Bushra Rana - Academia.edu (original) (raw)

Papers by Bushra Rana

Research paper thumbnail of Three‐Dimensional Echocardiography in Valvular Heart Disease

Echocardiography, 2012

Two‐dimensional echocardiography (2DE) with color Doppler has been the standard tool for assessin... more Two‐dimensional echocardiography (2DE) with color Doppler has been the standard tool for assessing valvular heart disease. However, this requires conceptualizing three‐dimensional (3D) valvular anatomy from individual 2D slices, which is inadequate for complex valvular abnormalities. Similarly, Doppler‐based methods are inherently limited by several assumptions and are influenced by hemodynamics and concomitant valvular disease. 3DE has improved both morphological and functional assessment of valvular heart disease. It provides additional morphological information, which leads to better understanding of the mechanism of valvular dysfunction and surgical planning. 3D planimetry has proven to be accurate in the evaluation of valvular stenosis. This direct assessment eliminates measurement errors and could potentially serve as new gold standard. The continuity equation for aortic stenosis can be simplified by directly measuring left ventricular outflow tract area and stroke volume. In ...

Research paper thumbnail of Echocardiographic RV-E/e′ for predicting right atrial pressure: a review

Echo Research and Practice, 2020

Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance,... more Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance, yet current two-dimensional echocardiographic methods are inadequate for the accurate estimation of this haemodynamic marker. Right-heart trans-tricuspid Doppler and tissue Doppler echocardiographic techniques can be combined to calculate the right ventricular (RV) E/e′ ratio – a reflection of RV filling pressure which is a surrogate of RAP. A systematic search was undertaken which found seventeen articles that compared invasively measured RAP with RV-E/e′ estimated RAP. Results commonly concerned pulmonary hypertension or advanced heart failure/transplantation populations. Reported receiver operating characteristic analyses showed reasonable diagnostic ability of RV-E/e′ for estimating RAP in patients with coronary artery disease and RV systolic dysfunction. The diagnostic ability of RV-E/e′ was generally poor in studies of paediatrics, heart failure and mitral stenosis, whilst results...

Research paper thumbnail of Mechanisms of atrial mitral regurgitation: insights using 3D transoesophageal echo

European heart journal cardiovascular Imaging, 2014

Functional mitral regurgitation (FMR) is a consequence of mitral annular enlargement, leaflet tet... more Functional mitral regurgitation (FMR) is a consequence of mitral annular enlargement, leaflet tethering and reduced co-aptation. The importance of the left atrium (LA) as a cause of mitral regurgitation (MR) is less clear. We applied a co-aptation index using three-dimensional (3D) transoesophageal echocardiography to FMR and MR secondary to LA dilatation (atrial mitral regurgitation, AMR). Seventy-two patients underwent comprehensive 3D echo studies: FMR (n = 19); AMR (n = 33); and 20 controls. We recorded: LV size and function; LA dimensions; mitral annular area (MVA); and leaflet area in early and late systole. MVA fractional change was defined: (MVA late systole - MVA early systole)/MVA late systole × 100%; the co-aptation index was defined: (leaflet area early systole - leaflet area late systole)/leaflet area early systole × 100%. Despite normal LV size and function in AMR, MVA was increased similarly to FMR (AMR 12.86 cm(2) vs. FMR 12.33 cm(2), P = ns; both P < 0.01 vs. con...

Research paper thumbnail of Anatomy of the mitral valve: understanding the mitral valve complex in mitral regurgitation

European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology, 2010

Imaging the mitral valve requires an understanding of the normal anatomy and how this complex str... more Imaging the mitral valve requires an understanding of the normal anatomy and how this complex structure is altered by disease states. Mitral regurgitation is increasingly prevalent. Despite the fall in rheumatic disease, it is the second most common valvular lesion seen in adults in Europe. In this review, the morphology of the normal and abnormal valve is reconsidered in relation to the key structures, with a view to aiding the reader in understanding how this might relate to echocardiographic identification of abnormalities.

Research paper thumbnail of A novel surgical approach to close an acute ventricular septal defect using an occluder device

The Journal of Thoracic and Cardiovascular Surgery, 2007

Figure 1. Five-chamber apical view showing site of ventricular septal defect (VSD). LV, Left vent... more Figure 1. Five-chamber apical view showing site of ventricular septal defect (VSD). LV, Left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium; AV, aortic valve. Markers on side of image are 1 cm apart. Brief Communications

Research paper thumbnail of How much echo left ventricular hypertrophy would be missed in diabetics by applying the Losartan Intervention For Endpoint Reduction electrocardiogram criteria to select patients for angiotensin receptor blockade?

Journal of Hypertension, 2004

(LIFE) study demonstrated a clear mortality benefit in treating hypertensive patients with electr... more (LIFE) study demonstrated a clear mortality benefit in treating hypertensive patients with electrocardiogram (ECG) evidence of left ventricular hypertrophy (LVH) with losartan rather than atenolol. Previous studies have also shown that identifying and treating echo LVH is associated with prognostic benefits in hypertensive subjects, and is independent of the presence of ECG LVH. We sought to determine how many cases of echo LVH would be missed by applying the ECG criteria for LVH used in the LIFE study. Design A prospective study of 219 patients with type 2 diabetes recruited from the hospital diabetic clinic. Methods Fifteen ECG criteria were assessed on each subject and compared with the presence or absence of LVH on echocardiography. Results All the proposed ECG criteria are poor at identifying echo LVH in people with diabetes. Conclusion Using ECG LVH to select patients for angiotensin receptor blockade would lead to many diabetics with echo LVH missing out on the benefits of treatment. This assumes that the benefits seen in the LIFE study would also occur if the LIFE strategy were extended to echo LVH patients as well as to ECG LVH patients.

Research paper thumbnail of Patent Foramen Ovale Closure Without Echocardiography

JACC: Cardiovascular Interventions, 2009

Research paper thumbnail of Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device Closure

JACC: Cardiovascular Imaging, 2010

High-quality imaging of the atrial septum has never been so relevant to the adult cardiologist. T... more High-quality imaging of the atrial septum has never been so relevant to the adult cardiologist. This article focuses on the role of echocardiography in the evaluation of patent foramen ovale for closure. It provides a systematic and comprehensive approach to transesophageal echocardiographic study in such a patient. The salient information required for planning the device and equipment needed for the closure procedure are discussed.

Research paper thumbnail of Relation of QT interval dispersion to the number of different cardiac abnormalities in diabetes mellitus

The American Journal of Cardiology, 2002

Three studies have clearly shown that a prolonged QT dispersion (QTD) is the best predictor of ca... more Three studies have clearly shown that a prolonged QT dispersion (QTD) is the best predictor of cardiac death in patients with type 2 diabetes mellitus (DM). This was originally believed to be because QTD identified electrical inhomogeneity, but recent data suggests that this is unlikely. The alternative possibility is that QTD is a convenient identifier of hidden but lethal cardiac abnormalities. We explored whether the latter possibility is true by examining exactly what spectrum of cardiac abnormalities, if any, are over-represented in diabetics with a prolonged QTD. Two hundred nineteen patients with type 2 DM who had been first diagnosed with DM 3 to 6 years previously underwent intensive cardiac examinations. Patients with prolonged QTD had a significantly increased incidence of myocardial ischemia and left ventricular (LV) hypertrophy, and to a lesser extent, autonomic dysfunction. The main independent determinant of a prolonged QTD was ischemia, as seen on both ambulatory ST-segment monitoring (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) and Duke score on treadmill testing (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). It was also observed that QTD increased progressively as the number of different cardiac abnormalities increased (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). These studies suggest that QTD is a useful, general prescreening test to select diabetics for more detailed cardiac examinations (especially for ischemia and LV hypertrophy), and that if cardiac examinations were targeted by way of QTD screening, then a high incidence of hidden but treatable cardiac abnormalities could be found.

Research paper thumbnail of Tricuspid Regurgitation: No Longer the ‘Forgotten’ Valve

EMJ Cardiology

Considered initially as a bystander, tricuspid regurgitation has shown to be an important predict... more Considered initially as a bystander, tricuspid regurgitation has shown to be an important predictor of mortality in patients with left-side valvular or myocardial disease. However, a sizeable number of patients remain untreated until the end stage when cardiac surgery presents a prohibitive risk. The emergent need in finding a treatment for patients with tricuspid regurgitation deemed for surgery options have encouraged the development of transcatheter tricuspid valve interventions. These procedures mimic classical surgery techniques and they are mainly divided in two categories: repair (annuloplasty, coaptation devices, edge-to-edge techniques) and transcatheter tricuspid valve replacement. This review aims to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve interventions, highlighting potential challenges and future directions.

Research paper thumbnail of Percutaneous Device Closure of Paravalvular Leak: Combined Experience from the United Kingdom and Ireland

Research paper thumbnail of A guide for performing adult TTE: the British Society of Echocardiography minimum dataset

Echo research and practice, 2020

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century... more Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease1. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined 'standard' two dimensional and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommende...

Research paper thumbnail of Current Devices in Mitral Valve Replacement and Their Potential Complications

Frontiers in Cardiovascular Medicine, 2020

Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical trea... more Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical treatment is not feasible in all cases. The elderly and frail with several comorbidities and left ventricular dysfunction are often managed conservatively. Percutaneous treatment (repair or replacement) of the mitral valve has emerged as a potential option for those patients who are at a high risk for surgery. Mitral valve repair with the Mitraclip device proved both increased safety and mortality reduction in patients with severe mitral regurgitation. On the other hand, in the last decade, percutaneous mitral replacement opened new frontiers in the field of cardiac structural interventions. There are few mitral devices; some are in the early phase of development and some are waiting for CE mark of approval. The evolution of these devices was more complicated compared to the aortic technology due to the native mitral valve's complexity and access. This review aims to provide an overview ...

Research paper thumbnail of Percutaneous devices for the treatment of complex native valve mitral leaflet and aortomitral continuity defects: Review and case series

Cardiovascular Revascularization Medicine

Percutaneous closure of paravalvar leaks (PVLs) was once only performed in extreme or non-surgica... more Percutaneous closure of paravalvar leaks (PVLs) was once only performed in extreme or non-surgical risk cases not suitable for redo-surgery with tissue or mechanical valves. This technique is now the treatment of choice with long term outcomes that are better than redo operations.123 As interventionalists become more familiar with using PVL devices, more off label device use has been reported in non-surgical cases involving complex native mitral valve regurgitation (NVMR). In this review, we appraise the literature regarding percutaneous treatment of paravalvar leaks and more recently esoteric off label use. We also describe two recent challenging cases where percutaneous devices were used to treat severe leaks that developed as a sequela of previous infective endocarditis. We also provide specific recommendations regarding periprocedural strategy and focus on the importance of device choice to provide an optimal outcome.

Research paper thumbnail of Restricted Use of Echocardiography in Suspected Endocarditis during COVID-19 Lockdown: A Multidisciplinary Team Approach

Cardiology Research and Practice

Background. Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period,... more Background. Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes. Methods. All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study. Results. In total, 38 patients were referred for ET review (71% male, median age 54 [interquartile range 48, 65.5] years). At the time of ET discussion, 21% had no echo imaging, 16% had point-of-care ultrasound only, and 63% had formal TTE. In total, only 16% underwent TOE. The ability of e...

Research paper thumbnail of BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab

Research paper thumbnail of Automated Left Ventricular Dimension Assessment Using Artificial Intelligence Developed and Validated by a UK-Wide Collaborative

Circulation: Cardiovascular Imaging

Background: Artificial intelligence (AI) for echocardiography requires training and validation to... more Background: Artificial intelligence (AI) for echocardiography requires training and validation to standards expected of humans. We developed an online platform and established the Unity Collaborative to build a dataset of expertise from 17 hospitals for training, validation, and standardization of such techniques. Methods: The training dataset consisted of 2056 individual frames drawn at random from 1265 parasternal long-axis video-loops of patients undergoing clinical echocardiography in 2015 to 2016. Nine experts labeled these images using our online platform. From this, we trained a convolutional neural network to identify keypoints. Subsequently, 13 experts labeled a validation dataset of the end-systolic and end-diastolic frame from 100 new video-loops, twice each. The 26-opinion consensus was used as the reference standard. The primary outcome was precision SD, the SD of the differences between AI measurement and expert consensus. Results: In the validation dataset, the AI’s p...

Research paper thumbnail of The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Echo Research and Practice

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for v... more Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in Western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is, therefore, one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic, transoesophageal and exercise stress echocardiography play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease, and for helping to determine the appropriate timing and method of intervention. This guideline from the British Society of Echocardiography (BSE) describes the assessment of mitral regurgitation and mitral stenosis, and replaces previous BSE guidelines that describe the echocardi...

Research paper thumbnail of British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab

Echo Research and Practice

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in pati... more The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology f...

Research paper thumbnail of COVID-19 and its impact on the cardiovascular system

Open Heart

ObjectivesThe clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascul... more ObjectivesThe clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.MethodsWe retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention.ResultsMean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angio...

Research paper thumbnail of Three‐Dimensional Echocardiography in Valvular Heart Disease

Echocardiography, 2012

Two‐dimensional echocardiography (2DE) with color Doppler has been the standard tool for assessin... more Two‐dimensional echocardiography (2DE) with color Doppler has been the standard tool for assessing valvular heart disease. However, this requires conceptualizing three‐dimensional (3D) valvular anatomy from individual 2D slices, which is inadequate for complex valvular abnormalities. Similarly, Doppler‐based methods are inherently limited by several assumptions and are influenced by hemodynamics and concomitant valvular disease. 3DE has improved both morphological and functional assessment of valvular heart disease. It provides additional morphological information, which leads to better understanding of the mechanism of valvular dysfunction and surgical planning. 3D planimetry has proven to be accurate in the evaluation of valvular stenosis. This direct assessment eliminates measurement errors and could potentially serve as new gold standard. The continuity equation for aortic stenosis can be simplified by directly measuring left ventricular outflow tract area and stroke volume. In ...

Research paper thumbnail of Echocardiographic RV-E/e′ for predicting right atrial pressure: a review

Echo Research and Practice, 2020

Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance,... more Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance, yet current two-dimensional echocardiographic methods are inadequate for the accurate estimation of this haemodynamic marker. Right-heart trans-tricuspid Doppler and tissue Doppler echocardiographic techniques can be combined to calculate the right ventricular (RV) E/e′ ratio – a reflection of RV filling pressure which is a surrogate of RAP. A systematic search was undertaken which found seventeen articles that compared invasively measured RAP with RV-E/e′ estimated RAP. Results commonly concerned pulmonary hypertension or advanced heart failure/transplantation populations. Reported receiver operating characteristic analyses showed reasonable diagnostic ability of RV-E/e′ for estimating RAP in patients with coronary artery disease and RV systolic dysfunction. The diagnostic ability of RV-E/e′ was generally poor in studies of paediatrics, heart failure and mitral stenosis, whilst results...

Research paper thumbnail of Mechanisms of atrial mitral regurgitation: insights using 3D transoesophageal echo

European heart journal cardiovascular Imaging, 2014

Functional mitral regurgitation (FMR) is a consequence of mitral annular enlargement, leaflet tet... more Functional mitral regurgitation (FMR) is a consequence of mitral annular enlargement, leaflet tethering and reduced co-aptation. The importance of the left atrium (LA) as a cause of mitral regurgitation (MR) is less clear. We applied a co-aptation index using three-dimensional (3D) transoesophageal echocardiography to FMR and MR secondary to LA dilatation (atrial mitral regurgitation, AMR). Seventy-two patients underwent comprehensive 3D echo studies: FMR (n = 19); AMR (n = 33); and 20 controls. We recorded: LV size and function; LA dimensions; mitral annular area (MVA); and leaflet area in early and late systole. MVA fractional change was defined: (MVA late systole - MVA early systole)/MVA late systole × 100%; the co-aptation index was defined: (leaflet area early systole - leaflet area late systole)/leaflet area early systole × 100%. Despite normal LV size and function in AMR, MVA was increased similarly to FMR (AMR 12.86 cm(2) vs. FMR 12.33 cm(2), P = ns; both P < 0.01 vs. con...

Research paper thumbnail of Anatomy of the mitral valve: understanding the mitral valve complex in mitral regurgitation

European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology, 2010

Imaging the mitral valve requires an understanding of the normal anatomy and how this complex str... more Imaging the mitral valve requires an understanding of the normal anatomy and how this complex structure is altered by disease states. Mitral regurgitation is increasingly prevalent. Despite the fall in rheumatic disease, it is the second most common valvular lesion seen in adults in Europe. In this review, the morphology of the normal and abnormal valve is reconsidered in relation to the key structures, with a view to aiding the reader in understanding how this might relate to echocardiographic identification of abnormalities.

Research paper thumbnail of A novel surgical approach to close an acute ventricular septal defect using an occluder device

The Journal of Thoracic and Cardiovascular Surgery, 2007

Figure 1. Five-chamber apical view showing site of ventricular septal defect (VSD). LV, Left vent... more Figure 1. Five-chamber apical view showing site of ventricular septal defect (VSD). LV, Left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium; AV, aortic valve. Markers on side of image are 1 cm apart. Brief Communications

Research paper thumbnail of How much echo left ventricular hypertrophy would be missed in diabetics by applying the Losartan Intervention For Endpoint Reduction electrocardiogram criteria to select patients for angiotensin receptor blockade?

Journal of Hypertension, 2004

(LIFE) study demonstrated a clear mortality benefit in treating hypertensive patients with electr... more (LIFE) study demonstrated a clear mortality benefit in treating hypertensive patients with electrocardiogram (ECG) evidence of left ventricular hypertrophy (LVH) with losartan rather than atenolol. Previous studies have also shown that identifying and treating echo LVH is associated with prognostic benefits in hypertensive subjects, and is independent of the presence of ECG LVH. We sought to determine how many cases of echo LVH would be missed by applying the ECG criteria for LVH used in the LIFE study. Design A prospective study of 219 patients with type 2 diabetes recruited from the hospital diabetic clinic. Methods Fifteen ECG criteria were assessed on each subject and compared with the presence or absence of LVH on echocardiography. Results All the proposed ECG criteria are poor at identifying echo LVH in people with diabetes. Conclusion Using ECG LVH to select patients for angiotensin receptor blockade would lead to many diabetics with echo LVH missing out on the benefits of treatment. This assumes that the benefits seen in the LIFE study would also occur if the LIFE strategy were extended to echo LVH patients as well as to ECG LVH patients.

Research paper thumbnail of Patent Foramen Ovale Closure Without Echocardiography

JACC: Cardiovascular Interventions, 2009

Research paper thumbnail of Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device Closure

JACC: Cardiovascular Imaging, 2010

High-quality imaging of the atrial septum has never been so relevant to the adult cardiologist. T... more High-quality imaging of the atrial septum has never been so relevant to the adult cardiologist. This article focuses on the role of echocardiography in the evaluation of patent foramen ovale for closure. It provides a systematic and comprehensive approach to transesophageal echocardiographic study in such a patient. The salient information required for planning the device and equipment needed for the closure procedure are discussed.

Research paper thumbnail of Relation of QT interval dispersion to the number of different cardiac abnormalities in diabetes mellitus

The American Journal of Cardiology, 2002

Three studies have clearly shown that a prolonged QT dispersion (QTD) is the best predictor of ca... more Three studies have clearly shown that a prolonged QT dispersion (QTD) is the best predictor of cardiac death in patients with type 2 diabetes mellitus (DM). This was originally believed to be because QTD identified electrical inhomogeneity, but recent data suggests that this is unlikely. The alternative possibility is that QTD is a convenient identifier of hidden but lethal cardiac abnormalities. We explored whether the latter possibility is true by examining exactly what spectrum of cardiac abnormalities, if any, are over-represented in diabetics with a prolonged QTD. Two hundred nineteen patients with type 2 DM who had been first diagnosed with DM 3 to 6 years previously underwent intensive cardiac examinations. Patients with prolonged QTD had a significantly increased incidence of myocardial ischemia and left ventricular (LV) hypertrophy, and to a lesser extent, autonomic dysfunction. The main independent determinant of a prolonged QTD was ischemia, as seen on both ambulatory ST-segment monitoring (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) and Duke score on treadmill testing (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). It was also observed that QTD increased progressively as the number of different cardiac abnormalities increased (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). These studies suggest that QTD is a useful, general prescreening test to select diabetics for more detailed cardiac examinations (especially for ischemia and LV hypertrophy), and that if cardiac examinations were targeted by way of QTD screening, then a high incidence of hidden but treatable cardiac abnormalities could be found.

Research paper thumbnail of Tricuspid Regurgitation: No Longer the ‘Forgotten’ Valve

EMJ Cardiology

Considered initially as a bystander, tricuspid regurgitation has shown to be an important predict... more Considered initially as a bystander, tricuspid regurgitation has shown to be an important predictor of mortality in patients with left-side valvular or myocardial disease. However, a sizeable number of patients remain untreated until the end stage when cardiac surgery presents a prohibitive risk. The emergent need in finding a treatment for patients with tricuspid regurgitation deemed for surgery options have encouraged the development of transcatheter tricuspid valve interventions. These procedures mimic classical surgery techniques and they are mainly divided in two categories: repair (annuloplasty, coaptation devices, edge-to-edge techniques) and transcatheter tricuspid valve replacement. This review aims to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve interventions, highlighting potential challenges and future directions.

Research paper thumbnail of Percutaneous Device Closure of Paravalvular Leak: Combined Experience from the United Kingdom and Ireland

Research paper thumbnail of A guide for performing adult TTE: the British Society of Echocardiography minimum dataset

Echo research and practice, 2020

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century... more Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease1. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined 'standard' two dimensional and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommende...

Research paper thumbnail of Current Devices in Mitral Valve Replacement and Their Potential Complications

Frontiers in Cardiovascular Medicine, 2020

Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical trea... more Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical treatment is not feasible in all cases. The elderly and frail with several comorbidities and left ventricular dysfunction are often managed conservatively. Percutaneous treatment (repair or replacement) of the mitral valve has emerged as a potential option for those patients who are at a high risk for surgery. Mitral valve repair with the Mitraclip device proved both increased safety and mortality reduction in patients with severe mitral regurgitation. On the other hand, in the last decade, percutaneous mitral replacement opened new frontiers in the field of cardiac structural interventions. There are few mitral devices; some are in the early phase of development and some are waiting for CE mark of approval. The evolution of these devices was more complicated compared to the aortic technology due to the native mitral valve's complexity and access. This review aims to provide an overview ...

Research paper thumbnail of Percutaneous devices for the treatment of complex native valve mitral leaflet and aortomitral continuity defects: Review and case series

Cardiovascular Revascularization Medicine

Percutaneous closure of paravalvar leaks (PVLs) was once only performed in extreme or non-surgica... more Percutaneous closure of paravalvar leaks (PVLs) was once only performed in extreme or non-surgical risk cases not suitable for redo-surgery with tissue or mechanical valves. This technique is now the treatment of choice with long term outcomes that are better than redo operations.123 As interventionalists become more familiar with using PVL devices, more off label device use has been reported in non-surgical cases involving complex native mitral valve regurgitation (NVMR). In this review, we appraise the literature regarding percutaneous treatment of paravalvar leaks and more recently esoteric off label use. We also describe two recent challenging cases where percutaneous devices were used to treat severe leaks that developed as a sequela of previous infective endocarditis. We also provide specific recommendations regarding periprocedural strategy and focus on the importance of device choice to provide an optimal outcome.

Research paper thumbnail of Restricted Use of Echocardiography in Suspected Endocarditis during COVID-19 Lockdown: A Multidisciplinary Team Approach

Cardiology Research and Practice

Background. Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period,... more Background. Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes. Methods. All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study. Results. In total, 38 patients were referred for ET review (71% male, median age 54 [interquartile range 48, 65.5] years). At the time of ET discussion, 21% had no echo imaging, 16% had point-of-care ultrasound only, and 63% had formal TTE. In total, only 16% underwent TOE. The ability of e...

Research paper thumbnail of BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab

Research paper thumbnail of Automated Left Ventricular Dimension Assessment Using Artificial Intelligence Developed and Validated by a UK-Wide Collaborative

Circulation: Cardiovascular Imaging

Background: Artificial intelligence (AI) for echocardiography requires training and validation to... more Background: Artificial intelligence (AI) for echocardiography requires training and validation to standards expected of humans. We developed an online platform and established the Unity Collaborative to build a dataset of expertise from 17 hospitals for training, validation, and standardization of such techniques. Methods: The training dataset consisted of 2056 individual frames drawn at random from 1265 parasternal long-axis video-loops of patients undergoing clinical echocardiography in 2015 to 2016. Nine experts labeled these images using our online platform. From this, we trained a convolutional neural network to identify keypoints. Subsequently, 13 experts labeled a validation dataset of the end-systolic and end-diastolic frame from 100 new video-loops, twice each. The 26-opinion consensus was used as the reference standard. The primary outcome was precision SD, the SD of the differences between AI measurement and expert consensus. Results: In the validation dataset, the AI’s p...

Research paper thumbnail of The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Echo Research and Practice

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for v... more Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in Western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is, therefore, one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic, transoesophageal and exercise stress echocardiography play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease, and for helping to determine the appropriate timing and method of intervention. This guideline from the British Society of Echocardiography (BSE) describes the assessment of mitral regurgitation and mitral stenosis, and replaces previous BSE guidelines that describe the echocardi...

Research paper thumbnail of British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab

Echo Research and Practice

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in pati... more The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology f...

Research paper thumbnail of COVID-19 and its impact on the cardiovascular system

Open Heart

ObjectivesThe clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascul... more ObjectivesThe clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.MethodsWe retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention.ResultsMean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angio...