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Everett R.J.,Royal Free Hospital | Sheppard M.N.,Royal Brompton and Harefield Foundation NHS Trust | Lefroy D.C.,Hammersmith Hospital
Circulation | Year: 2013

This case highlights the importance of considering a wide differential diagnosis in a young patient with chest pain and an abnormal ECG. Rarer causes of myocarditis such as GCM should be sought in patients who develop ventricular arrhythmias or high-grade heart block because the treatment is different and dramatically influences outcome. Our patient is the first reported case of GCM and a concurrent diagnosis of tuberculosis. It is most likely that the histological appearance of GCM was due to the presence of mycobacterial infection within the myocardium, and we believe that effective antituberculous therapy has led to resolution of the GCM without the need for continued long-term immunosuppression. © 2013 American Heart Association, Inc.

Jowett V.,Imperial College London | Aparicio P.,Royal Brompton and Harefield Foundation NHS Trust | Santhakumaran S.,Imperial College London | Seale A.,Royal Brompton and Harefield Foundation NHS Trust | And 2 more authors.
Ultrasound in Obstetrics and Gynecology | Year: 2012

Objectives: Isolated fetal coarctation of the aorta (CoA) has high false-positive diagnostic rates by cardiologists in tertiary centers. Isthmal diameter Z-scores (I), ratio of isthmus to duct diameters (I:D), and visualization of CoA shelf (Shelf) and isthmal flow disturbance (Flow) distinguish hypoplastic from normal aortic arches in retrospective studies, but their ability to predict a need for perinatal surgery is unknown. The aim of this study was to determine whether these four sonographic features could differentiate prenatally cases which would require neonatal surgery in a prospective cohort diagnosed with CoA by a cardiologist. Methods: From 83 referrals with cardiac disproportion (January 2006 to August 2010), we identified 37 consecutive fetuses diagnosed with CoA. Measurements of I and I:D were made and the presence of Shelf or Flow recorded. Sensitivity, specificity and areas under receiver-operating characteristics curves, using previously reported limits of I < - 2 and I:D < 0.74, as well as Shelf and Flow were compared at first and final scan. Associations between surgery and predictors were compared using multivariable logistic regression and changes in measurements using ANCOVA. Results: Among the 37 fetuses, 30 (81.1%) required surgery and two with an initial diagnosis of CoA were revised to normal following isthmal growth, giving an 86% diagnostic accuracy at term. The median age at first scan was 22.4 (range. 16.6-7.0) weeks and the median number of scans per fetus was three (range, one to five). I < - 2 at final scan was the most powerful predictor (odds ratio, 3.6 (95% CI, 0.47-27.3)). Shelf was identified in 66% and Flow in 50% of fetuses with CoA. Conclusion: Incorporation of these four sonographic parameters in the assessment of fetuses with suspected CoA at a tertiary center resulted in better diagnostic precision regarding which cases would require neonatal surgery than has been reported previously. Copyright © 2012 ISUOG.

Ali O.F.,Royal Brompton and Harefield Foundation NHS Trust | Schultz C.,Erasmus Medical Center | Jabbour A.,Royal Brompton and Harefield Foundation NHS Trust | Rubens M.,Royal Brompton and Harefield Foundation NHS Trust | And 10 more authors.
International Journal of Cardiology | Year: 2015

Objectives We sought to investigate the role of balloon size during pre-implantation valvuloplasty in predicting AR and optimal Medtronic CoreValve (MCS) implantation depth. Background Paravalvular aortic regurgitation (AR) is common following MCS implantation. A number of anatomical and procedural variables have been proposed as determinants of AR including degree of valve calcification, valve undersizing and implantation depth. Methods We conducted a multicenter retrospective analysis of 282 patients who had undergone MCS implantation with prior cardiac CT annular sizing between 2007 and 2011. Native valve minimum (Dmin), maximum (Dmax) and arithmetic mean (Dmean) annulus diameters as well as agatston calcium score were recorded. Nominal and achieved balloon size was also recorded. AR was assessed using contrast angiography at the end of each procedure. Implant depth was measured as the mean distance from the nadir of the non- and left coronary sinuses to the distal valve frame angiographically. Results 29 mm and 26 mm MCS were implanted in 60% and 39% of patients respectively. The majority of patients (N = 165) developed AR < 2 following MCS implantation. AR ≥ 3 was observed in 16% of the study population. High agatston calcium score and Dmean were found to be independent predictors of AR ≥ 3 in multivariate analysis (P < 0.0001). Nominal balloon diameter and the number of balloon inflations did not influence AR. However a small achieved balloon diameter-to-Dmean ratio (≤ 0.85) showed modest correlation with AR ≥ 3 (P = 0.04). This observation was made irrespective of the degree of valve calcification. A small MCS size-to-Dmean ratio is also associated with AR ≥ 3 (P = 0.001). A mean implantation depth of ≥ 8 + 2 mm was also associated with AR ≥ 3. Implantation depth of ≥ 12 mm was associated with small MCS diameter-to-Dmean ratio and increased 30-day mortality. Conclusion CT measured aortic annulus diameter and agatston calcium score remain important predictors of significant AR. Other procedural predictors include valve undersizing and low implantation depth. A small achieved balloon diameter-to-Dmean ratio might also predict AR ≥ 3. Our findings confirm that a small achieved balloon size during pre-implantation valvuloplasty predicts moderate-severe AR in addition to previously documented factors.

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