David Majdalany - Academia.edu (original) (raw)

Papers by David Majdalany

Research paper thumbnail of Anomalous Left Coronary Artery from the Pulmonary Artery: How to Diagnose and Treat

Journal of Personalized Medicine

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronar... more Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronary anomaly that can present in childhood or adulthood with a multitude of symptoms depending on the age of presentation. It should be suspected in infants presenting with heart failure in the setting of left ventricular systolic dysfunction and associated mitral regurgitation from papillary muscle ischemia. Adults with ALCAPA may present with cardiac ischemic symptoms. Prompt diagnosis with echocardiography and cross-sectional chest imaging is important to guide surgical intervention and improve the patients’ survival and prognosis. The goal of surgery is to establish a dual-coronary system with mid-term results revealing progressive recovery of left ventricular function and improvement in mitral regurgitation. Patients with ALCAPA should maintain life-long follow-up with a cardiologist with congenital heart disease expertise for surveillance of post-operative complications.

Research paper thumbnail of Adults with Down Syndrome: Update on Safety and Long-Term Outcomes of Cardiac Surgery and Percutaneous Interventions

Journal of the American College of Cardiology, Mar 1, 2023

Research paper thumbnail of Congenital Heart Disease: A Growing Population with Challenges to Patients and Providers

Journal of Personalized Medicine

Congenital heart disease (CHD) is the most frequent disorder encountered in the newborn period an... more Congenital heart disease (CHD) is the most frequent disorder encountered in the newborn period and the most frequent cause of infant mortality [...]

Research paper thumbnail of Levo-Transposition of the Great Arteries: Basic Imaging Findings and Management

Journal of Radiology Nursing

Research paper thumbnail of Pregnancy in Patients with Shone Complex: A Single-Center Case Series

Congenital Heart Disease

Background: There is limited literature written on the course and outcomes for pregnant mothers w... more Background: There is limited literature written on the course and outcomes for pregnant mothers with Shone complex. Methods: We describe a case series of five pregnancies in four women with Shone complex within a multidisciplinary cardio-obstetrics clinic from 2016-2018. Results: Maternal age ranged from 21-39 years. Three patients had preserved left ventricular function while one had moderately decreased function. Gestational age at presentation ranged from 6-15 weeks. There were three successful pregnancies (mean gestational age = 37 weeks, range 35-39 weeks) with one patient accounting for two unsuccessful pregnancies. All infants were delivered via Cesarean section. One infant required a NICU stay, but all other infants delivered were healthy. Conclusion: Patients with Shone complex can have successful pregnancies although complications can occur for both the mother and the baby. Comprehensive prenatal care, coordinated and consistent management during pregnancy, and tertiary care support can promote positive maternal and fetal outcomes.

Research paper thumbnail of Congenital Bicuspid Pulmonary Valve in a Tricuspid Valve Regurgitation with Right Ventricle Dysfunction : Multi-Modality Approach

Journal of the American College of Cardiology

Research paper thumbnail of Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

American Heart Journal Plus: Cardiology Research and Practice, 2021

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of D-Transposition of the Great Arteries: Management, Complications, and Basic Imaging Findings

Journal of Radiology Nursing, 2020

Transposition of the great arteries (TGAs) is a condition with ventriculo-arterial discordance wh... more Transposition of the great arteries (TGAs) is a condition with ventriculo-arterial discordance where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. Broadly speaking, two forms exist: (1) a dextro type (referred as D-TGA) and (2) a levo type (referred to as L-TGA). Traditionally, diagnosis is made by echocardiography. Cardiac magnetic resonance imaging (CMR), cardiac computed tomography (CCT), and heart catheterization and angiography are supplemental tools in further characterization of the anatomy. The frequency of routine imaging testing, including echocardiography, CMR, and CCT, depends on severity of heart failure, cyanosis, valvular disease, arrhythmia, pulmonary hypertension, and end-organ damage. The aim of this review is to explore important imaging findings for different types of D-TGA: (1) uncorrected D-TGA, (2) D-TGA after the Mustard/Senning atrial switch surgery; (3) D-TGA after the arterial switch operation; and (4) D-TGA af...

Research paper thumbnail of Light on valvular bumps

Journal of Echocardiography, 2021

Nonbacterial thrombotic endocarditis (NBTE), previously known as marantic endocarditis, can mimic... more Nonbacterial thrombotic endocarditis (NBTE), previously known as marantic endocarditis, can mimic bacterial endocarditis, and is typically diagnosed in the setting of systemic embolization, valvular abnormalities, or heart failure [1]. NBTE is typically associated with antiphospholipid syndrome, systemic lupus erythematosus, or malignancy with the mitral and aortic valves being most frequently affected [2, 3]. Echocardiography plays a major role in the diagnosis once infectious etiology is ruled out. Early disease may be missed even on transesophageal echocardiography and three dimensional (3D) imaging may improve detection. We present a case of NBTE showcasing the incremental diagnostic value of transillumination 3D imaging (3DTI) when compared to two-dimensional (2D) transthoracic echocardiography (TTE), 2D transesophageal echocardiography (2DTEE), and conventional 3D transesophageal echocardiography (3DTEE). 3DTI delineated the anatomical lesion better providing better details of the multinodular nature of valvular NBTE (Fig. 1). A 62-year-old female with prior history of a stroke 14 years ago, hypertension, diabetes mellitus, and hyperlipidemia presented with sudden dysarthria and facial droop. Brain MRI revealed right basal ganglia and subcortical temporal lobe infarct (red arrow A) suggestive of an embolic stroke. Nodular thickening was seen on TTE on the anterior mitral valve leaflet (AML) (white arrow B) and on the posterior mitral valve leaflet (PML) (red arrows B) on the parasternal short axis view. On 2DTEE, bileaflet nodular thickening was seen on the atrial and ventricular aspects of the mitral valve (MV) (C) which was associated with mild-moderate eccentric mitral regurgitation (D). 3DTEE showed marked nodular thickening on the atrial aspect of A3 (white arrows E and F), P3 (red arrows E and F) and P2 (yellow arrows E and F) scallops of the MV in diastole (E) and systole (F). 3DTI rendering in diastole showed more welldefined nodules on the MV (arrows G) and a large multinodular conglomerate mass in systole on the anterior (white arrow H) and posterior leaflets (red arrow H)). Note multiple smaller sub-nodules on the surface of the large conglomerate mass both on the posterior leaflet mass (red arrow) and the anterior leaflet mass (white arrow). These sub-nodules were not seen on conventional 3DTEE images which only showed larger masses without clear assessment of the surface of the masses (F). The patient had an unremarkable infectious work-up and a negative age-appropriate cancer screening. A diagnosis of marantic endocarditis causing an embolic stroke was made. All other work-up, including heart rhythm monitoring, was negative except for positive antiphospholipid antibody × 2 and anticoagulation with warfarin was started.

Research paper thumbnail of Using a novel echo-marker to identify high mortality risk patients with moderate aortic stenosis

BackgroundRecent studies have shown that patients with moderate aortic stenosis and reduced left ... more BackgroundRecent studies have shown that patients with moderate aortic stenosis and reduced left ventricular ejection fraction may benefit from earlier intervention instead of periodic surveillance. Identifying patients at higher risk is therefore warranted concerning the possibility of expanding aortic valve replacement indication.ObjectiveWe aim to investigate the usefulness of a novel echo-marker, augmented mean arterial pressure (AugMAP), in identifying high-risk patients with moderate aortic stenosis.MethodsAdult patients with moderate aortic stenosis (aortic valve area 1.0-1.5 cm2) at Mayo Clinic sites in 1/2010-12/2020 were identified. Baseline demographics, echocardiography, and all-cause mortality data were retrieved. Patients were grouped into higher and lower AugMAP groups using a cutoff of 80 mmHg for analysis. Kaplan-Meier and Cox regression analyses were used to assess the performance of AugMAP.ResultsA total of 4,563 patients with moderate aortic stenosis were include...

Research paper thumbnail of Pregnancy outcomes in women with a systemic right ventricle and transposition of the great arteries results from the ESC-EORP Registry of Pregnancy and Cardiac disease (ROPAC)

Heart, 2021

ObjectiveCardiac disease is a major cause of maternal mortality. Data regarding pregnancy outcome... more ObjectiveCardiac disease is a major cause of maternal mortality. Data regarding pregnancy outcomes in women with a systemic right ventricle (sRV) are scarce. We studied pregnancy outcomes in women with an sRV after the atrial switch procedure for transposition of the great arteries (TGA) or congenitally corrected TGA (CCTGA).MethodsThe ESC EORP Registry of Pregnancy and Cardiac Disease is an international prospective registry of pregnant women with cardiac disease. Pregnancy outcomes (maternal/fetal) in all women with an sRV are described. The primary end point was a major adverse cardiac event (MACE) defined as maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischaemic coronary event and other thromboembolic events.ResultsAltogether, 162 women with an sRV (TGA n=121, CCTGA n=41, mean age 28.8±4.6 years) were included. No maternal mortality occurred. In 26 women, at least one MACE occurred, heart failure...

Research paper thumbnail of Near Complete Resolution of Nonbacterial Thrombotic Endocarditis in a Patient with Antiphospholipid Antibody Syndrome

The Anatolian Journal of Cardiology, 2020

of hepatocellular carcinoma (HCC). Transesophageal echocardiography from both midesophageal bicav... more of hepatocellular carcinoma (HCC). Transesophageal echocardiography from both midesophageal bicaval view (Fig. 1, Panel E, Supplementary Video S2) and four-chamber view (Fig. 1, Panel F) highlighted the highly mobile mass that occupied the right chambers and extended into the PA and therefore, blocked both the RV inflow and outflow tract. However, few hours after admission and despite the attempted rescue thrombolysis, the patient experienced sudden cardiac arrest. HCC patients are known to have an increased risk of thrombosis; however, a giant metastatic thrombus that extends from the IVC to the PA is still considered an unusual presentation of HCC. Informed consent: The informed consent was obtained from the patient. Supplementary Video S1. Transthoracic echocardiography, subcostal view: giant mass occupying the right atrium (RA), protruding into the right ventricle (RV), and significantly obliterating the tricuspid valve. Supplementary Video S2. Transesophageal echocardiography, midesophageal bicaval view revealing highly mobile mass occupying the right chambers.

Research paper thumbnail of Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus

The Annals of Thoracic Surgery, 2020

BACKGROUND Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended trans-se... more BACKGROUND Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended trans-septal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel trans-conal approach in seven consecutive patients. METHODS Retrospective review of a prospectively collected database for consecutive patients undergoing trans-conal unroofing of trans-septal AAOLCA. Surgical repair entails transection of the right ventricular outflow tract (RVOT), unroofing the septal course of the AAOLCA followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted. RESULTS All seven patients identified were symptomatic. Median age was 48 (range 12-62) years. AAOLCA with trans-septal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound (IVUS) and indexed fractional flow reserve (iFFR), confirming flow-limiting lesion. Importantly, 3 patients had negative provocative non-invasive testing for ischemia. Median post-operative hospital length of stay was 6 (range 4-12) days. No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved iFFR compared to preoperative (0.59±0.16 vs. 0.90±0.03, P=0.05). CONCLUSIONS Complete unroofing of AAOLCA with trans-septal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. IVUS with iFFR is clinically useful to confirm the hemodynamic significance of specific lesions.

Research paper thumbnail of Early Outcomes for In Situ Pericardial Roll Repair for Distant Anomalous Pulmonary Venous Return

The Annals of Thoracic Surgery, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of Tetralogy of Fallot: Basic Imaging Findings and Management

Journal of Radiology Nursing, 2019

Tetralogy of Fallot (TOF) is one of the most common cyanotic, congenital heart disease with compl... more Tetralogy of Fallot (TOF) is one of the most common cyanotic, congenital heart disease with complex anatomic malformations and unknown etiology. With medical advancements, most patients in this cohort require early total correction and survive into adulthood. This review addresses various imaging modalities that help diagnose TOF, methods to correct and repair TOF-associated cardiac malformations, and the sequelae and long-term complications of this disease.

Research paper thumbnail of Temporal Trend and Predictors of New Onset Post Operative Atrial Fibrillation After Cardiac Valvular Surgery

Journal of the American College of Cardiology, 2018

Background: Atrial fibrillation (AF) is common after cardiac surgery. This study explores the tem... more Background: Atrial fibrillation (AF) is common after cardiac surgery. This study explores the temporal trend of new-onset AF after mitral valve (MV) and/or tricuspid valve (TV) surgery and its associated risk factors Methods: Medical records of patients above 18 years undergoing MV and/or TV surgery, in isolation or combination with other valve or coronary surgery, from 2003-2013, without a history of pre-operative AF were analyzed. AF was described using electrocardiograms (ECG) read by a cardiologist. AF prevalence over time was estimated using multiphase non-linear logistic mixed effects model. Machine learning and repeated measurements multivariable model were used to identify associated risk factors Results: 10,461 patient records [age (61.1±13.9) years, 61% males] with 100,149 post-operative ECGs qualified for analysis. Median follow up time was 4 months [IQR 2 days-2 years, range 12 hours-14 years]. New-onset AF prevalence post-surgery peaked (13%) at 2 weeks, declined near 3 months (3%) [figure 1a] and then gradually increased (9%) near 7 years [figure 1b]. Age, MV replacement, higher degree of TV regurgitation and history of prior cardiac surgery were associated with higher overall risk of AF independent of time since surgery. TV repair, higher blood urea nitrogen, hypertension and peripheral vascular disease were time dependent risk factors for AF after cardiac surgery Conclusion: Post-valvular surgery AF risk is time dependent with both time dependent and independent risk factors

Research paper thumbnail of Dilated Cardiomyopathy and Atrial Arrhythmia in a Patient with a Prior Repaired Atrial Septal Defect: Don't Let the History Fool You

Journal of the American College of Cardiology, 2019

Background: Unrepaired sinus venosus ASD is a rare but recognized congenital cardiac lesion. Mode... more Background: Unrepaired sinus venosus ASD is a rare but recognized congenital cardiac lesion. Modern multimodality imaging is required for comprehensive diagnosis and to direct surgical management. Case: A 58 year old male with history of remote surgical ASD closure presented with dilated cardiomyopathy thought to be atrial flutter induced. TTE revealed a severely dilated right compared to the left ventricle. TEE (Figure 1a) revealed an inferior sinus venosus ASD with predominantly left to right shunting. Decision-making: The patient presented with atrial flutter and tachycardia induced cardiomyopathy, disproportionately dilated RV, and cyanosis. Details of his prior ASD repair were unavailable. MRI, CTA (Figure 1b), and RHC showed an inferior sinus venosus ASD with a 1.8 cm posterior defect of the interatrial septum, moderate TR, partial anomalous drainage of the pulmonary vein into the IVC with a Qp/ Qs of 1.9:1, and PA pressures 20/8 mmHg (mean 12 mmHg). Surgical closure of the inferior sinus venosus ASD with autologous pericardial patch, Maze procedure, and TV repair were performed. Conclusion: This case highlights the importance of comprehensive multimodality cardiac imaging in the setting of new atrial arrhythmias and unexplained RV enlargement after ASD closure. Sinus venosus ASD frequently is missed on routine echocardiography. Patients presenting with dilated RV and cyanosis should prompt further investigation and adult congenital disease consultation.

Research paper thumbnail of Beyond Scimitar Syndrome: A Unique Combination of Complex Congenital Heart Disease

Journal of the American College of Cardiology, 2019

Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical pres... more Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical presentation may be insidious and associated with a number of cardiopulmonary anomalies. Case: A 47 year old male presented with progressive exertional dyspnea, palpitations, and a new systolic murmur in the setting of known dextrocardia. He underwent TTE which showed mildly reduced biventricular function, dilated RV, and moderate TR. Decision-making: Given the suspicion for underlying congenital disease, he underwent cardiac MRI, X-ray, and CTA (Figure 1) which confirmed dextrocardia with evidence of Scimitar syndrome with all right sided pulmonary veins draining into the IVC, a Qp/Qs of 1.6:1, and concomitant dilation of the RA, RV, and PA. Additional findings included an anomalous single coronary artery originating from the right coronary cusp, aortic root dilation (5 cm) and moderate TR. Surgical repair was performed with in-situ pericardial repair of scimitar vein routing to the LA, repair of the TV, and repair of the noncoronary aortic sinus with CardioCel. On follow up, the patient reported resolution of dyspnea on exertion and improved functional capacity. Conclusion: This unique case highlights dextrocardia with Scimitar Syndrome, aortopathy, and anomalous single coronary artery. This congenital complex went undiagnosed for nearly five decades with only mild symptom burden. Multimodality cardiac imaging played a crucial role in the diagnosis and surgical planning of this case.

Research paper thumbnail of Extensive unroofing of myocardial bridge: A case report and literature review

SAGE Open Medical Case Reports, 2019

Background: Myocardial bridge is defined as a segment of a coronary artery that takes an intramyo... more Background: Myocardial bridge is defined as a segment of a coronary artery that takes an intramyocardial course. The presence of myocardial bridge has been observed in as many as 40%–80% of cases on autopsy, angiographically from 0.5% to 16.0%, and often asymptomatic. However, it has been associated with angina, coronary spasm, myocardial infarction, arrhythmias, syncope, sudden cardiac arrest, and death. Conflicting opinions exist on the timing of surgical intervention for myocardial bridge. Methods: We present an unusual case of a young female, with prior aortic surgery, who had refractory chest pain despite optimal medical therapy. Stress testing revealed anterior ischemia. Cardiac catherization showed myocardial bridge of the left anterior descending artery with significant compromise of blood flow (fractional flow reserve = 0.75 with adenosine). We proceeded with surgery. Intraoperatively, we found an unusually long (10-cm) intramyocardial segment of the left anterior descendin...

Research paper thumbnail of Pregnancy-Associated Cardiac Hypertrophy in Corin-Deficient Mice: Observations in a Transgenic Model of Preeclampsia

Canadian Journal of Cardiology, 2018

See editorial by Vaiman, pages 19e22 of this issue.

Research paper thumbnail of Anomalous Left Coronary Artery from the Pulmonary Artery: How to Diagnose and Treat

Journal of Personalized Medicine

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronar... more Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronary anomaly that can present in childhood or adulthood with a multitude of symptoms depending on the age of presentation. It should be suspected in infants presenting with heart failure in the setting of left ventricular systolic dysfunction and associated mitral regurgitation from papillary muscle ischemia. Adults with ALCAPA may present with cardiac ischemic symptoms. Prompt diagnosis with echocardiography and cross-sectional chest imaging is important to guide surgical intervention and improve the patients’ survival and prognosis. The goal of surgery is to establish a dual-coronary system with mid-term results revealing progressive recovery of left ventricular function and improvement in mitral regurgitation. Patients with ALCAPA should maintain life-long follow-up with a cardiologist with congenital heart disease expertise for surveillance of post-operative complications.

Research paper thumbnail of Adults with Down Syndrome: Update on Safety and Long-Term Outcomes of Cardiac Surgery and Percutaneous Interventions

Journal of the American College of Cardiology, Mar 1, 2023

Research paper thumbnail of Congenital Heart Disease: A Growing Population with Challenges to Patients and Providers

Journal of Personalized Medicine

Congenital heart disease (CHD) is the most frequent disorder encountered in the newborn period an... more Congenital heart disease (CHD) is the most frequent disorder encountered in the newborn period and the most frequent cause of infant mortality [...]

Research paper thumbnail of Levo-Transposition of the Great Arteries: Basic Imaging Findings and Management

Journal of Radiology Nursing

Research paper thumbnail of Pregnancy in Patients with Shone Complex: A Single-Center Case Series

Congenital Heart Disease

Background: There is limited literature written on the course and outcomes for pregnant mothers w... more Background: There is limited literature written on the course and outcomes for pregnant mothers with Shone complex. Methods: We describe a case series of five pregnancies in four women with Shone complex within a multidisciplinary cardio-obstetrics clinic from 2016-2018. Results: Maternal age ranged from 21-39 years. Three patients had preserved left ventricular function while one had moderately decreased function. Gestational age at presentation ranged from 6-15 weeks. There were three successful pregnancies (mean gestational age = 37 weeks, range 35-39 weeks) with one patient accounting for two unsuccessful pregnancies. All infants were delivered via Cesarean section. One infant required a NICU stay, but all other infants delivered were healthy. Conclusion: Patients with Shone complex can have successful pregnancies although complications can occur for both the mother and the baby. Comprehensive prenatal care, coordinated and consistent management during pregnancy, and tertiary care support can promote positive maternal and fetal outcomes.

Research paper thumbnail of Congenital Bicuspid Pulmonary Valve in a Tricuspid Valve Regurgitation with Right Ventricle Dysfunction : Multi-Modality Approach

Journal of the American College of Cardiology

Research paper thumbnail of Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

American Heart Journal Plus: Cardiology Research and Practice, 2021

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of D-Transposition of the Great Arteries: Management, Complications, and Basic Imaging Findings

Journal of Radiology Nursing, 2020

Transposition of the great arteries (TGAs) is a condition with ventriculo-arterial discordance wh... more Transposition of the great arteries (TGAs) is a condition with ventriculo-arterial discordance where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. Broadly speaking, two forms exist: (1) a dextro type (referred as D-TGA) and (2) a levo type (referred to as L-TGA). Traditionally, diagnosis is made by echocardiography. Cardiac magnetic resonance imaging (CMR), cardiac computed tomography (CCT), and heart catheterization and angiography are supplemental tools in further characterization of the anatomy. The frequency of routine imaging testing, including echocardiography, CMR, and CCT, depends on severity of heart failure, cyanosis, valvular disease, arrhythmia, pulmonary hypertension, and end-organ damage. The aim of this review is to explore important imaging findings for different types of D-TGA: (1) uncorrected D-TGA, (2) D-TGA after the Mustard/Senning atrial switch surgery; (3) D-TGA after the arterial switch operation; and (4) D-TGA af...

Research paper thumbnail of Light on valvular bumps

Journal of Echocardiography, 2021

Nonbacterial thrombotic endocarditis (NBTE), previously known as marantic endocarditis, can mimic... more Nonbacterial thrombotic endocarditis (NBTE), previously known as marantic endocarditis, can mimic bacterial endocarditis, and is typically diagnosed in the setting of systemic embolization, valvular abnormalities, or heart failure [1]. NBTE is typically associated with antiphospholipid syndrome, systemic lupus erythematosus, or malignancy with the mitral and aortic valves being most frequently affected [2, 3]. Echocardiography plays a major role in the diagnosis once infectious etiology is ruled out. Early disease may be missed even on transesophageal echocardiography and three dimensional (3D) imaging may improve detection. We present a case of NBTE showcasing the incremental diagnostic value of transillumination 3D imaging (3DTI) when compared to two-dimensional (2D) transthoracic echocardiography (TTE), 2D transesophageal echocardiography (2DTEE), and conventional 3D transesophageal echocardiography (3DTEE). 3DTI delineated the anatomical lesion better providing better details of the multinodular nature of valvular NBTE (Fig. 1). A 62-year-old female with prior history of a stroke 14 years ago, hypertension, diabetes mellitus, and hyperlipidemia presented with sudden dysarthria and facial droop. Brain MRI revealed right basal ganglia and subcortical temporal lobe infarct (red arrow A) suggestive of an embolic stroke. Nodular thickening was seen on TTE on the anterior mitral valve leaflet (AML) (white arrow B) and on the posterior mitral valve leaflet (PML) (red arrows B) on the parasternal short axis view. On 2DTEE, bileaflet nodular thickening was seen on the atrial and ventricular aspects of the mitral valve (MV) (C) which was associated with mild-moderate eccentric mitral regurgitation (D). 3DTEE showed marked nodular thickening on the atrial aspect of A3 (white arrows E and F), P3 (red arrows E and F) and P2 (yellow arrows E and F) scallops of the MV in diastole (E) and systole (F). 3DTI rendering in diastole showed more welldefined nodules on the MV (arrows G) and a large multinodular conglomerate mass in systole on the anterior (white arrow H) and posterior leaflets (red arrow H)). Note multiple smaller sub-nodules on the surface of the large conglomerate mass both on the posterior leaflet mass (red arrow) and the anterior leaflet mass (white arrow). These sub-nodules were not seen on conventional 3DTEE images which only showed larger masses without clear assessment of the surface of the masses (F). The patient had an unremarkable infectious work-up and a negative age-appropriate cancer screening. A diagnosis of marantic endocarditis causing an embolic stroke was made. All other work-up, including heart rhythm monitoring, was negative except for positive antiphospholipid antibody × 2 and anticoagulation with warfarin was started.

Research paper thumbnail of Using a novel echo-marker to identify high mortality risk patients with moderate aortic stenosis

BackgroundRecent studies have shown that patients with moderate aortic stenosis and reduced left ... more BackgroundRecent studies have shown that patients with moderate aortic stenosis and reduced left ventricular ejection fraction may benefit from earlier intervention instead of periodic surveillance. Identifying patients at higher risk is therefore warranted concerning the possibility of expanding aortic valve replacement indication.ObjectiveWe aim to investigate the usefulness of a novel echo-marker, augmented mean arterial pressure (AugMAP), in identifying high-risk patients with moderate aortic stenosis.MethodsAdult patients with moderate aortic stenosis (aortic valve area 1.0-1.5 cm2) at Mayo Clinic sites in 1/2010-12/2020 were identified. Baseline demographics, echocardiography, and all-cause mortality data were retrieved. Patients were grouped into higher and lower AugMAP groups using a cutoff of 80 mmHg for analysis. Kaplan-Meier and Cox regression analyses were used to assess the performance of AugMAP.ResultsA total of 4,563 patients with moderate aortic stenosis were include...

Research paper thumbnail of Pregnancy outcomes in women with a systemic right ventricle and transposition of the great arteries results from the ESC-EORP Registry of Pregnancy and Cardiac disease (ROPAC)

Heart, 2021

ObjectiveCardiac disease is a major cause of maternal mortality. Data regarding pregnancy outcome... more ObjectiveCardiac disease is a major cause of maternal mortality. Data regarding pregnancy outcomes in women with a systemic right ventricle (sRV) are scarce. We studied pregnancy outcomes in women with an sRV after the atrial switch procedure for transposition of the great arteries (TGA) or congenitally corrected TGA (CCTGA).MethodsThe ESC EORP Registry of Pregnancy and Cardiac Disease is an international prospective registry of pregnant women with cardiac disease. Pregnancy outcomes (maternal/fetal) in all women with an sRV are described. The primary end point was a major adverse cardiac event (MACE) defined as maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischaemic coronary event and other thromboembolic events.ResultsAltogether, 162 women with an sRV (TGA n=121, CCTGA n=41, mean age 28.8±4.6 years) were included. No maternal mortality occurred. In 26 women, at least one MACE occurred, heart failure...

Research paper thumbnail of Near Complete Resolution of Nonbacterial Thrombotic Endocarditis in a Patient with Antiphospholipid Antibody Syndrome

The Anatolian Journal of Cardiology, 2020

of hepatocellular carcinoma (HCC). Transesophageal echocardiography from both midesophageal bicav... more of hepatocellular carcinoma (HCC). Transesophageal echocardiography from both midesophageal bicaval view (Fig. 1, Panel E, Supplementary Video S2) and four-chamber view (Fig. 1, Panel F) highlighted the highly mobile mass that occupied the right chambers and extended into the PA and therefore, blocked both the RV inflow and outflow tract. However, few hours after admission and despite the attempted rescue thrombolysis, the patient experienced sudden cardiac arrest. HCC patients are known to have an increased risk of thrombosis; however, a giant metastatic thrombus that extends from the IVC to the PA is still considered an unusual presentation of HCC. Informed consent: The informed consent was obtained from the patient. Supplementary Video S1. Transthoracic echocardiography, subcostal view: giant mass occupying the right atrium (RA), protruding into the right ventricle (RV), and significantly obliterating the tricuspid valve. Supplementary Video S2. Transesophageal echocardiography, midesophageal bicaval view revealing highly mobile mass occupying the right chambers.

Research paper thumbnail of Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus

The Annals of Thoracic Surgery, 2020

BACKGROUND Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended trans-se... more BACKGROUND Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended trans-septal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel trans-conal approach in seven consecutive patients. METHODS Retrospective review of a prospectively collected database for consecutive patients undergoing trans-conal unroofing of trans-septal AAOLCA. Surgical repair entails transection of the right ventricular outflow tract (RVOT), unroofing the septal course of the AAOLCA followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted. RESULTS All seven patients identified were symptomatic. Median age was 48 (range 12-62) years. AAOLCA with trans-septal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound (IVUS) and indexed fractional flow reserve (iFFR), confirming flow-limiting lesion. Importantly, 3 patients had negative provocative non-invasive testing for ischemia. Median post-operative hospital length of stay was 6 (range 4-12) days. No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved iFFR compared to preoperative (0.59±0.16 vs. 0.90±0.03, P=0.05). CONCLUSIONS Complete unroofing of AAOLCA with trans-septal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. IVUS with iFFR is clinically useful to confirm the hemodynamic significance of specific lesions.

Research paper thumbnail of Early Outcomes for In Situ Pericardial Roll Repair for Distant Anomalous Pulmonary Venous Return

The Annals of Thoracic Surgery, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of Tetralogy of Fallot: Basic Imaging Findings and Management

Journal of Radiology Nursing, 2019

Tetralogy of Fallot (TOF) is one of the most common cyanotic, congenital heart disease with compl... more Tetralogy of Fallot (TOF) is one of the most common cyanotic, congenital heart disease with complex anatomic malformations and unknown etiology. With medical advancements, most patients in this cohort require early total correction and survive into adulthood. This review addresses various imaging modalities that help diagnose TOF, methods to correct and repair TOF-associated cardiac malformations, and the sequelae and long-term complications of this disease.

Research paper thumbnail of Temporal Trend and Predictors of New Onset Post Operative Atrial Fibrillation After Cardiac Valvular Surgery

Journal of the American College of Cardiology, 2018

Background: Atrial fibrillation (AF) is common after cardiac surgery. This study explores the tem... more Background: Atrial fibrillation (AF) is common after cardiac surgery. This study explores the temporal trend of new-onset AF after mitral valve (MV) and/or tricuspid valve (TV) surgery and its associated risk factors Methods: Medical records of patients above 18 years undergoing MV and/or TV surgery, in isolation or combination with other valve or coronary surgery, from 2003-2013, without a history of pre-operative AF were analyzed. AF was described using electrocardiograms (ECG) read by a cardiologist. AF prevalence over time was estimated using multiphase non-linear logistic mixed effects model. Machine learning and repeated measurements multivariable model were used to identify associated risk factors Results: 10,461 patient records [age (61.1±13.9) years, 61% males] with 100,149 post-operative ECGs qualified for analysis. Median follow up time was 4 months [IQR 2 days-2 years, range 12 hours-14 years]. New-onset AF prevalence post-surgery peaked (13%) at 2 weeks, declined near 3 months (3%) [figure 1a] and then gradually increased (9%) near 7 years [figure 1b]. Age, MV replacement, higher degree of TV regurgitation and history of prior cardiac surgery were associated with higher overall risk of AF independent of time since surgery. TV repair, higher blood urea nitrogen, hypertension and peripheral vascular disease were time dependent risk factors for AF after cardiac surgery Conclusion: Post-valvular surgery AF risk is time dependent with both time dependent and independent risk factors

Research paper thumbnail of Dilated Cardiomyopathy and Atrial Arrhythmia in a Patient with a Prior Repaired Atrial Septal Defect: Don't Let the History Fool You

Journal of the American College of Cardiology, 2019

Background: Unrepaired sinus venosus ASD is a rare but recognized congenital cardiac lesion. Mode... more Background: Unrepaired sinus venosus ASD is a rare but recognized congenital cardiac lesion. Modern multimodality imaging is required for comprehensive diagnosis and to direct surgical management. Case: A 58 year old male with history of remote surgical ASD closure presented with dilated cardiomyopathy thought to be atrial flutter induced. TTE revealed a severely dilated right compared to the left ventricle. TEE (Figure 1a) revealed an inferior sinus venosus ASD with predominantly left to right shunting. Decision-making: The patient presented with atrial flutter and tachycardia induced cardiomyopathy, disproportionately dilated RV, and cyanosis. Details of his prior ASD repair were unavailable. MRI, CTA (Figure 1b), and RHC showed an inferior sinus venosus ASD with a 1.8 cm posterior defect of the interatrial septum, moderate TR, partial anomalous drainage of the pulmonary vein into the IVC with a Qp/ Qs of 1.9:1, and PA pressures 20/8 mmHg (mean 12 mmHg). Surgical closure of the inferior sinus venosus ASD with autologous pericardial patch, Maze procedure, and TV repair were performed. Conclusion: This case highlights the importance of comprehensive multimodality cardiac imaging in the setting of new atrial arrhythmias and unexplained RV enlargement after ASD closure. Sinus venosus ASD frequently is missed on routine echocardiography. Patients presenting with dilated RV and cyanosis should prompt further investigation and adult congenital disease consultation.

Research paper thumbnail of Beyond Scimitar Syndrome: A Unique Combination of Complex Congenital Heart Disease

Journal of the American College of Cardiology, 2019

Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical pres... more Background: Scimitar Syndrome is a rare entity within congenital heart disease. The clinical presentation may be insidious and associated with a number of cardiopulmonary anomalies. Case: A 47 year old male presented with progressive exertional dyspnea, palpitations, and a new systolic murmur in the setting of known dextrocardia. He underwent TTE which showed mildly reduced biventricular function, dilated RV, and moderate TR. Decision-making: Given the suspicion for underlying congenital disease, he underwent cardiac MRI, X-ray, and CTA (Figure 1) which confirmed dextrocardia with evidence of Scimitar syndrome with all right sided pulmonary veins draining into the IVC, a Qp/Qs of 1.6:1, and concomitant dilation of the RA, RV, and PA. Additional findings included an anomalous single coronary artery originating from the right coronary cusp, aortic root dilation (5 cm) and moderate TR. Surgical repair was performed with in-situ pericardial repair of scimitar vein routing to the LA, repair of the TV, and repair of the noncoronary aortic sinus with CardioCel. On follow up, the patient reported resolution of dyspnea on exertion and improved functional capacity. Conclusion: This unique case highlights dextrocardia with Scimitar Syndrome, aortopathy, and anomalous single coronary artery. This congenital complex went undiagnosed for nearly five decades with only mild symptom burden. Multimodality cardiac imaging played a crucial role in the diagnosis and surgical planning of this case.

Research paper thumbnail of Extensive unroofing of myocardial bridge: A case report and literature review

SAGE Open Medical Case Reports, 2019

Background: Myocardial bridge is defined as a segment of a coronary artery that takes an intramyo... more Background: Myocardial bridge is defined as a segment of a coronary artery that takes an intramyocardial course. The presence of myocardial bridge has been observed in as many as 40%–80% of cases on autopsy, angiographically from 0.5% to 16.0%, and often asymptomatic. However, it has been associated with angina, coronary spasm, myocardial infarction, arrhythmias, syncope, sudden cardiac arrest, and death. Conflicting opinions exist on the timing of surgical intervention for myocardial bridge. Methods: We present an unusual case of a young female, with prior aortic surgery, who had refractory chest pain despite optimal medical therapy. Stress testing revealed anterior ischemia. Cardiac catherization showed myocardial bridge of the left anterior descending artery with significant compromise of blood flow (fractional flow reserve = 0.75 with adenosine). We proceeded with surgery. Intraoperatively, we found an unusually long (10-cm) intramyocardial segment of the left anterior descendin...

Research paper thumbnail of Pregnancy-Associated Cardiac Hypertrophy in Corin-Deficient Mice: Observations in a Transgenic Model of Preeclampsia

Canadian Journal of Cardiology, 2018

See editorial by Vaiman, pages 19e22 of this issue.