Knowledge and Attitudes Amongst Internal Medicine Clinicians in Referring Valvular Heart Disease Patients: A Survey Study

Raja Ezman Faridz Raja Shariff,Khairul Shafiq Ibrahim,Hafisyatul Aiza Zainal Abidin,Sazzli Kasim 아시아심장혈관영상의학회 2021 Cardiovascular Imaging Asia Vol.5 No.4

Objective: Little is known regarding the levels of knowledge and attitudes amongst non-cardiology clinicians in managing valvular heart diseasel (VHD). Materials and Methods: To determine the knowledge and attitudes towards management of VHD patients amongst internal medicine clinicians in Malaysia. We conducted a 20-item survey study, distributed amongst internal medicine clinicians. Results: A total of 75 responses was obtained. Respondents included medical officers (50.7%), consultants (32.0%), and pre-consultant specialist (17.3%). Respondents were comfortable using online resources from both formal (94.7%) and informal (74.7%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients (36.0%), and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (49.4%). Although many were felt to be overzealous with echocardiography monitoring in mild VHD (55.9% felt that it was required within 2 years), nevertheless attitudes regarding referrals to cardiology services for consult and intervention were felt to be appropriate. Conclusion: The survey highlights the need for education amongst internal medicine clinician to tackle both the overzealous attitude in monitoring patients with mild valvular disease on one extreme and in improving early referrals for VHD indicated for intervention on the other.

An Uncommon Case of Bioprosthetic Mitral Valve Thrombosis Complicated by Intracerebral Haemorrhage

Shariff Raja Ezman Raja,Khir Rizmy Najme,Zainal Abidin Hafisyatul Aiza,Kasim Sazzli 아시아심장혈관영상의학회 2021 Cardiovascular Imaging Asia Vol.5 No.2

An 82-year-old man presented with bioprosthetic valve thrombosis (BVT) following a cardioembolic stroke due to mitral valve infective endocarditis. The patient had previously undergone bioprosthetic mitral valve replacement. After being discharged postoperatively, he represented with weakness due to a novel left-sided stroke and right-sided occipital intracerebral haemorrhage. Both transthoracic and transoesophageal echocardiography revealed BVT on the anterior portion of the prosthesis. Following a multi-disciplinary team discussion, it was agreed that thrombolytics and anticoagulation would be detrimental. The patient continued to worsen and eventually succumbed to congestive cardiac failure. BVT is uncommon, and patients often present with signs and symptoms of heart failure, shock, or embolism. There are no guidelines available for managing BVT in patients with concurrent intracerebral haemorrhage, which highlights the importance of multi-disciplinary decision-making.

An Unexpected Mass in a Patient With a Left Ventricular Assist Device

Raja Shariff Raja Ezman Faridz,Beng Koh Hui,Ting Yuen Beh,Yee Sin Tey,Mohd Ghazi Azmee 아시아심장혈관영상의학회 2022 Cardiovascular Imaging Asia Vol.6 No.4

Left ventricular assist devices (LVAD) have helped improve survival, functional status, and quality of life for end-stage heart-failure patients, worldwide. Unfortunately, the risk of complications associated with such devices, including infections, has increased with improved survival. We report a unique case of pump pocket infections (PPI) and collection, diagnosed using multi-modality cardiovascular imaging in a young male patient implanted with a HeartWare LVAD. He had multiple admissions in the past for driveline infections (DLI). Transthoracic echocardiography revealed a 1.4×4.6-cm hyperechoic mass. An 18F-FDG PET-CT scan was performed revealing multiple foci of hypermetabolism seen along the driveline and pump, as well as from a lesion with high radiotracer uptake anterior to the right ventricle, suggesting collection. The patient underwent extensive wound debridement and prolonged intravenous antibiotics, followed by life-long oral antibiotics. Although uncommon, following the current trend in preferential use of centrifugal pumps, PPI remains a possibility, especially in the presence of chronic DLI. Our case highlights the value of multi-modality imaging, including PET-CT imaging, in managing LVAD-related infections, as it may alter the course of subsequent management.

Acute Right Intracardiac Thrombus-in-Transit Complicated by Submassive Pulmonary Embolism

Raja Shariff Raja Ezman,Badrul Zaman Nazurah,Mohamad Razi Adli Azam,Najme Khir Rizmy,Kasim Sazzli 아시아심장혈관영상의학회 2021 Cardiovascular Imaging Asia Vol.5 No.1

A 61-year-old female presented with symptoms suggestive of congestive cardiac failure that was confirmed on transthoracic echocardiography (TTE) with the absence of an intracardiac thrombus. In the hospital, she suffered episodes of syncope, prompting further investigations. Repeat TTE revealed an acute mobile right atrial thrombus, and CT imaging of the pulmonary artery confirmed the presence of a massive pulmonary embolism (PE). Despite a low pulmonary embolism severity index (PESI) score, the patient underwent surgical pulmonary embolectomy. The prevalence of right-sided thrombi ranges between 4–18% in the presence of acute PE, and right-sided thrombi will almost always lead to PE. Our case highlights the limitation of the PESI score and emphasizes urgent management for the presence of a thrombus-in-transit, despite a low PESI score.

A Unique Case of Non-Capture of Permanent Pacemaker Lead: Delayed Lead Perforation and Cardiac Tamponade

Raja Ezman Faridz Raja Shariff,Lim Chiao Wen,Rizmy Najme Khir,Khairul Shafiq Ibrahim,Sazzli Kasim 아시아심장혈관영상의학회 2021 Cardiovascular Imaging Asia Vol.5 No.3

We report a rare case of delayed cardiac perforation that progressed to cardiac tamponade and initially presented as loss of pacemaker lead capture. A 50-year-old female with a singlelead permanent pacemaker for third-degree atrioventricular dissociation presented with lethargy, dyspnea, and reduced effort tolerance. Home monitoring by her cardiac device and an electrocardiogram performed on arrival showed loss of capture. Transthoracic echocardiogram revealed cardiac tamponade requiring urgent pericardiocentesis, revealing hemorrhagic effusion. Delayed perforation of her device leads was suspected, even though neither CT nor cardiac MRI revealed contrast leakage or displaced lead position. Cardiac perforation following device implantation is rare. This case is unique as it highlights an extreme presentation in which delayed perforation led to gradual accumulation progressing to tamponade and loss of device capture, both of which resolved following emergency pericardiocentesis. The main treatment of suspected lead perforation remains revision of leads, although evidence to support either a percutaneous or surgical approach remain debatable.

A Unique Cause of Mitral Regurgitation–Mitral Commissural Prolapse

Nur Farihah Yaacob,Raja Ezman Raja Shariff,Mohd Rahal Yusoff,Khairul Shafiq Ibrahim,Sazzli Kasim 아시아심장혈관영상의학회 2023 Cardiovascular Imaging Asia Vol.7 No.3

A 65-year-old female patient was referred following worsening failure symptoms. Transthoracic echocardiography (TTE) demonstrated a prolapsed posterior leaflet of the mitral valve (MV). However, there was a widely spreading mitral regurgitation (MR) jet, casting some suspicion on the exact etiology of the MR. Transesophageal echocardiography, using three-dimensional (3D) reconstruction and multi-planar imaging, revealed changes suggestive of a postero-medial commissure prolapse. Commissural prolapse is an often-overlooked cause of MR. Accurate diagnosis is only achieved in approximately one-third of cases using two-dimensional TTE as conventional views are often unable to visualize the exact mechanism of MR. Meticulous assessment and early recognition of MV commissural prolapse, or flail, is important for accurate diagnosis and pre-procedural or surgical planning. Alongside some unique features to suggest the presence of commissural prolapse, we hope to highlight the pivotal role of multi-planar imaging and 3D reconstruction in such a diagnosis.

A Multi-Modality Approach to Danon Disease

Farah Nur Izzrin Zainuddin,Raja Ezman Raja Shariff 아시아심장혈관영상의학회 2024 Cardiovascular Imaging Asia Vol.8 No.1

Danon disease is a rare genetic cardio-skeletal myopathy. We present a case of an 18-year-old patient experiencing intermittent chest pain, dyspnea, and palpitations. Initial investigations unveiled elevated NT-pro brain natriuretic peptide, creatinine kinase, and cardiac enzyme levels. Electrocardiogram findings displayed left ventricular hypertrophy with a strain pattern and left bundle branch block. Transthoracic echocardiography and cardiac magnetic resonance imaging confirmed severe concentric left ventricular hypertrophy, accompanied by late gadolinium enhancement in specific myocardial regions. Genetic testing identified prevalent frameshift mutations in the lysosomal-associated membrane protein-2 (LAMP2) gene, indicative of Danon disease. This condition manifests as a severe, early-onset cardiomyopathy with associated complications such as heart failure, arrhythmias, and conduction disturbances, particularly in males. Diagnosis relies on genetic evidence, emphasizing the significance of testing in conjunction with clinical and imaging tools.