh, Saudi Arabia.

The Ross procedure has been considered in children as an optimal surgical procedure due to potential growth of the aortic annulus, lack of anticoagulation requirement, very low morbidity rate and excellent survival. Five-hundred-thirty-six (366 male, mean age 29.4 ± 11.1 years) underwent Ross procedure between 1990 and 2016 and had complete clinical and echocardiographic follow-up. Mean follow-up was 16.3 ± 4.9 years. Patients were divided in 2 groups according to age at surgery. Group 1 consisted of 320 (60%) patients less than 18 years old (223 male, mean age at surgery of 9.5 ± 5.6 years). Group 2 consisted of 216 (40%) patients older than 18 years of age (143 male, mean age at surgery of 26.3 ± 8.2 years). One-hundred-thirty (24%) patients had a redo procedure or surgery. Freedom from all re-operation and or percutaneous reintervention on either the aortic and pulmonary valves was 99% after 1 year, 94% after 5 years, 89% after 10 years, 83% after 15 years and 78% after 20 years. Freedom from redo surgery for AV 99% after 1 year, 94% after 5 years, 90% after 10 years, 81% after 15 years and 80% after 20 years. Freedom from redo surgery for PV was 100% after 1 year, 95% after 5 years, 89% after 10 years, 78% after 15 years and 76% after 20 years. The ideal candidate for Ross operation is a patient with congenital aetiology and an aortic root diameter ≤ 15 mm/m. A pulmonary fresh preserved homograft seems to perform better on the long term.
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http://dx.doi.org/10.1016/j.ijcard.2020.07.009DOI Listing
December 2020

Imaging Cardiovascular Emergencies: Real World Clinical Cases.

Heart Fail Clin 2020 Jul;16(3):331-346

Division of Cardiac Rehabilitation - Echo Lab, A Cardarelli Hospital, Naples, Italy. Electronic address:

Cardiovascular emergencies represent life-threatening conditions requiring a high index of clinical suspicion. In an emergency scenario, a simple stepwise biomarker/imaging diagnostic algorithm may help prompt diagnosis and timely treatment along with related improved outcomes. This article describes several clinical cases of cardiovascular emergencies, such as coronary stent thrombosis-restenosis, takotsubo syndrome, acute myocarditis, massive pulmonary embolism, type A acute aortic dissection, cardiac tamponade, and endocarditis.
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http://dx.doi.org/10.1016/j.hfc.2020.03.003DOI Listing
July 2020

Cavitation phenomenon in mechanical prosthetic valves: Not only microbubbles.

Echocardiography 2020 06 16;37(6):876-882. Epub 2020 May 16.

Dipartimento Ingegneria e Architettura, University of Trieste, Trieste, Italy.

Introduction: Microbubbles (MBs) or cavitation is high-velocity, echo-bright findings present during the closing or opening of a mechanical valve (MVP). Cavitation bubble growth or gas emboli are less frequently described. We evaluated the hemodynamic parameters involved in the formation of gas emboli and the impact of gas emboli on requests for additional investigations.

Methods And Results: Transthoracic echocardiographic studies (TTE) of 57 patients (31 males, mean age 46.8 ± 13.8 years) with gas emboli were evaluated after heart valve replacement surgery. The majority (72%, n = 42) had a mitral or combined mitral/aortic MVP, with 28% (n = 16) an aortic MVP. The last TTE with and without gas emboli were considered for the same patient and the no emboli group was the control group (42 patients). The patient's blood pressure (BP) and heart rate (HR) were available for each TTE. Comparing the two TTEs, the systolic and diastolic BP, transmitral and aortic gradients, and left ventricular ejection fraction were similar but the HR (80.9 ± 18.7 vs 72.5 ± 13.9 bpm, P = .02) was significantly higher in the group with gas emboli. A TEE was performed 52 times in 27 patients, due to gas emboli, with one case positive for thrombus/vegetation. For 19 patients, a brain CT was requested. In two patients, the indication for the brain CT was gas emboli but the result was negative.

Conclusion: Gas emboli are frequently present and associated to an increased HR. They can cause the misdiagnosis of endocarditis or thrombus formation with significant additional requests for diagnostic examinations.
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http://dx.doi.org/10.1111/echo.14692DOI Listing
June 2020

Three dimensional echocardiographic imaging of multiple recurrent myxomas.

Monaldi Arch Chest Dis 2020 Jan 21;90(1). Epub 2020 Jan 21.

College of Medicine, King Saud University, Riyadh.

We report a case of a recurrence of 5 cardiac myxomas in both atria with atypical anatomical features difficult to image. Although a multimodality imaging was performed, three-dimensional echocardiography (3DE) was the only technique able to correctly identify all the recurrences and the anatomical characteristics of the myxomas. MRI detected the blood supply of the mass but even after careful review was able to identify only 4 of the 5 lesions. Even though it was already reported the usefulness of 3DE to better delineate the site of attachment of cardiac tumors, it was never reported its sensibility in the setting of multiple myxomas; this case highlights the ability of the 3DE in this challenging scenario and its potential for being considered the key adjunctive modality for the anatomy when advanced surgical plan is required.
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http://dx.doi.org/10.4081/monaldi.2020.1188DOI Listing
January 2020

Three dimensional transesophageal echocardiography: a missing link in infective endocarditis imaging?

Int J Cardiovasc Imaging 2020 Mar 4;36(3):403-413. Epub 2020 Jan 4.

Ecocardiografia Basale e Complessa, Azienda Ospedaliera Universitaria, Policlinico di Bari, Bari, Italy.

The role of two dimensional (2D) echocardiography (ECHO) for the diagnosis and clinical decision making in infective endocarditis (IE) has been extensively studied and described in the medical literature. Some reports have demonstrated the incremental value of three dimensional (3D) transesophageal (TE) ECHO in the setting of IE. However, a systematic review focusing on the role of 3D imaging is lacking. In this manuscript, we examine the role of 3D TE ECHO in the diagnosis of IE. IE is a challenging disease in which 2D transthoracic (TT) and TE ECHO have complementary roles and are unequivocally the mainstay of diagnostic imaging. Still, 2D imaging has important limitations. Technological advances in 3D imaging allow for the reconstruction of real-time anatomical images of cardiac structure and function. 3D imaging has emerged as a diagnostic technique that overcame some of the limitations of 2D ECHO. Currently, both transthoracic and transesophageal echocardiography transducers are able to generate 3D images. However, 3D TE ECHO provides images of a higher quality in comparison to 3D TT ECHO, and is the best echocardiographic modality able to allow for a detailed anatomical imaging. 3D TE ECHO may represent the key adjunctive echocardiographic technique being able to positively impact on IE-related surgical planning and intervention and to facilitate the interaction between the surgeon and the imaging specialist. Importantly, 3D TE ECHO is not the recommended initial modality of choice for the diagnosis of IE; however, in highly specialized centers, it has become an important complementary technique when advanced surgical planning is required. Furthermore, anatomical imaging has become the link between the different techniques that play a role in IE imaging. In fact, both computed tomography and magnetic resonance allow three dimensional reconstruction. An important future goal should allow for the fusion among various imaging modalities. Our review highlights the role of 3D TE ECHO in IE imaging and emphasize where it offers incremental value.
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http://dx.doi.org/10.1007/s10554-019-01747-xDOI Listing
March 2020

A rare case of takotsubo syndrome within the first day after heart transplantation.

Monaldi Arch Chest Dis 2019 Oct 7;89(3). Epub 2019 Oct 7.

Cardiology Center, King Saud Medical City, Riyadh.

A 39-year-old woman underwent heart transplantation (HTx) for advanced heart failure. The donor was a 36-year-old young woman without past medical history. The first day after HTx, T-waves changes were noted. Echocardiography revealed akinesia/dyskinesia of all basal segments of the two ventricles. Coronary catheterization plus biopsy were done 7 days later showing no coronary obstruction, no rejection and complete recovery of wall motion abnormalities on echocardiogram, suggesting biventricular inverted takotsubo syndrome (TTS). This is a case of TTS during the first day after HTx, with completely denervated heart but because of the inotropic drug support it still represents a target for catecholamine-induced cardiac dysfunction.
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http://dx.doi.org/10.4081/monaldi.2019.1149DOI Listing
October 2019

Sudden death as a first manifestation of left atrium thrombus in rheumatic severe mitral stenosis.

J Cardiol Cases 2019 Sep 6;20(3):99-102. Epub 2019 Jul 6.

Echocardiography Department, Heart Centre, MBC-16, King Faisal Specialist Hospital & Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia.

Left atrium and left atrial appendage thrombus is common in patients with mitral stenosis, causing significant morbidity and mortality. We described a case of rheumatic mitral stenosis, a 48-year-old female patient, who had undergone percutaneous transvenous mitral commissurotomy 26 years back. She presented with an episode of palpitations and breathlessness on mild exertion. She found to have rapid atrial fibrillation and heart failure. Her echocardiography showed severe mitral stenosis and large left atrial thrombus intermittently obstructing the mitral valve. While she was prepared for urgent valve replacement she had cardiac arrest and died. The echocardiogram showed the thrombus was stuck and closed the mitral valve orifice. From this events we did a review in our institution about the mitral stenosis patients who found to have left atrium thrombus by routine transthoracic echocardiography in five years period. Looking for factors contributing to thrombus formation and outcome predictor, as to outline management plan. < Our aim is to give more attention to the factors contributing for left atrium thrombus formation and thrombus character in mitral stenosis patients and its clinical impact to prevent miserable events in such high risk patients.>.
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http://dx.doi.org/10.1016/j.jccase.2019.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718824PMC
September 2019

Age related structural and functional changes in left ventricular performance in healthy subjects: a 2D echocardiographic study.

Int J Cardiovasc Imaging 2019 Nov 11;35(11):2037-2047. Epub 2019 Jul 11.

U.O.C Riabilitazione Cardiovascolare, A Cardarelli, Naples, Italy.

Left ventricular (LV) adaptation to aging is currently poorly understood. We aimed to characterize age related changes in LV structure and function by studying a large group of healthy subjects across a wide age range. Prospectively enrolled healthy volunteers (n = 778, 327 females; age 18 to 100 years, mean age 49.8 ± 18.1 years), were divided into 4 age groups: 18 to 34 years (n = 165); 35 to 49 years (n = 242), 50 to 79 years (n = 334) and ≥ 80 years (n = 40). All subjects underwent clinical examination, as well as comprehensive transthoracic echocardiogram [TTE]. Body mass index, systolic blood pressure (BP), and left atrial volume (p < 0.0001) increased with age while diastolic BP (p < 0.0001) decreased over time. LV mass/body surface area (BSA) and relative wall thickness increased with age (p < 0.0001) coincident with worsening parameters of diastolic function (E/A and E/Em, p < 0.0001). The ejection fraction and Sm did not change significantly. Stroke volume, ejection time index, flow rate and stroke work significantly increased with age (p < 0.01). The arterial elastance (Ea), a measure of ventricular afterload, and ventricular elastance (Ees), an index of LV systolic stiffness did not change with age nor did their ratio (Ees/Ea) the latter being an expression of ventricular-arterial coupling. Age, gender and LVM were the main independent variables associated with LV systolic function. In conclusion, LV adaptation to aging in a healthy cohort is characterized by concentric LV remodeling, increased contractility and preserved ventricular-arterial coupling.
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http://dx.doi.org/10.1007/s10554-019-01665-yDOI Listing
November 2019

Three-Dimensional Echocardiographic Imaging of a Gerbode Defect Complicating Transcatheter Aortic Valve Replacement.

J Cardiovasc Echogr 2019 Jan-Mar;29(1):14-16

The Heart Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

We describe a case of a 77-year-old male who underwent transcatheter aortic valve implantation (TAVR) with Edwards SAPIEN XT size 26 mm for severe aortic stenosis. Postprocedural transesophageal echocardiography (TEE) showed left-to-right shunt between the left ventricular outflow tract just below the bioprosthesis and the right atrium across the atrioventricular septum (Gerbode defect). Three-dimensional echocardiography (3DE) allowed a detailed anatomical imaging of the shape and the location of a small, circular, atrioventricular defect that was a type II, direct, supravalvular, Gerbode-type defect. This is the third report of a Gerbode defect after TAVR whose diagnosis has important implications on clinical decision-making. TEE plays a key role; its diagnostic ability is enriched by the additional value of 3DE.
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http://dx.doi.org/10.4103/jcecho.jcecho_56_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450239PMC
April 2019

Manifestations of Cardiovascular Disorders on Doppler Interrogation of the Hepatic Veins.

JACC Cardiovasc Imaging 2019 09 13;12(9):1872-1877. Epub 2019 Mar 13.

Heart Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; Alfaisal University, Riyadh, Saudi Arabia; CHU Limoges, Limoges, France. Electronic address:

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http://dx.doi.org/10.1016/j.jcmg.2019.01.028DOI Listing
September 2019

The role of 3D echocardiographic imaging in the differential diagnosis of an atypical left atrial myxoma.

Monaldi Arch Chest Dis 2018 09 4;88(3):906. Epub 2018 Sep 4.

King Faisal Specialist Hospital & Research Center, Heart Center.

We describe a case of a left atrial myxoma atypical for its anatomical features and site of attachment. Although an initial multimodality imaging was performed, the diagnosis of myxoma was possible only by three dimensional echocardiography (3DE) which was able to identify the pedicle and the attachment at the base of the interatrial septum, close to the origin of right inferior pulmonary vein. In fact the 3DE can electronically section the structures and obtain unique planes useful in visualizing correctly the anatomical features of the myxomas and as a result, it facilitates the surgical decision planning. Even the anatomical appearance was uncommon at surgery and the diagnosis could be confirmed only by pathology.  This case highlights the diagnostic ability of the 3DE in similar challenging scenarios.
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http://dx.doi.org/10.4081/monaldi.2018.906DOI Listing
September 2018

A Case of Shunting Postoperative Patent Foramen Ovale Under Mechanical Ventilation Controlled by Different Ventilator Settings.

Clin Pract 2017 Jun 4;7(3):969. Epub 2017 Aug 4.

The Heart Centre, King Faisal Specialist Hospital and Research Centre, Ryadh, Saudi Arabia.

A 56-year old male with ischemic heart disease and an unremarkable preoperative echocardiogram underwent surgical coronary revascularization. An intraoperative post pump trans-esophageal echocardiogram (TOE) performed while the patient was being ventilated at a positive end expiratory pressure (PEEP) of 8 cm HO demonstrated a right to left interatrial shunt across a patent foramen ovale (PFO). Whereas oxygen saturation was normal, a reduction of the PEEP to 3 cm HO led to the complete resolution of the shunt with no change in arterial blood gases. Attempts to increase the PEEP level above 3 mmHg resulted in recurrence of the interatrial shunt. The remaining of the TEE was unremarkable. Mechanical ventilation, particularly with PEEP, causes an increase in intrathoracic pressure. The resulting rise in right atrial pressure, mostly during inspiration, may unveil and pop open an unrecognized PFO, thus provoking a right to left shunt across a seemingly intact interatrial septum. This phenomenon increases the risk of paradoxical embolism and can lead to hypoxemia. The immediate management would be to adjust the ventilatory settings to a lower PEEP level. A routine search for a PFO should be performed in ventilated patients who undergo a TEE.
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http://dx.doi.org/10.4081/cp.2017.969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5558089PMC
June 2017

Use of multidetector-row computed tomography scan to detect pannus formation in prosthetic mechanical aortic valves.

J Thorac Dis 2017 Apr;9(Suppl 4):S343-S348

Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.

Obstruction of a mechanical aortic valve by pannus formation at the subvalvular level is a major long-term complication of aortic valve replacement (AVR). In fact, pannus is sometime difficult to differentiate from patient-prosthesis mismatch or valve thrombosis. In most cases cine-angiography and echocardiography, either transthoracic or transesophageal, cannot correctly visualize the complication when the leaflets show a normal mobility. Recent technological refinements made this difficult diagnosis possible by ECG-gated computed tomography (CT) scan which shows adequate images in 90% of the cases and can differentiate pannus from fresh and organized thrombus.
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http://dx.doi.org/10.21037/jtd.2017.04.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422672PMC
April 2017

Gothic aortic arch and cardiac mechanics in young patients after arterial switch operation for d-transposition of the great arteries.

Int J Cardiol 2017 Aug 11;241:163-167. Epub 2017 Mar 11.

King Faisal Specialist Hospital and Research Centre, Al Faisal University, Heart Center, Riyadh, Saudi Arabia.

Background: In patients who have undergone arterial switch operation (ASO) for d-transposition of the great arteries a gothic aortic arch (GA) morphology has been found and it has been associated with abnormal aortic bio-elastic properties.

Hypothesis: GA is frequent in ASO patients and may have an impact on cardiac mechanics. Our study aims were to assess 1- the occurrence of GA in a large sample of patients after ASO; 2- the association between GA and aortic bio-elastic properties; and 3- the impact of GA on left ventricular (LV) function using speckle tracking echocardiography (STE).

Methods: We studied one hundred and five asymptomatic patients, who have undergone first stage ASO for d-TGA, with normal left ventricular ejection fraction (LVEF ≥53%).

Results: Forty-six (44%) patients showed a GA (mean age 11.5±7.2years, 26 males) while fifty-nine (56%) patients (mean age 9.6±6.7years, 37 males) did not present GA. The two groups were comparable for age, sex, BSA, and office blood pressure values. In group GA aortic root was significantly dilated (27.4±7.5mm vs. 21.2±6.9mm, p<0.0001), aortic stiffness index (Group GA=1.8±1.2 vs. 1.4±0.7, p=0.025) was significantly increased, left atrial volume was larger (p=0.0145), global longitudinal strain (Group GA=-18.4±2.5% vs. -20.1±3.3%, p=0.012) and basal LV longitudinal strains (Group GA=-16.9±4.8% vs. -20.4±7.0%, p=0.013) were significantly reduced.

Conclusions: After ASO the presence of a GA is associated with a significantly dilated aortic root, stiffer aortic wall, larger left atrial volume, and worse LV longitudinal systolic deformations, well known predictors of cardiovascular morbidity and mortality.
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http://dx.doi.org/10.1016/j.ijcard.2017.03.044DOI Listing
August 2017

Left Ventricular Mechanics in Patients with Abnormal Origin of the Left Main Coronary Artery from the Pulmonary Trunk Late after Successful Repair.

Cardiology 2017;136(2):71-76. Epub 2016 Aug 26.

King Faisal Specialist Hospital and Research Center, Al Faisal University Heart Center, Riyadh, Saudi Arabia.

Objective: Our aim was to evaluate left ventricular (LV) mechanics by using speckle tracking echocardiography (STE) in asymptomatic patients with abnormal origin of the left main coronary artery from the pulmonary trunk (ALCAPA), late after successful repair, in the presence of LV ejection fraction (EF) >50%.

Methods: We studied 30 ALCAPA patients (median age 4 years, range 1-25 years, NYHA class I, LVEF >50%) and 16 healthy age- and sex-matched controls (median age 5 years, range 1-25 years). All underwent standard echocardiographic evaluation and STE.

Results: LV dimensions and LVEF (63.6 ± 8.2% vs. 64.1 ± 5.1%, p = 0.826) were not different between patients and controls. Diastolic parameters were significantly abnormal in our patients versus controls (E/e' average: 11.9 ± 5.8 vs. 6.6 ± 3.0, p = 0.0014). Global LV longitudinal strain was significantly lower in ALCAPA patients versus controls (-17.6 ± 3.5% vs. -23.4 ± 3.1%, p < 0.0001). LV torsion (9.1 ± 4.9° vs. 11.9 ± 3.3°, p = 0.046) was significantly impaired in ALCAPA patients.

Conclusions: After successful repair in asymptomatic ALCAPA patients, despite an LVEF >50%, diastolic function, LV longitudinal deformation and LV torsion remain impaired. We suggest including a detailed study of the diastolic function and cardiac mechanics in the clinical follow-up of these patients to identify the subgroup of patients at higher risk.
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http://dx.doi.org/10.1159/000447961DOI Listing
August 2018

Intermittent Malfunction of a Prosthetic Valve-A Diagnostic Challenge.

Echocardiography 2016 Jun 16;33(6):916-9. Epub 2016 Mar 16.

King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.

Intermittent malfunction of a mechanical valve prosthesis is a rare condition that carries serious clinical implications. It results from the periodic entrapment of a prosthetic disk in either an open or closed position leading to transient intravalvular regurgitation or obstruction to flow. The intermittent nature of the malfunction poses a diagnostic challenge, particularly in the era of digital echocardiography. In this manuscript, we describe the Doppler and two-dimensional echocardiographic findings in a patient with intermittent prosthetic mitral valve malfunction.
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http://dx.doi.org/10.1111/echo.13210DOI Listing
June 2016

Massive pericardial effusion without cardiac tamponade.

Eur Heart J 2016 09 3;37(33):2612. Epub 2016 Mar 3.

Second University of Naples, Monaldi Hospital, Naples, Italy.

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http://dx.doi.org/10.1093/eurheartj/ehw076DOI Listing
September 2016

An unusual myocardial infarction.

Echo Res Pract 2014 Dec 13;1(2):K9-K12. Epub 2014 Oct 13.

Department of Cardiovascular Disease, Mayo Clinic , Rochester, Minnesota , USA.

Unlabelled: We present a 74-year-old male with a chondrosarcoma, who presented with chest pain. The history, electrocardiogram (ECG), and biomarkers established the diagnosis of myocardial infarction (MI); angiography did not show coronary atherosclerosis and, both initial transthoracic echocardiogram and chest computed tomography (CT), did not demonstrate any cardiac abnormalities. A second echocardiogram following a routine ECG showed presence of a mass involving the right ventricle and the cardiac apex that was confirmed by chest CT scan. We underline the importance of considering cardiac tumors in the clinical arena of MI management.

Learning Points: Cardiac tumors cause ECG changes similar to ischemic heart diseases.Keep in mind cardiac tumors when performing transthoracic echocardiogram (TTE) in the setting of suspected MI.TTE is the technique of choice in detecting cardiac tumors.
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http://dx.doi.org/10.1530/ERP-14-0017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676451PMC
December 2014

The Coronary Tree of the Anatomical Machines of the Prince of Sansevero: The reality of a legend.

J Cardiovasc Echogr 2015 Jan-Mar;25(1):34-36

Three Dimensional and Transesophageal Echocardiographic Laboratory, Cardiology Division, San Gennaro Hospital, Naples, Italy.

During the 18 century in Naples, Raimondo di Sangro, Prince of Sansevero, gave definitive form to the family chapel, the so-called "Cappella San Severo". The chapel houses not only extraordinarily beautiful and spectacularly detailed statues but also two human skeletons known as anatomical machines ("Macchine Anatomiche") in the basement. These two skeletons, a man and a pregnant woman, are entirely surrounded by their own circulatory system, just as they were suddenly and mysteriously, fixed. Legend, believed as truth until few years ago, tells that Prince Raimondo had prepared and injected an unknown embalming substance in their blood vessels convicting them to eternal fixity. Most recent investigations, however, demonstrated that while the bones are authentic, the blood vessels are actually an extraordinary artifact, even though the perfect reproduction of the coronary vascular tree, including congenital malformations in detail, raises some doubts about the technique used by the Prince. The dreadful aspect of these two skeletons appears to be in strident contrast with the classic beauty of the statues, which glorifies and celebrates the ideal of morphology. Conversely, the two "Anatomical Machines", protagonists of legends and superstitions since centuries, represent a marvelous example of science and art.
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http://dx.doi.org/10.4103/2211-4122.158431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353455PMC
May 2017

Science, art, and mistery in the statues and in the anatomical machines of the prince of sansevero: the masterpieces of the "Sansevero Chapel".

Am J Med Genet A 2013 Nov 3;161A(11):2920-9. Epub 2013 Oct 3.

Unità Operativa di Genetica Medica, Ospedale Gaetano Rummo, Benevento, Italy.

During the 18th century in Naples, Raimondo di Sangro, Prince of Sansevero, completed works on the family chapel, the so-called "Cappella Sansevero." The chapel houses statues of extraordinary beauty and spectacularly detailed but also, in the basement, two human skeletons known as the "Anatomical Machines" ("Macchine Anatomiche"). These two skeletons, a man and a pregnant woman, are entirely surrounded by their circulatory systems, just as if these were suddenly fixed. Legend, believed as truth until few years ago, says that Prince Raimondo had prepared and injected an unknown embalming substance in the blood vessels of two of his servants convicting them to eternal fixity. Recent investigations have demonstrated that, while the bones are authentic, the blood vessels are actually extraordinary artifacts that also reproduce some congenital malformations. The dreadful aspect of these two skeletons appears to be in strident contrast with the classic beauty of the statues which glorify and celebrate the ideal of morphology. Conversely, the two Anatomical Machines, protagonists of legends and superstitions since centuries, represent a marvelous example of science mixed with art.
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http://dx.doi.org/10.1002/ajmg.a.36258DOI Listing
November 2013
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