A Misclassification of Pulmonary Stenosis Using Conventional Echocardiographic Methods.
A 20-year-old pregnant woman with secundum ASD and severe PS presented with progressive dyspnoea and was referred to our clinic for a percutaneous ASD closure and a pulmonary valvuloplasty. She was in the second trimester (16 weeks) of pregnancy. At admission, her arterial blood pressure and heart rate were 120/70 mmHg and 64 beats/min, respectively. The physical exam was unremarkable except for a grade 2/6 ejection systolic murmur best heard over the left second intercostal space and fixed splitting of the second heart sound. An electrocardiogram showed an incomplete right bundle branch block. A two-dimensional transthoracic echocardiography (2D TTE) was done using a Philips (Bothell, WA, USA) iE33 ultrasound system with an x5-1 transducer. It showed a secundum ASD with a left-to-right shunt, severe PS (maximal gradient= 79 mmHg and maximal velocity= 4.4 m/s) (Figure 1), an enlarged right ventricle (RV) (basal diameter= 4.4 cm), normal left ventricular function and mild tricuspid regurgitation. The RV free wall was 0.4 cm. Tricuspid annular plane systolic excursion were measured at 1.5 cm. Then. 2D transoesophageal echocardiography (TEE) was done using the X7-2t matrix transducer and the same ultrasound system as the 2D TTE. The 2D TEE findings were the same as those of 2D TTE, but the three leaflets of the PV were still not visualized; however, there were thickening of leaflets and a doming motion. For further evaluation, we performed a 3D TEE using the same system and transducer. Full-volume data of the PV and interatrial septum were taken, and all images were systematically and sequentially cropped to view both the ASD and PV en face in both non-multiplanar reconstruction (MPR) and MPR modes. The secundum ASD was measured 2.4 x 1.6 cm with an area of 4.5 cm2 and all rims were larger than 5 mm. Thus, the ASD was determined to be appropriate for a percutaneous closure procedure. The PV was noted to be tricuspid (Figure 2) and the PV area was 1.89 [cm.sup.2] (Figure 3). PS was classified according to the planimetric method as a mild stenosis (5,6).
There was an inconsistency between the Doppler and 3D classification of PS severity. During pregnancy, ESC guidelines on the management of cardiovascular diseases during pregnancy (7) provide follow-up recommendations for patients with mild or moderate PS, but balloon valvuloplasty should be advised for symptomatic severe PS with RV dysfunction as in our patient. Therefore, we decided to follow up our patient during pregnancy. After the pregnancy was completed, the peak PV gradient was reduced to 41 mmHg (a moderate PS according to the gradient/velocity-based classification). The patient then underwent a percutaneous closure of the ASD. After a successful procedure, the peak PV gradient reduced to 26 mmHg (a mild PS according to the gradient/velocity-based classification), and the discrepancy between the Doppler and planimetry-based classification for PS was eliminated. Written informed consent was obtained from the patient.
Pregnancy results in profound physiologic changes. Chief among these changes are increases in cardiac output, heart rate, blood volume, biventricular stroke work and oxygen consumption. Also, women with congenital heart disease may not tolerate these hemodynamical changes very well. However, most women with unrepaired ASDs have successful pregnancies (8). In addition, ASDs can cause left-to-right shunts and volume overload of the right atrium and RV. In our patient, the maximal PV gradient was overestimated for these two reasons. We know the planimetric method is not affected by flow rate (4); thus, it is more useful than gradient- and velocity-based classifications, especially in situations such as these.
We were unable to provide a correct treatment decision based only on symptoms such as dyspnoea, palpitation or chest pain because these symptoms are common among pregnant women. Symptom- and Doppler-based misclassifications of PS may influence the accuracy of the valvuloplasty time and may lead to a termination of the pregnancy due to unnecessary radiation exposure. Therefore, the 3D TEE planimetric method is useful and safe, especially in the RV volume overloading period when the transvalvular peak gradient of the PV is affected. The planimetric calculation of the PV opening area using 3D TEE may be helpful, especially when specialized conditions such as ASD or/and pregnancy can cause inaccurate recordings of the transvalvular peak gradient and maximal velocity.
Conflict of interest: No conflict of interest was declared by the authors.
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Tugba Kemaloglu Oz (1), Mehmet Eren (1), Tayfun Gurol (2), Ozer Soylu (2), Bahadir Dagdeviren (2)
(1) Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
(2) Department of Cardiology, Bahcesehir University School of Medicine, Istanbul, Turkey
Address for Correspondence: Dr. Tugba Kemaloglu Oz, Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
Phone: +90 506 265 04 37
ORCID ID: orcid.org/0000-0003-1168-8237
Received: 22 November 2016
Accepted: 4 August 2017
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|Title Annotation:||Original Article|
|Author:||Oz, Tugba Kemaloglu; Eren, Mehmet; Gurol, Tayfun; Soylu, Ozer; Dagdeviren, Bahadir|
|Publication:||Balkan Medical Journal|
|Article Type:||Clinical report|
|Date:||Jan 1, 2018|
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