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Characterization of the fossa Ovalis with Real Time 3D TEE PI – Dr Ed Gill (HMC Cardiology)

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Presentation on theme: "Characterization of the fossa Ovalis with Real Time 3D TEE PI – Dr Ed Gill (HMC Cardiology)"— Presentation transcript:

1 Characterization of the fossa Ovalis with Real Time 3D TEE PI – Dr Ed Gill (HMC Cardiology)

2 Background: Real-time 3D transesophageal echo (RT3D TEE) has been a major advance for echocardiography and has been shown to provide incremental value for the evaluation of atrial septal defects, from both diagnostic and therapeutic angles

3 Aim of study to evaluate the fossa ovalis of the interatrial septum by 3D TEE and compare the size and structure with that seen in historical controls and our own data from measuring pathologic specimens to correlate the structure of the fossa ovalis identified by 3D echo to the structure seen in pathologic specimens

4 Methods: In a series of 100 patients with a variety of accompanying abnormaliies both valvular and non- valvular, we measured the fossa ovalis using RT3DTEE to acquire and analyze the image of the fossa and an offline workstation with Q lab (Philips Medical Systems) to measure the diameter and area of the fossa ovalis. In 13 normal hearts and 14 hearts with valve prolapse (MVP), the fossa ovalis was measured by the combination transillumination of the fossa digital photography capture of the transilluminated image followed by offline planimetry using NIH Image J.

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8 Results: The fossa ovalis in the pathology specimens was greater in the MVP as compared to normal specimens (1.64±0.87 vs 1.10±0.47, p=0.04). The fossa ovalis could be adequately captured and measured in 86% of series of 25/100 patients The fossa ovalis measured by RT3D TEE averaged 2.3±1.47 by direct planimetry and 2.3±1.86 calculating from the measured diameter, p=NS. The measurement of the fossa ovalis in the pathologic specimens was also within the range of previous reports of historical controls

9 Results continued: 50% of pathologic specimens a septal “pouch” was present and opened in the left atrium. Septal pouch could only be identified in 3% of the RT3DTEE images

10 Conclusion: The measurement of the fossa ovalis by 3D TEE is feasible in most cases. Correlation with measured valvues in pathologic specimen is reasonable, but the size of the fossa ovalis was typically overestimated by RT3DTEE. Further enhancements are necessary to improve the diagnosis of the left atrial septal pouch

11 Tissue Urate Crystal Study PI: Dr Peter Simkin (UWMC Rheumatology) Co Investigators: Dr Nahush Mokadam (UWMC CT Surg) Dr Gordon Starkebaum (VAMC Rheumatology) Collaborator: Dr Kevin O’Brien (UWMC Cardiology) Specific vascular changes in Gout. Trout Et al. 1954

12 Background Hyperuricemia - risk factor for Coronary artery disease ? Is it an independent risk factor or is it confounded by the fact that it is associated with conventional risk factors like diabetes, hypertension, hyperlipidemia (metabolic syndrome), chronic kidney injury and diuretic therapy? Prelim studies showing reduced mortality and MI in patients treated with allopurinol or colchicine

13 Background Tissue super saturation driving articular crystallization in a hyperuricemic patient with gout could also be present under the vascular endothelium, if so this could contribute to local deposition and chronic inflammation Could calcium and cholesterol crystals promote epitaxial crystallization of urate? Inflammation - a central role

14 Background: pathologists may have failed to recognize urate crystal deposits in these tissues due to formaldehyde fixation which forms highly soluble addition products with urate and leaches this molecule out of the tissue.

15 Aim: Primary Aim: To examine cardiac and arterial specimens (aortic valves from aortic valve replacement surgery, coronary arteries from explanted hearts etc) for the presence of sodium urate crystals Secondary Aim: To identify epitaxial urate crystallization on existing calcium and or cholesterol crystals To correlate crystal findings with the presence and extent of hyperuricemia To see if there is pathologic evidence of inflammation secondary to the urate crystals

16 Inclusion Criteria: All patients undergoing aortic valve replacement and cardiac transplants at the UWMC for a period of 2 yrs or 60 native aortic valves/ 50 coronaries whichever comes first

17 Study Design/Methods: Resected specimens (Aortic valves and coronary arteries)  absolute alcohol (methyl carnoy’s) for fixation. Each specimen will then be embedded in paraffin and sectioned for examination with plain and polarized microscopy. We will look for sodium urate crystals and cellular inflammation. Sections may be treated with uricase and/or lipid solvents to confirm presence of urate crystals.

18 A few changes Repository of Coronary arteries and Aortic Valves in Methyl Carnoy's (10% glacial acetic acid, 60% methanol, 30% chloroform) from explanted hearts collected over a 10 year period by Dr Kevin O’Brien Adding tissue from appropriate patient population going to autopsy at UWMC.

19 Results: Surgical Samples : 10 Aortic Valves Slide Repository: 30 Hearts (LAD, RCA) - 5

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26 Thank you! Dr Gill and Dr Simkin


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