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We present the case of a 60-year-old man who was successfully treated for obstructive fungal infective endocarditis of the ascending aorta caused by Geotrichum capitatum. This extremely rare cause of fungal infective endocarditis required surgical and prolonged medical management, facilitated by effective multidisciplinary cooperation. (Level of Difficulty: Intermediate.), Central Illustration

Objective We employed echocardiographic tissue characterization for the assessment of single ventricle systolic function and examined its relationship with cardiopulmonary exercise testing (CPET) performance in the Fontan circulation. Methods 40 consecutive adult Fontan patients (16 female, 24 male; mean age 26.3 ± 5.9) were enrolled in our prospective cross-sectional study. All patients underwent echocardiographic assessment including tissue characterization and CPET within 3 days from each other. Results LAPSE (lateral annular plane systolic excursion) was higher in patients with a dominant left ventricle compared to a dominant right ventricle (12.3 + −2.6 vs 9.8 + −1.1 mm, p = .008) and in patients with AP (right atrium-pulmonary artery) connection than with lateral tunnel or extracardiac conduits (13.9 ± 1.7 vs 11.3 ± 2.6 and 10.9 ± 2.2 mm, p = .014 and p = .014, respectively). Maximal oxygen pulse (O2 pulse max) was significantly higher in patients with a dominant left or common ventricle compared to patients with a dominant right ventricle (10.3 and 12.0 vs 6.6 ml/beat, p = .002 and p = .032, respectively). There was a positive correlation between O2 pulse max and LAPSE (r = 0.442, p = .009), atrioventricular valve annulus systolic velocity (S′) (r = 0.606, p Conclusions LAPSE and S′ are suitable parameters for the assessment of systolic function in Fontan patients. Subclinical systolic dysfunction of longitudinal fibers is associated with worse CPET performance. O2 pulse max seems to be the best parameter reflecting Fontan patients' physical performance.

Cost estimation helps build confidence in the feasibility of the development of novel manufacturing processes. This paper focuses on the exploration of the cost estimation for novel manufacturing processes for decision support. One of the aspects of estimation is building credibility around the analysis, especially, in the early stages of planning. Cost estimating guidelines provide a good overview of the cost estimation steps but there is a requirement for guidelines for cost estimation model development. Through building on an understanding of the cost estimation principles, as well as cost estimation modelling, a high-level generic approach for process cost estimation is proposed. Further, a demonstration of a cost estimation modelling approach used for composites manufacturing in the automotive sector is provided, outlining the steps in cost estimation model development.

Background Heart failure (HF) is the leading cause of death in adults with congenital heart disease (ACHD). Heart transplantation can be an effective therapy for them, albeit unfavourable anatomy, end-organ damage, pulmonary vascular disease, HLA sensitization and lack of robust selection criteria currently limit its application. Methods Consecutive CHD patients considered for heart or combined heart and lung transplantation at our tertiary ACHD centre between 2000 and 2018 constitute our study population. Baseline characteristics and outcome, including transplantation and death, were obtained for all patients from designated databases, medical records and the UK Office for National Statistics. Results From a total of more than 9000 active ACHD patients under follow-up, 166 (median age 40.4 years) fulfilled inclusion criteria, with a broad spectrum of underlying diagnosis: univentricular heart 22.3%, systemic right ventricle 22.3%, systemic-to-pulmonary shunts and Eisenmenger syndrome 16.3%, left sided valvular lesions 14.5%, tetralogy of Fallot 12.7%, CHD associated with cardiomyopathy 4.8% and other 7.2%. There was a high overall mortality with 39.2% of patients dying over a median follow-up of 2.7 years. A minority of patients (22.9%) were eventually listed and only 13.3% from the 166 patients were actually transplanted. Survival at 1 year after transplantation was 81.8% and remained high long-term (65.5% at 15 years). We describe herewith in detail characteristics and outcome of our cohort and present the transplantation pathway followed. Conclusion Of the small number of patients with ACHD considered for heart transplantation at a large tertiary centre, there was high overall mortality, with only a fraction of patients being actually transplanted. Patients who received transplantation, however, had a good outcome. Better patient selection and timing are clearly warranted so that more ACHD patients are considered and potentially benefit from this effective form of therapy.

Background Congenitally corrected transposition of the great arteries (ccTGA) is a rare clinical condition in which the morphologically right ventricle sustains systemic circulation. This congenital heart anomaly exposes patients with ccTGA to adverse events over time. Strategies to identify persons who are at high risk of clinical events will be crucial for improving patient outcomes. Thus the aim of this study was to identify screening tools that enable morbidity and mortality risk stratification in adults with ccTGA. Methods This was a prospective observational study. Electrocardiography, laboratory testing, echocardiography, and cardiopulmonary exercise testing were performed at baseline. A Cox proportional hazards regression analysis was conducted to establish determinants of composite clinical endpoints, including death, heart transplantation, systemic ventricular device assist implantation, worsening of heart failure, vascular events, tricuspid valve regurgitation requiring intervention, and clinically relevant arrhythmias. Results Fifty-one patients—30 male and 21 female—with a mean age of 36 years were studied. During a median follow-up period of 3.15 years, 19 patients experienced 39 clinical events. Detectable high-sensitivity troponin T (hsTnT) combined with echocardiography-derived systemic right ventricular end-diastolic (sRVED) area were the best predictors of adverse outcomes (hazard ratio [HR] = 6.25, P = 0.02 and HR = 1.05, P = 0.02, respectively). Conclusions A combination of detectable hsTnT and an increased sRVED area are the best predictors of adverse clinical events in adults with ccTGA. This observation may be useful to guide follow-up, as both risk determinants are widely available and simple to obtain in everyday practice.

Wstep: Czestoskurcze przedsionkowe (AT) są jedną z wiodących przyczyn chorobowości i śmiertelności u pacjentow po operacji Fontana, a skutecznośc terapii lekami antyarytmicznymi w tej grupie chorych jest z reguly ograniczona. Cel: Celem pracy byla ocena wynikow bezpośrednich i odleglych ablacji AT u pacjentow po operacji Fontana oraz ocena charakterystyki klinicznej, elektrofizjologicznej i elektroanatomicznej arytmii. Metody: Retrospektywną analizą objeto dane 8 pacjentow (5 mezczyzn, 3 kobiety) po operacji Fontana kierowanych na ablacje w latach 2002–2013 z powodu AT. Istotnośc kliniczną i nasilenie arytmii przed i po ablacji oceniono za pomocą zmodyfikowanego wskaźnika arytmicznego. Jest on sumą czterech skladowych wartościujących, takich jak: 1) maksymalny czas trwania arytmii, 2) objawy związane z arytmią, 3) metody przerywania arytmii, 4) terapia antyarytmiczna konieczna do zapobiegania napadom. Wskaźnik ten przyjmuje wartości od 0 (bez istotnej arytmii) do 12 punktow (ciezka arytmia). U wszystkich pacjentow zabiegi ablacji wykonywano z zastosowaniem systemu CARTO, co pozwolilo na polilościową ocene wielkości obszarow niskoamplitudowych (< 0,5 mV) i blizn w obrebie przedsionka. Wyniki: U 7 chorych obecne bylo polączenie prawy przedsionek–tetnica plucna, a u 1 chorego — tunel zewnątrzsercowy. Średni wiek pacjentow w trakcie wykonania operacji Fontana wynosil 9,4 ± 3,1 roku, a w trakcie wykonywania pierwszej ablacji — 26,2 ± 4,6 roku. W badanej grupie wykonano lącznie 18 ablacji bez istotnych powiklan, 1–4 ablacje/chorego; mediana 2,5. U pacjentow, u ktorych przeprowadzono wiecej niz 1 ablacje, odstep czasu miedzy pierwszym a ostatnim zabiegiem wynosil średnio 34,8 miesiąca (zakres 1–64 miesiące). W trakcie zabiegow u poszczegolnych pacjentow obserwowano od 1 do ponad 4 roznych morfologii czestoskurczow (mediana 2,5). Średni cykl AT wynosil 334 ± 95 ms. U 6 pacjentow obszary istotnego uszkodzenia z amplitudą < 0,5 mV zajmowaly 25–50% powierzchni prawego przedsionka, a u dwoch kolejnych osob, odpowiednio, 10–25% i < 10% jego powierzchni. Siedem ablacji bylo w pelni skuteczne (usunieto wszystkie AT — kliniczne i wywolane stymulacją), kolejne 7 ablacji bylo cześciowo skuteczne (nie usunieto wszystkich arytmii, ale usunieto kliniczny AT), a 4 ablacje byly nieskuteczne (nie usunieto klinicznego AT). Średnie czasy zabiegu, skopii rentgenowskiej i dostarczania energii o czestotliwości radiowej wynosily odpowiednio: 176 ± 54,6; 13,7 ± 5,7 i 21,7 ± 11,9 minut. W obserwacji odleglej, średnio 58,6 ± 46 (zakres 11–127) miesiecy po ostatniej ablacji, u 4 pacjentow nie stwierdzono arytmii. Mediana wskaźnika arytmicznego przed pierwszą ablacją wynosila 8 punktow, a po ostatniej ablacji — 4,5 punktu (p < 0.05). Wnioski: Ablacja AT u pacjentow po operacji Fontana jest zabiegiem bezpiecznym, ale jej skutecznośc bezpośrednia i odlegla jest ograniczona. Wynika to z rozleglego i zlozonego substratu oraz trudnych warunkow anatomicznych. Uzyskanie dobrych efektow moze wymagac wykonania wiecej niz jednej ablacji. Opanowanie arytmii przyczynia sie do poprawy stanu klinicznego pacjentow.

INTRODUCTION The effect of obstructive sleep apnea (OSA) on right ventricular (RV) function and pulmonary circulation parameters is unclear. OBJECTIVES The aim of this study was to determine whether newly diagnosed OSA and its severity has any impact on RV performance and echocardiographic parameters of pulmonary circulation in patients with true resistant hypertension. PATIENTS AND METHODS The study included 155 patients (93 men and 62 women; mean age, 47.5 ±10 years). The apnea-hypopnea index (AHI), end-diastolic and end-systolic area of the right ventricle, main pulmonary artery diameter (MPAd) at diastole, acceleration time (AccT), tricuspid annular systolic velocity wave, and tricuspid annular plane systolic excursion were evaluated. RESULTS Patients were divided into 4 groups: without OSA (AHI5; n = 43), with mild OSA (AHI = 5-15; n = 45), moderate OSA (AHI = 15-30; n = 27), and severe OSA (AHI30; n = 40). There were no differences in RV systolic function between the groups. Patients with severe OSA had a wider MPAd (26.0 ±2.6 vs 23.1 ±3.7 mm; P0.0001) and shorter AccT (114.2 ±15.7 vs 133.4 ±22.1 ms; P0.001) in comparison with patients without OSA. The cut-off for the best predictive value of severe OSA was an MPAd of 25 mm or higher with a sensitivity of 63.6% and specificity of 78.9%. The area under the receiver operating characteristic curve for severe OSA in relation to an MPAd of 25 mm or higher was 0.766 (95% confidence interval, 0.673-0.859; P0.0001). Factors independently associated with an MPAd of 25 mm or higher were severe OSA and nighttime diastolic blood pressure levels. CONCLUSIONS Our study showed a relationship between pulmonary artery dilation and the presence of newly diagnosed severe OSA. Among the parameters studied, an MPAd of 25 mm or higher turned out to be the most useful parameter in identifying patients with severe OSA.

Background Left aberrant subclavian artery (LASA), is a type of right aortic arch (RAA) branching, which takes-off distally to the right subclavian artery and usually crosses behind the esophagus to the left upper limb. Taking into account the rarity of RAA, LASA is much more rarely seen than the right aberrant subclavian artery (RASA) originating from the left aortic arch. However, RAA may be associated with much more frequent presence of LASA, than left aortic arch with RASA. Anatomical LASA characteristics were not described up to date. Methods Individual patient records filed in the electronic database from a single high-volume tertiary cardiac center were retrospectively screened for the presence of RAA in the consecutive patients who underwent chest computed tomography from 2008 to 2016. Results 14 patients with LASA were identified. Only 3 were free of coexisting intra- or extra-cardiac anomalies. The most common defect was tetralogy of Fallot (3 patients). One patient had five congenital defects. Kommerell's diverticulum (KD) was present in 9 patients. In all patients the LASA course was retrotracheal and retroesophageal. In all but one patients esophageal modelling or compression by KD or LASA was present. Conclusions Knowledge of Kommerell's diverticulum presence and morphology as well as the LASA course during preinterventional work-up of patients with congenital heart defects is critical, since it may have surgical implications during corrective procedures.

background Diastolic dysfunction has been shown to be an independent factor of cardiovascular diseases in patients with hypertension. Very often, obstructive sleep apnea (OSA) and metabolic syndrome (MS) coexist with resistant hypertension (RHTN) and may lead to diastolic dysfunction. Thus, the purpose of this study was to investigate whether OSA and MS are associated with diastolic dysfunction in patients with RHTN independently from other factors, including age, left ventricular mass index (LVMI), and blood pressure (BP). methods Data from 155 patients (n = 92 men and 63 women) were analyzed. All patients underwent thorough examination, including biochemical evaluations, ambulatory blood pressure monitoring, polysomnography with assessment of apnea/hypopnea index (AHI), and echocardiography. LVMI and diastolic function parameters were obtained. results Patients were divided into 2 groups based on the presence or absence of diastolic dysfunction: group 1 (E’ 10 cm/second; n = 68). AHI, LVMI, and 24-hour systolic BP/diastolic BP values were higher in group 1. E’ correlated with AHI (r = −0.25; P < 0.001), LVMI (r = −0.36; P < 0.0001), 24-h systolic BP/24-h diastolic BP (r = −0.28, P

A 35-year-old asymptomatic woman was referred for percutaneous closure of patent ductus arteriosus (PDA). Loud continuous murmur at the left and right sternal border was detected. Successful percutaneous closure of PDA with an Amplatzer 9-PDA-005 Duct Occluder was performed. The next day, however, loud continuous murmur was still present. Echo showed Amplatzer Duct Occluder in the site of PDA. CT …

Department of Cardiac Surgery and Transplantology, Institute of Cardiology, Warsaw, PolandPostep Kardiol Inter 2012; 8, 2 (28): 114 –119 DOI: 10.5114/pwki.2012.29652 Key words: bicuspid aortic valve, aortic regurgitation, aortic aneurysm, aortic dissection, inheritanceCorresponding author:Justyna Rybicka MD, Department of Congenital Heart Diseases, Institute of Cardiology, 42 Alpejska, 04-628 Warsaw, Poland, tel.: +48 22 34 34 263, fax: +48 22 34 34 538, e-mail: jrybicka@ikard.plPraca wplynela: 27.03.2012, wersja poprawiona:15.05.2012, przyjeta do druku: 28.05.2012.

Background and aim: The aim of this study was to evaluate the potential clinical application of ultrasonic tissue indices, with a focus on systolic strain (SS) and systolic strain rate (SSR) parameters derived from transthoracic echocardiography, in the assessment of left anterior descending artery (LAD) stenosis. Methods: The data of 30 patients with significant LAD stenosis were analysed. All patients underwent transthoracic echocardiography to obtain systolic myocardial velocity (Sm), longitudinal SS, and SSR from basal, mid, and apical segments of anterior and inferior walls in two-chamber apical view. Severity of LAD obstruction was measured by means of fractional flow reserve (FFR) during coronary catheterisation. Results: Systolic velocities, strain, and strain rate measured in basal, middle, and apical segments of the anterior left ventricular (LV) wall were lower when compared to those obtained from the corresponding, i.e. unaffected, inferior LV wall. There was a significant correlation between FFR and the value of SS, SSR characterising the apical LV segment of the anterior wall (r = –0.583, p = 0.01; r = –0.598, p = 0.01, respectively). Moreover, we found significant correlation between FFR and Sm in the mid-segment of the LV anterior wall (r = 0.611, p = 0.009). Conclusions: We conclude that SS and SSR obtained from the apical segment of the anterior LV wall may be related to the severity of LAD stenosis.

The necessity of high performance materials has become latent in high technology sectors such as aerospace, automotive, renewable energy, nuclear engineering and sports. The expanding impact on future manufacturing of the EU waste management legislation and increasing price of current waste management methods stress the importance of an efficient and sustainable way of recycling waste generated in the composites industry. Aerospace companies estimated that 30–50% of materials in aircraft production are scrapped due to the way it is manufactured. Companies need to pay for landfilling the composite materials that otherwise can be a valuable resource. In a view that looking at individual production waste outputs could maximise the material reuse or recycling capability, gaining information about the type of scrap materials could inform the development of composite reuse/recycling supply chain. This research paper focuses on understanding the scale of scrap created in individual composites manufacturing processes to assess its potential value in terms of reuse/recycle capabilities. A Material flow analysis based data collection workshop has been performed with four composite manufacturers. Through the case studies it has been identified that there are three fibre related waste outputs captured: dry fibres, fibre material sheet off-cuts, and curried composite off-cuts. The captured information allows for the material specification development. This allows bridging the gap between the manufacturers and the waste processors in composites to address the lack of infrastructure and lack of waste material specification barriers outlined by the Composites Strategy 2009.

A parachute mitral valve is a rare congenital malformation resulting from fusion of the mitral chordae tendineae and their attachment to the one prominent papillary muscle. It can be found either as an isolated lesion or, more often, associated with left heart obstructive lesions, patent ductus arteriosus or ventricular septal defect. Congenital mitral stenosis usually presents with severe symptoms in early childhood, otherwise remains stable and hardly ever requires surgical intervention. We present a case of a young adult with severe stenosis of a parachute mitral valve and history of recurrent pulmonary oedema treated by mitral commissurotomy.

We investigated the impact of obstructive sleep apnea (OSA) and night blood pressure (BP) on left ventricular geometry and systolic function in patients with resistant hypertension (RHTN).Data from 155 patients with RHTN were analyzed. All patients underwent biochemical evaluations, ambulatory blood pressure monitoring (ABPM), and polysomnography. Left ventricular mass index (LVMI), relative wall thickness (RWT), left ventricular ejection fraction (LVEF), midwall fractional shortening (mwFS) and global longitudinal strain (GLS) were measured. Patients were divided into four groups based on the presence of metabolic syndrome (MS) and OSA: group 1: OSA(-), MS(-) [n = 42]; group 2: OSA(+), MS(-) [n = 14]; group 3: OSA(-), MS(+) [n = 46]; and group 4: OSA(+), MS(+) [n = 53]. In group 3 and 4 concentric geometry was present in 53.2% and 79.6% respectively (P = 0.004). There were no differences in LVEF between groups. Group 3 and 4 had lower mwFS as compared with group 1 (16.40 ± 1.9 and 15.38 ± 2.2 vs 17.44 ± 1.9; P0.049 and P0.0001 respectively). Group 4 had significantly lower GLS as compared with group 1 (-12.64 ± 3.3 vs -15.59 ± 4.0; P0.001). In the multivariable analysis, factors independently associated with concentric geometry were age, nighttime SBP (OR -1.04; 95%Cl 1.019-1.082; P0.0001) and OSA (OR -3.97; 95%Cl 1.835-8.590; P0.0001). In the other multivariable analysis, factors independently associated with GLS were OSA (beta = 0.279; P = 0.001), and nighttime DBP (beta = 0.168; P = 0.048) whereas factors independently associated with mwFS were age, gender, nighttime SBP, concentric geometry, and metabolic syndrome.In patients with true RHTN without diabetes concentric geometry and systolic dysfunction are independently associated with moderate and severe OSA and nighttime BP levels.

Stroke is a second cause of mortality worldwide and a leading cause of acquired disability in adults. Approximately 20% of all ischaemic strokes are of cardioembolic origin. We present a case of a 60-year-old man with a history of stroke without changes in carotid and vertebral arteries. Echocardiography exam revealed patent foramen ovale (PFO) and abnormal echos in the aorta that were verified as advanced complex atheromas by computed tomography. Due to small size PFO was deemed insignificant and the source of embolism were most probably aortic atheromas. Patient was put on acenocumarol, aspirin and statin.

A 31-year old woman with tricuspid atresia, after Bjork Fontan modification and reoperation due to homograft narrowing, was evaluated because of progressive exercise intolerance; she was planning a pregnancy. The right atrium (RA) to right ventricle (RV) homograft narrowing and calcification with significant reversal flow were found. Successful reoperation was performed—calcified conduit was excised and extracardiac pulmonary homograft tipped with vascular prosthesis was implanted between the RA and the RV.

A 52-year-old man diagnosed in childhood with bicuspid aortic valve (BAV) was admitted with heart failure. Echo showed severe BAV stenosis ( Panel A ) (gradient 80/50 mmHg, AVA 0.8 cm2), significant LV dysfunction [ejection fraction (EF) 27%, global longitudinal strain −8%], severe pulmonary hypertension (RVSP ≈ 115 mmHg), and narrowing/interruption of the descending aorta with holodiastolic forward flow …

Purpose: To evaluate the impact of night blood pressure (BP) and coexisting obstructive sleep apnea (OSA) and metabolic syndrome (MS) on left ventricle geometry and systolic function in patients with resistant hypertension (RHT). Methods: We analyzed data from 155 patients with true RHT (92M, 63F). All patients underwent thorough examination including: biochemical evaluations (MS was defined by The Adult Treatment Panel (ATP) III), ambulatory blood pressure monitoring (ABPM), polysomnography (OSA was defined as apnea/hypopnea index>15/h) and echocardiography. LVMI, relative wall thickness (RWT), LVEF, midwall fractional shortening (mwFS) and global longitudinal strain (GLS) were measured. Results: Patients were divided into 4 groups based on presence of MS and OSA: group 1) OSA(-), MS (-) [n=42], group 2) OSA(+), MS(-) [n=14], group 3) OSA (-), MS(+) [n=46] and group 4) OSA(+), MS(+) [n=53]. There were no differences in 24h BP values between these groups. In group 3 and 4 concentric geometry was present in 48,9 and 60,4% respectively. There were no differences in LVEF between groups. Group 3 and 4 characterized by lower mwFS as compared with 1 group (16,40±1,9 and 15,38±2,2 vs 17,44±1,9; p

Composite materials made of glass and carbon fibres have revolutionised many industries. Demand for\ud composites is experiencing rapid growth and global demand is expected to double. As demand for\ud composites grows it is clear that waste management will become an important issue for businesses.\ud Technically composite materials evoke difficult recycling challenges due to the heterogeneity of their\ud composition. As current waste management practices in composites are dominated by landfilling, governments\ud and businesses themselves foresee that this will need to change in the future. The recycling of\ud composites will play a vital role in the future especially for the aerospace, automotive, construction and\ud marine sectors. These industries will require different recycling options for their products based on\ud compliance with current legislation, the business model as well as cost effectiveness. In order to be able\ud to evaluate waste management strategies for composites, a review of recycling technologies has been\ud conducted based on technology readiness levels and waste management hierarchy. This paper analyses\ud 56 research projects to identify growing trends in composite recycling technologies with pyrolysis,\ud solvolysis and mechanical grinding as the most prominent technologies. These recycling technologies\ud attained high scores on the waste management hierarchy (either recycling or reuse applications) suggesting\ud potential development as future viable alternatives to composite landfilling. The research\ud concluded that recycling as a waste management strategy is most popular exploration area. It was found\ud mechanical grinding to be most mature for glass fibre applications while pyrolysis has been most mature\ud in the context of carbon fibre. The paper also highlights the need to understand the use of reclaimed\ud material as important assessment element of recycling efforts. This paper contributes to the widening\ud and systematising knowledge on maturity and understanding composites recycling technologies.