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BACKGROUND: The prevalence of secondary tricuspid regurgitation (TR) increases with ageing, but the exact mechanisms and the pattern of tricuspid valve (TV) remodelling are yet to be defined. This knowledge is needed to guide patient selection for the evolving therapeutic options. We sought to explore the prevalence and predictors of secondary TR in the elderly, as well as the associated pattern of right-heart chamber and TV remodelling. METHODS: Consecutive older subjects (60-year-old or older) were prospectively enrolled and detailed analysis of right-heart chambers and TV was conducted (ClinicalTrials.gov ID: NCT05784883). TR severity was defined based on a multiparametric approach. RESULTS: Out of 213 patients (age, 67.1 ± 5.9 years, 52.6% female), 48.8% had mild and 15.5% had moderate-severe TR. The frequency of moderate-severe TR increased from 4.5% in those without to 32.9% in those with underlying abnormalities of the left/right heart. There was a significant trend of worsening right-heart chamber and TV remodelling across the three grades of TR severity (none-trace, mild, and moderate-severe; p-value for linear trend < 0.001). ROC curve-defined cut-points of TV remodelling parameters predicting moderate-severe TR were annular dilatation ≥3.75 cm (AUC: 0.74), tenting area ≥1.45 cm2 (AUC: 0.67), and leaflet length ≥2.25 cm (AUC: 0.61) with increasing frequency of moderate-severe TR from 7.2% through 64.7%, in those with none vs. all three criteria (p < 0.001). The most important correlate of the three TV remodelling parameters was right ventricular and atrial (RV and RA) dilatation. CONCLUSION: Rather than ageing per se, the presence of underlying cardiac abnormalities determines the frequency of moderate-severe TR. Progressive remodelling of right-heart chambers and TV geometry starts with the development of mild TR. TA dilatation, increased tenting, and leaflet elongation are three important correlates of the development of TR that parallel progressive RV and RA dilatation.Study Registration: ClinicalTrials.gov ID: NCT05784883.

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Aims: Pulmonary atresia with intact ventricular septum (PA/IVS) can be treated by catheter-based interventions and complemented by various surgical procedures. We aim to determine a long-term treatment strategy to enable patients to be surgery free, depending solely on percutaneous interventions. Methods and Results: We selected five patients from among a cohort of patients with PA/IVS treated at birth with radiofrequency perforation and dilatation of the pulmonary valve. Patients had reached a pulmonary valve annulus of 20 mm or larger on their biannual echocardiographic follow-up, with right ventricular dilatation. The findings, together with the right ventricular outflow tract and pulmonary arterial tree, were confirmed by multislice computerised tomography. Based on the angiographic size of the pulmonary valve annulus, all patients were successfully implanted with either Melody® or Edwards® pulmonary valves percutaneously, regardless of their small weights and ages. No complications were encountered. Conclusion: We managed to stretch the age and weight limitations for performing percutaneous pulmonary valve implantation (PPVI): interventions were attempted whenever a pulmonary annulus size of >20 mm was reached, which was rationalised by the prevention of progressive right ventricular outflow tract dilatation and accommodating valves between 24 and 26 mm, which is enough to sustain a normal pulmonary flow in adulthood.

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Introduction & aim of work: Transcatheter treatment for critical pulmonary stenosis and membranous pulmonary atresia has become the gold standard of care in many centers. We aimed at evaluating the predictors of outcome in interventions for treatment of duct-dependent right ventricular outflow tract obstruction with intact interventricular septum. Subjects & methods: 68 cases with pulmonary atresia with intact interventricular septum (PA/IVS) and 50 cases with critical pulmonary stenosis (CPS), all younger than 3 months of age, were operated during the period of 10 years; excluding patients with tricuspid valve annulus Z-score smaller than -4, evidence of right ventricular-dependent coronary circulation or additional malformations. Results: Age, weight, body surface area as well as tricuspid & pulmonary valve Z-scores were significantly less in PA/IVS; right ventricular pressure was similar in both groups however procedural success and survival to hospital discharge was higher in the CPS group. Lower age, weight and body surface area were associated with procedural failure. Weight was the only predictor of procedural success; while weight and lower post-procedural right ventricular pressure were independent predictors for survival to hospital discharge. Post-procedural right ventricular pressure and length of stay were less in the CPS group. tricuspid and pulmonary valve annulus Z-scores were the only independent predictors of the post-procedural milrinone duration in PA/IVS. Conclusion: We advocate for the use of larger balloon/pulmonary annulus ratio, to achieve a lower right ventricular pressure not fearing excessive pulmonary regurgitation that might be beneficial for right ventricular growth; and for the combination with ductal stenting in borderline or bipartite right ventricles.

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Two paediatric patients suffering from recurrent coarctation after native coarctation surgery were scheduled for cardiac catheterisation in a hybrid setting by the age of two and three years. Through a right anterior mini-thoracotomy, unmounted stents were successfully placed in the coarctant segment. One-year follow up did not show echocardiographic improvement but the patients were controlled on medical therapy. Five-year follow up showed stent breakage in the first case, while the second showed stent stenosis that needed balloon dilatation.

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BACKGROUND: We reported our experience in managing patients with single ventricle (SV) physiology and increased pulmonary blood flow (PBF), aiming to assess if it is feasible to proceed with primary Bidirectional Glenn (BDG) without a prior operation to limit PBF. MATERIALS AND METHODS: This is a retrospective study with 51 consecutive patients who underwent BDG operation as a primary operation or a second stage prior to the definitive Fontan operation at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia between 2010 and 2018. Patients were categorized into two groups based on their PBF prior to the operation: Patients who had SV physiology and increased PBF (seven patients) vs. patients with SV physiology and restricted PBF (44 patients). RESULTS: The median age for the increased PBF group was 9.9 months [interquartile range (IQR): 2-16.9 months], and the median age for the restricted PBF group was 15.3 months (IQR: 6.7-42.6 months). Although the length of hospital stay was longer in patients with increased PBF (P = 0.039), we couldn't find a statistically significant difference in early mortality, duration of mechanical ventilation, length of pleural drainage, and length of intensive care unit (ICU) stay between the groups. CONCLUSION: In our experience, we found that primary BDG could be done safely for patients having SV physiology and increased PBF with acceptable short-term outcomes. It might further reduce the morbidity and mortality for those patients by avoiding the risk of initial pulmonary artery banding or aortopulmonary shunts.

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BACKGROUND: Balloon pulmonary valvuloplasty is the treatment of choice for patients with moderate to severe pulmonary valve stenosis. METHODS: An observational retrospective cross-sectional study including neonates, small infants, and children who underwent balloon pulmonary valvuloplasty in the period from 2007 to 2016 in the cardiac catheterisation unit of the paediatric cardiology department in Cairo University. Multivariable models were built to report the predictors of the outcome of balloon pulmonary valvuloplasty and its complications. RESULTS: A total of 1200 patients were included in the study and divided according to age into 3 groups: neonates and early infants (n = 282), infants (n = 362), and children (n = 556). Procedural success, defined as a drop pressure gradient across the pulmonary valve to less than or equal to 50% of the baseline measurements, was achieved in 82.7% of the patients. Multivariate analysis revealed that only infundibular pulmonary stenosis (p value 0.032), supravalvular in association with valvular pulmonary stenosis (p value <0.001), and pulmonary valve diameter by angiogram (p value <0.001) were significant predictors of success. The presence of supravalvular in association with valvular pulmonary stenosis (p value <0.001) was associated with a lower weight (p value 0.007) and higher right ventricular pressure before the intervention (p value <0.001), and a minor immediate drop in the pressure gradient post-intervention (p value <0.001) was found to be the most significant predictor of the occurrence of complications. CONCLUSION: The absence of infundibular and supravalvular stenosis and a large pulmonary valve diameter were the most significant predictors of success.

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AIM: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral stenosis using the three-dimensional (3D) scoring system. METHODS: A two-staged study was conducted. The first stage was designed to select the best 3D images of MV leaflets and chordae through analysis of 471 images. The second stage was designed to organize the best 3D images into protocols for complete scoring of MV. It included 35 consecutive patients; 23 had sinus rhythm (SR) and 12 had atrial fibrillation (AF). Both single- and multi-beat 3D acquisition from apical and parasternal windows were focused on MV leaflets and chordae using all 3D modalities (live, zoom, and full volume). To propose the protocols, 1563 images were analyzed. RESULTS: In SR with good apical window, 2 protocols were recommended for complete scoring of leaflets and chordae (4 zoom 3D images [1 image for leaflets and 3 images for chordae] and 1 full-volume 3D image) using single- and multi-beat acquisition. In AF, the same 2 protocols using single-beat acquisition were recommended. From parasternal window, complete scoring of leaflets was obtained by 3 recommended protocols (single- or multi-beat zoom 3D images from parasternal short axis [PSAX], multibeat live 3D images from PSAX, and single- or multi-beat full-volume 3D images from parasternal long axis) in SR and 1 protocol in AF (single-beat zoom 3D images from PSAX). Scoring of chordae was incomplete in all patients by all 3D modalities. CONCLUSIONS: The proposed 3D-transthoracic echocardiography protocols suit all patients regardless of echo window and heart rhythm and enabled complete MV scoring.

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OBJECTIVE: Real-time three-dimensional echocardiography, using both reconstruction methods and RT3D, has been used as an extra helping tool in several forms of congenital heart diseases. Our aim was to understand the relation of the ASD device to all surrounding structures by 3-dimensional echocardiography (3D). METHODS: This prospective study included 37 patients diagnosed as ASD secundum by transthoracic (TTE) and transesophageal echocardiography (TEE) referred for transcatheter closure from October 2013 to July 2016. Follow-up for 1 year using 2D and 3D-echocardiography was performed to assess the relations of the device to the surrounding structures. RESULTS: Transcatheter ASD closure and echocardiographic examinations were successfully performed for all patients. By 3D echocardiography, 16 patients (43.24%) had their ASD device close to the aortico-mitral continuity plane without apparent regurgitation, while the rest of our patients (56.75%) the devices were away from this plane. The following variables were significantly different between the two groups; body surface area, atrioventricular rim (AV), device size, left disc size and ratio of left disc to interatrial septum. A cut-off AV rim length not less than 8 mm was found optimal to avoid device encroachment on the sensitive surrounding structures. New Formula was constructed to aid in device choice. CONCLUSION: Use of 3D before and after ASD closure is of value to determine the device relation to the surrounding structures. AV rim by TEE is an important rim to avoid eventual encroachment on the mitral valve and aorta.

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BACKGROUND: Advances in echocardiographic studies have identified a massive burden of rheumatic heart disease (RHD) which continues to be a major health hazard in most developing countries. The aim of this study was to investigate the correlation between cardiac affection as regards the presence of single or multiple valvular lesions, and their severity and the growth parameters in a group of Egyptian children with RHD. METHODS: This study is a cross-sectional study, that was conducted on 200 children with RHD and 400 age-matched healthy. All subjects were subjected to anthropometric measurement and echocardiographic evaluation of the different cardiac parameters. RESULTS: Isolated mitral incompetence (MI) was the most frequent type of valvular lesion in RHD (54.0%), followed by mixed MI and aortic incompetence (AI) (26.5%). Patients with RHD were more liable to be underweight and stunted compared to controls (P<0.05). Growth retardation was significantly noticed in patients with RHD in general (P<0.05), and particularly in patients mixed MI and AI in particular (P<0.05). Also a significant association was detected between growth retardation and the severity of the valvular lesion in the group of rheumatic heart patients (P<0.05). CONCLUSIONS: Associations between growth retardation and RHD with its various patterns of valvular affection and severity were detected in the present study.

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In cases of pulmonary atresia with ventricular septal defect (PA-VSD), coronary-pulmonary arterial fistula (CPAF) as the main source of pulmonary blood supply is extremely rare. These fistulae may arise from the left coronary artery, right coronary artery, or a single coronary artery. Fistulae from a single coronary artery are unusual. We are reporting a case of PA-VSD with single coronary artery and CPAF as the main source of pulmonary supply in addition to two major aortopulmonary collateral arteries (MAPCAS). Successful surgical correction with VSD closure and right ventricle (RV) to the pulmonary artery (PA) conduit was made.

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AIMS: In this study, we examined the differences in cost and effectiveness of various devices used for the closure of small to medium sized patent ductus arteriosus (PDA). SETTING AND DESIGN: We retrospectively studied 116 patients who underwent closure of small PDAs between January 2010 and January 2015. SUBJECTS AND METHODS: Three types of devices were used: the Amplatzer duct occluder (ADO) II, the cook detachable coil and the Nit Occlud coil (NOC). Immediate and late complications were recorded and patients were followed up for 3 months after the procedure. STATISTICAL METHODS: All statistical calculations were performed using Statistical Package for the Social Science software. P <0.05 were considered significant. RESULTS: We successfully deployed ADO II devices in 33 out of 35 cases, cook detachable coils in 36 out of 40 cases and NOCs in 38 out of 41 cases. In the remaining nine cases, the first device was unsuitable or embolized and required retrieval and replacement with another device. Eleven patients (9.5%) developed vascular complications and required anticoagulation therapy. Patients who had hemolysis or vascular complications remained longer in the intensive care unit, with consequently higher total cost (P = 0.016). Also, the need for a second device increased the cost per patient. CONCLUSIONS: The cook detachable coil is the most cost-effective device for closure of small-to medium-sized PDAs. Calculations of the incremental cost-effectiveness. (ICE) revealed that the Cook detachable coil had less ICE than the ADO II and NOC. The NOC was more effective with fewer complications.

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BACKGROUND: Whartons jelly-derived mesenchymal stem cells are a valuable alternative source that possess multipotent properties, easy to obtain and available in large scale compared to BMMSCs. We investigated the possibility of cardiac function improvement post isoproterenol induced cardiac injury in a rat model following human WJMSCs transplantation. MATERIALS AND METHODS: MSCs were extracted and cultured from cord WJ, characterized by morphology, Immunophenotyping and differentiation to osteoblast and adipocytes. WJMSCs were labeled with PKH2 linker dye. Wistar rats were divided into control group, ISO group (injected with 2 doses of isoproterenol) to induce myocardial injury and ISO group transplanted with labelled WJMSCs. ECG, electrocardiographic patterns, cardiac marker enzymes, tracing of labeled MSCs and immunohistochemical analysis of myocardial cryosections were studied. RESULTS AND CONCLUSIONS: WJ derived MSCs were expanded for more than 14 passages while maintaining their undifferentiated state, were positive for MSC markers and were able to differentiate into adipocyte and osteoblast. We demonstrated that intravenously administered WJMSCs were capable of homing predominently in the ischemic myocardium. Cardiac markers were positively altered in stem cell treated group compared to ISO group. ECG and ECHO changes were improved with higher survival rate. WJMSCs could differentiate into cardiac-like cells (positive for cardiac specific proteins) in vivo. WJMSCs infusion promoted cardiac protection and reduced mortality, emphasizing a promising therapeutic role for myocardial insufficiency.

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To evaluate the right ventricular (RV) function in relation to that of the left ventricle (LV) in patients with dilated cardiomyopathy (DCM). Echocardiographic examination was done using tissue Doppler imaging (TDI) and two-dimensional speckle tracking echocardiography (2D-STE) for 32 pediatric patients with DCM comparing them to another 32 normal matched controls. The global longitudinal strain (GLS) derived from 2D-STE was used to reflect the LV systolic function. Tricuspid annular plan systolic excursion (TAPSE) and the following RV TDI derived indexes: peak systolic velocity (S'), peak early diastolic velocity E', peak late diastolic velocity A', isovolumic acceleration (IVA) and myocardial performance index (MPI) were measured. RV had significant systolic and diastolic dysfunction; TAPSE, S' velocity, IVA, peak early diastolic velocity (E') and peak early diastolic velocity/peak late diastolic velocity (E'/A') ratio were significantly decreased while MPI was significantly prolonged compared to controls. Moreover, TAPSE, S', IVA, E', E'/A' and RV MPI were significantly correlated to LV GLS. For prediction of LV dysfunction among patients, the area under the receiver operating characteristic curve was 0.98 for RV MPI, 0.906 for RV IVA. For identifying severe LV dysfunction; RV MPI  > 0.29 had 100% sensitivity and 93.7% specificity, while the RV IVA  ≤ 3 had 84.4% sensitivity and 90.6% specificity. In pediatric patients with DCM the RV systolic and diastolic functions are affected beside the LV dysfunction. Non-conventional echocardiographic evaluation of RV function is recommended in among this cohort.

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Coronary artery fistulas are rare anomalies, their incidence range from 0.1 to 0.2% of congenital heart defects. The left circumflex coronary artery (LCX) fistula draining into the coronary sinus (CS) is a less common form, and most cases described in the literature were adult cases. We are describing this type of fistula in an 8-month-old asymptomatic female presenting with a continuous murmur over the pericordium. Electrocardiogram was normal. Echocardiography revealed a dilated LCX and CS with turbulent flow in CS; 2-D speckle tracking echocardiography revealed normal left ventricular strain with no regional wall abnormalities. Multidetector computed tomography demonstrated the fistula. As the patient was asymptomatic, with no ventricular dilatation or dysfunction, we decided conservatively. .

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The aim of this study was to determine the effect of induction dose of anthracycline chemotherapy on the biventricular function among children with acute hematological malignancies (AHM) using tissue Doppler imaging (TDI) and 2D speckle tracking echocardiography (2D-STE). Thirty pediatric patients with AHM and a mean age of 9.24 ± 4.14 years performed conventional echocardiography, TDI and 2D-STE. After induction chemotherapy, the RV showed mainly a diastolic alteration in its function manifested in significant reduction in the tricuspid TDI-derived E' and E'/A' ratio compared with the baseline (20.40 ± 3.81 vs. 17.47 ± 3.87 cm/s, p = 0.001, 1.29 ± 0.27 vs. 1.03 ± 0.37, p < 0.01, respectively), while the TDI-derived RV MPI and isovolumetric relaxation time of RV were significantly increased (0.32 ± 0.06 vs. 0.36 ± 0.08, p < 0.01, 24.73 ± 8.62 vs. 28.47 ± 11.51 ms, p < 0.05, respectively). The LV showed post-chemotherapy mainly an alteration in its longitudinal systolic function in the form of a reduction in MAPSE (13.61 ± 2.00 vs. 11.95 ± 1.75 mm; p < 0.001), TDI-derived systolic velocity of lateral mitral annulus (10.98 ± 2.34 vs. 10.03 ± 1.83 cm/s, p < 0.05), 2D-STE-derived global longitudinal strain (-21.58 ± 2.54 vs. -19.18 ± 3.59 %, p = 0.001) and 2D-STE-derived global longitudinal strain rate (-1.76 ± 0.22 vs. 1.55 ± 0.29 1/s, p < 0.05), with preservation of LV diastolic function when compared to baseline. TDI and 2D-STE could be used for early detection of anthracycline-induced cardiotoxicity in the pediatric age group. Early after induction chemotherapy, the RV develops mainly diastolic dysfunction, while the LV showed a relative longitudinal systolic impairment.

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AIM: Some difficult atrial septal defect (ASD) cases with deficient rims or large defects may require specific maneuvers to facilitate transcatheter occlusion of these defects with self-centering devices. In our center, we developed a modification of balloon-assisted technique (BAT) for difficult ASDs to assist proper positioning of the device. Our aim was to demonstrate the efficiency of ASD closure with self-centering devices in children and to present the results of the new pediatric version of BAT (PBAT) in young children and its relation to the interatrial septal thickness. METHODS AND RESULTS: Over 2 years, a total of 65 patients with ASD secundum were referred for closure, from which 50 cases were deemed suitable for transcatheter closure by transthoracic echocardiography during precatheter evaluation. Ten difficult defects required assisted techniques; 6 of these were successfully closed using the PBAT with a small-sized valvuloplasty balloon. The cut-off levels for needing an assistance technique in pediatric patients were age >5 years, ASD >16 mm, and weight >22 kg. The interatrial septal thickness was thinner in young ASD patients. CONCLUSION: The PBAT was needed to optimize device closure in difficult cases, especially in large defects without rim deficiency. This technique is easy to learn and results in quick and simple device closure.

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Stem cell transplantation has emerged as a promising technique for regenerative medicine in cardiovascular therapeutics. However, the results have been less than optimal. The aim of the present study was to investigate whether nicorandil could offer an additional benefit over bone marrow-derived mesenchymal stem cell therapy in isoproterenol-induced myocardial damage and its progression to heart failure in rats. Isoproterenol was injected subcutaneously for 2 consecutive days at doses of 85 and 170 mg/kg/day, respectively. Nicorandil (3 mg/kg/day) was then given orally with or without a single intravenous bone marrow-derived mesenchymal stem cell administration. Electrocardiography and echocardiography were recorded 2 weeks after the beginning of treatment. Rats were then sacrificed and the ventricle was isolated for estimation of tumor necrosis factor-alpha, vascular endothelial growth factor and transforming growth factor-beta. Moreover, protein expressions of caspase-3, connexin-43 as well as endothelial and inducible nitric oxide synthases were evaluated. Finally, histological studies of myocardial fibrosis and blood vessel density were performed and cryosections were done for estimation cell homing. Combined nicorandil/bone marrow-derived mesenchymal stem cell therapy provided an additional improvement compared to cell therapy alone toward reducing isoproterenol-induced cardiac hypertrophy, fibrosis and inflammation. Notably, combined therapy induced significant increase in angiogenesis and cell homing and prevented isoproterenol-induced changes in contractility and apoptotic markers. In conclusion, combined nicorandil/bone marrow-derived mesenchymal stem cell therapy was superior to cell therapy alone toward preventing isoproterenol-induced heart failure in rats through creation of a supportive environment for mesenchymal stem cells.

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A large amount of evidence indicates that aging is associated with immune system dysfunction. Brewer's yeast, one of the most notable species of yeast in health and wellness, has been shown to stimulate the immune system and improve human life span. In the present study, brewer's yeast (5, 25 or 125 µg/mouse) was orally supplemented to aged mice each other day for 4 weeks. Total number of leukocytes from peripheral blood (PBl), thymus (Thy), spleen (Sp), and peritoneal exudate cells (PEC) were counted. Carbon clearance, plaque-forming cell and rosette-forming cell assays were used to measure macrophage, B cell and T cell responses. In vitro proliferation of splenocytes and histological architecture of thymus from aged mice were tested. Yeast treated mice showed a significant increase in the total number of PBl leukocytes, total cellularity of both Thy and Sp, as well as a significant increase in total and differential numbers of PEC. A gradual increase in macrophages' phagocytic activity of PEC and a significant increase in both plaque-forming cell and rosette-forming cell responses were observed. In vitro results showed that incubation of splenocytes with brewer's yeast (0.5, 2.5 or 12.5µg/well) in the presence of concanavalin-A mitogen elicited a gradual increase in the proliferation of splenocytes. Histological examination of thymuses from yeast-treated aged mice revealed that the cortex was preferentially enlarged and repopulated with immature thymocytes. These results indicate that brewer's yeast supplementation to aged mice improves several baseline immune responses, and provides a valuable tool to identify nutritional strategies that could mitigate immunosenescence.

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Postulated Stem/progenitor cells involved in endometrium regeneration are epithelial, mesenchymal, and endothelial. Bone marrow (BM) has been implicated in endometrial stem cells. We aimed at studying gene expression profiling of endometrial mesenchymal stem cells compared to BM MSCS to better understand their nature and functional phenotype. Endometrial tissues were obtained from premenopausal hysterectomies (n = 3), minced and enzymatically digested as well as Normal BM aspirates (n=3). Immunophenotyping, differentiation to mesoderm, and proliferation were studied. The expression profile of 84 genes relevant to mesenchymal stem cells was performed. Fold change calculations were determined with SA Biosciences data analysis software. VEGF, G-CSF, and GM-CSF in cultures supernatants of MSCs were assayed by Luminex immunoassay. Endo MSCs possess properties similar to BM MSCs. Cumulative population doubling was significantly higher in Endo MSCs compared to BM MSCs (p < 0.001). 52 core genes were shared between both generated MSCs including stemness, self-renewal, members of the Notch, TGFB, FGF, and WNT.16 downregulated genes (VCAM, IGF1)and 16 upregulated in Endo MSCs compared to BM (p < 0.05 â†’ fourfolds). They included mostly cytokine and growth factor genes G-CSF, GM-CSF, VWF, IL1b, GDF15, and KDR. VEGF and G-CSF levels were higher in Endo MSCs supernatants (p < 0.0001). Cells sharing MSC and endothelial cell characteristics could be isolated from the human endometrium. Endo MSCs share a core genetic profile with BM MSCs including stemness. They show upregulation of genes involved in vasculogenesis, angiogenesis, cell adhesion, growth proliferation, migration, and differentiation of endothelial cells, all contributing to endometrial function.

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