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In obstructive hypertrophic cardiomyopathy (HC), extreme heterogeneity of septal morphology makes septal myectomy particularly challenging. Although cardiovascular magnetic resonance (CMR) reconstructs ventricular anatomy with high spatial resolution, CMR is not used systematically to plan preoperatively septal myectomy. In this study, we report our results with using CMR to plan the extent of septal excision in 112 consecutive HC patients who subsequently underwent myectomy. Depth and length of the myectomy planned at CMR were compared with those of the septal muscle excised in a single piece in all patients. Anterior septum maximal thickness at CMR was 22 ± 5 mm and excised muscle thickness 9 ± 3 mm. Planned myectomy length was 35 ± 11 mm (range 17 to 65) and excised muscle length 38 ± 10 mm (range 10 to 70), indicating extension of septal resection to mid-cavity. Thickness and length of the planned myectomy showed a significant correlation with the excised muscle (R2 = 0.345; p

In the presence of complex septal morphology or extra-cardiac factors like severe scoliosis or diaphragm paralysis, the procedure may become more challenging, and pre-formed sheaths and devices thought to facilitate the implantation might turn into a problem to address. Similarly to Herron and Kobayashi, we have experienced a similar issue during atrial septal defect closure with Gore Cardioform atrial septal defect device® in a 12-year-old female patient with severe scoliosis. After the conformation of the locking loop and the removal of the safety cord, the Gore Cardioform atrial septal defect device prolapsed in the right atrium.

Background This study was conducted to detect the association between radiologic features of CT pulmonary angiography (CTPA) and pulmonary embolism severity index (PESI). Methods A total of 150 patients with a definite diagnosis of PE entered the study. The CTPA feature including obstruction index, pulmonary trunk size, presence of backwash contrast, septal morphology, right ventricular (RV) and left ventricular (LV) dimensions, and RV/LV ratio were examined. The severity of the PE was estimated using PESI. The association between CTPA indices and PESI was measured. Statistical analysis was conducted using the SPSS software. P value < 0.05 was considered as statistically significant. Results A positive correlation was detected between the obstruction index and PESI (r = 0.45, P < 0.05). Moreover, PESI was significantly higher in patients with a more dilated pulmonary trunk (r = 0.20, P < 0.05). The backwash contrast and abnormal septal morphology were significantly more common among patients with higher PESI (P < 0.05). However, no significant correlation was detected between RV, LV, RV/LV, and PESI. The most predictor of high-risk PE was dilated pulmonary trunk with an odds ratio of 4.4. Conclusion Higher Obstruction index, dilated pulmonary trunk, presence of backwash contrast, and an abnormal septal morphology can be associated with a higher PESI.

Objective To evaluate the impact of different types of nasal septum deformity (NSD) on nasal obstruction, rhinitis severity and response to medical treatment among pediatric persistent allergic rhinitis (PER) patients. Methods In a prospective, real-life study, 150 children and adolescents (mean age 13 ± 2.8 years, females 32.6%) diagnosed with PER according to ARIA guidelines were assessed by nasal endoscopy for NSD according to Mladina's classification, their response to medical treatment (intranasal steroids and antihistamines or antileucotriens), the presence of comorbidities, rhinitis severity (modified-ARIA criterion) and nasal obstruction visual analog scale score (VAS). Results Most patients (87%) had 1 of the 7 types of septal deformities. There was a high prevalence of bilateral (types 4 and 6; 46%) and anterior unilateral (types 1 and 2; 25%) NSD in patients not responding to medical treatment. Type 4 (OR = 6.4; p = 0.005) or type 6 (OR = 4.4; p = 0.03) NSD increased the risk of lack of improvement with medical treatment. Coexistence of anterior unilateral or bilateral NSD with severe turbinate enlargement increased >20-fold the risk of lack of improvement. Patients with bilateral NSD presented greater rhinitis severity. Non-responder adolescents displayed higher prevalence of bilateral NSD than children (53% vs. 23%; p = 0.02). Nasal obstruction VAS was higher for patients with anterior than posterior NSD, and greater for patients with bilateral NSD than any other type of septal morphology. Conclusion Nasal endoscopy shows that bilateral and unilateral anterior nasal septum deformities are strongly associated with a poor response to medical treatment, greater rhinitis severity and higher nasal obstruction VAS. Consequently, nasal endoscopy is necessary in the PER patients to understand the disease severity as well as to plan a specific surgical treatment in order to improve nasal obstruction, disease severity, and patient's quality of life.

BackgroundCurrent published literature on hypertrophic cardiomyopathy (HCM) comes primarily from Western populations. There is no published data on clinical and echocardiographic characteristics and long-term outcome of HCM in an Arab population.MethodsWe conducted a retrospective analysis of all patients 16years or older diagnosed with HCM at our institution. Detailed clinical and echocardiographic data were collected and outcome was analyzed.ResultsA total of 69 patients were identified as having HCM. The mean age was 42±16years with 71% male patients. All patients were Saudi citizens with Arab ancestry. Details about family history and presenting symptoms were available for 44 and 48 patients consecutively. Nine (18%) patients were asymptomatic and were diagnosed based on abnormal cardiac auscultation. The commonest presenting symptoms were dyspnea with or without chest pain and palpitations occurring in 40 (81%) patients. Only four (9%) of 44 patients had a family history of HCM and /or sudden cardiac death (SCD). The most common ECG abnormality was left ventricular hypertrophy (LVH) present in 60 (86%) patients. The commonest septal hypertrophy morphology was mid-septal (catenoid) in 30 (43%) followed by neutral in 23 (33%), basal septal (sigmoid) in 3 (4%) and apical in 6 (8%) patients. Twenty (28%) patients had evidence of resting left ventricular cavity gradient of ⩾30mmHg. Eleven (16%) patients had evidence of biventricular hypertrophy. Left ventricular ejection fraction was normal in 65 (94%) patients. Over a median (25–75 percentile) follow-up of 7years (4.5–10), only three patients died, all of non-cardiac causes. There were no cases of SCD during the follow-up period. Six patients required an implantable cardioverter-defibrillator (ICD); five for primary prevention and one for secondary prevention. Only one patient progressed to end stage dilated cardiomyopathy.ConclusionThe natural history of hypertrophic cardiomyopathy in the Saudi population appears to be benign with catenoid morphology being the most common septal hypertrophy pattern. Risk of SCD appears to be quite low in this population.

Non-invasive cardiac imaging is pivotal for the diagnosis and decision making of patients with cardiovascular diseases. Recent innovations in echocardiography, nuclear imaging, computed tomography, and cardiac magnetic resonance have provided novel pathophysiological insights that may impact on the clinical management of patients. The current review provides a summary of selected articles on technological innovations in imaging and emerging clinical applications. In 2014, many articles were published on the use of non-invasive cardiovascular imaging, including echocardiography, nuclear imaging, computed tomography (CT), and cardiac magnetic resonance (CMR) imaging. A selection of these articles is presented here. The focus is on technical innovations and emerging applications in clinical cardiology. Accumulating data have demonstrated the role of speckle tracking echocardiography (STE) in characterization left ventricular (LV) mechanics and risk stratification of patients with various cardiac diseases. Geske et al .1 demonstrated that LV septal morphology rather than genetic basis is the main determinant of regional LV strain abnormalities in patients with hypertrophic cardiomyopathy (HCM). Genotype-positive HCM patients ( n = 51) were more likely to have reverse curve morphology of the interventricular septum (59%) whereas genotype-negative patients ( n = 80) had more frequently sigmoidal septal curvature (49%). Interestingly, while global LV strain (GLS) was not significantly different between groups, regional strain analysis revealed that genotype-positive HCM patients had significantly more impaired longitudinal strain in the mid inferoseptal, basal inferoseptal, and basal anteroseptal regions compared with genotype-negative patients. When patients were divided according to genotype and LV septal morphology, LV GLS was significantly more impaired among genotype-positive HCM patients with a reverse septal curvature than in genotype-negative HCM patients with a sigmoid septal morphology ( Figure 1 ). Figure 1 Speckle tracking echocardiography …

Background: The yield of positive sarcomere mutations in hypertrophic cardiomyopathy (HCM) is increased in probands with a family history of disease, younger age and asymmetric septal morphology, suggesting different clinical subgroups of disease occur. We hypothesized probands with no family

Morphogenesis of the intrabullar septum in Canis lupus Linnaeus, 1758 and Vulpes vulpes (Linnaeus, 1758), as well as the definitive septal morphology within the family, demonstrate that no bone of the auditory bulla bends its edge inwards the bulla to produce a septum.

Liver fibrosis is one of the most important and characteristic histologic alterations in progressive and chronic liver diseases. Thus, in both clinical and experimental practice, it is fundamental to have a reliable and objective method for its precise quantification. Several semi-quantitative scoring systems have been described. All are time-consuming and produce partially subjective fibrosis evaluations that are not very precise. This paper describes the design and validation of an original image analysis-based application, FibroQuant, for automatically and rapidly quantifying perisinusoidal, perivenular and portal-periportal and septal fibrosis and portal-periportal and septal morphology in liver histologic specimens.The implemented image-processing algorithms automatically segment interstitial fibrosis areas, while extraction of portal-periportal and septal region is carried out with an automatic algorithm and a simple interactive step. For validation, all automatically extracted areas were also manually segmented and quantified.Statistical analysis showed significant intra- and interoperator variability in manual segmentation of all areas. Automatic quantifications did not significantly differ from mean manual evaluations of the same areas. Comparison of our image analysis quantifications with staging histologic evaluations of liver fibrosis showed significant correlations (Spearman's, 0.72r0.83; p0.0001) and that the latter are based more on the distribution patterns than on the quantity of fibrosis.FibroQuant is a sensitive, precise, objective and reproducible method of fibrosis quantification, which complements semi-quantitative histologic evaluation systems. This novel tool could be of special value in clinical trials and for improving the prognosis and follow-up among patients with fibrosis-inducing hepatic diseases.

The aim of this study was to determine whether the differences in the baseline septal morphology influenced outcomes of patients after alcohol septal ablation (ASA). A total of 100 consecutive, highly symptomatic patients with HOCM and a neutral or sigmoid septum (74 patients vs 26 patients)

A characteristic feature of atrioventricular septal defects is a deficiency of the inlet part of the ventricular septum that results in a “scooped out” appearance. The depth of the scoop in relation to the disposition of the atrioventricular valves has been debated. To clarify the relation between the morphology of the ventricular septum and the disposition of the atrioventricular valves, we quantified these anatomic features in 151 hearts at autopsy to determine whether those features identified particular groups within the overall lesion. We found that 137 hearts had left atrioventricular valves with three leaflets. The left valve in the other 14 hearts exhibited a dual orifice, a two-leaflet or one-leaflet arrangement, or was imperforate. These anomalies could be analyzed in terms of a sequence of diminishing formation of the commissures. Also, three-leaflet valves displayed a variability in which the angular size of the mural leaflet correlated negatively with that of the inferior leaflet. In some of the hearts with a common atrioventricular orifice, the bridging leaflets did not meet over the ventricular septum, thus creating a “gap.” The mural leaflet's angular size corresponded to a deficiency of the combined inferior-mural leaflet complex. Hearts with an abnormal disposition of the left atrioventricular valve had the ventricular septum “scooped” to a greater extent than those with a common orifice, although most had separate right and left atrioventricular orifices.

Atrial septal defect (ASD) is a common congenital heart disease (CHD) occurring in 5 to 7 per 10 000 live births. Mutations in 5 human genes ( NKX2.5 , TBX5 , GATA4 , MYHC , ACTC ) are known to cause dominant ASD, but these account for a minority of cases. Human and mouse data suggest that ASD exists in an anatomical continuum with milder septal variants patent foramen ovale (PFO) and atrial septal aneurysm, strongly associated with ischemic stroke and migraine. We have previously shown in inbred mice that the incidence of PFO strongly correlates with length of the interatrial septum primum , defining a quantitative trait underlying PFO risk. To better understand genetic causation of atrial septal abnormalities, we mapped quantitative trait loci (QTL) influencing septal morphology using mouse strains (QSi5 and 129T2/SvEms) maximally informative for PFO incidence and 3 quantitative septal anatomical traits including septum primum length. [QSi5×129T2/SvEms]F2 intercross animals (n=1437) were phenotyped and a whole genome scan performed at an average 17-cM interval. Statistical methodology scoring PFO as a binary phenotype was developed as a confirmatory mapping technique. We mapped 7 significant and 6 suggestive QTL modifying quantitative phenotypes, with 4 supported by binary analysis. Quantitative traits, although strongly associated with PFO ( P

We sought to evaluate the effects of atrial septal and patent foramen ovale (PFO) morphology on the efficacy of transcatheter closure. We performed a retrospective analysis of all patients who underwent PFO device closure from January 1997 to January 2002. Forty-seven patients underwent percutaneous closure of a PFO with a median age of 45 years (range, 8–75) and weight of 76 kg (range 28–115). The septal morphology was flat in 33 and aneurysmal in 14 patients. The PFO morphology was a simple flap in 20 and complex in 27 patients. Complex morphologies included long-tunnel PFO (n = 15), coexistent small atrial septal defect (ASD) (n = 5), and aneurysmal septum without a tunnel or ASD (n = 7). Nonstretched PFO diameters were significantly smaller than stretched (4.8 ± 1.1 mm vs 11.6 ± 3.8 mm, p < 0.01). Median device size: stretched diameter ratio (DS:SD) was 3.7:1 (range, 2.2–9.1). The DS:SD ratio was significantly higher in patients with complex PFO (mean, 3.9:1 vs 2.6:1; p < 0.05). Device placement was successful in all patients. Five patients required transeptal puncture of the foraminal flap in long-tunnel PFOs. Effective closure on follow-up was achieved in 45 patients (95%). Of the 2 patients with residual shunts, 1 had a complex PFO and the other a simple PFO. Two patients (5%) experienced recurrent neurologic symptoms after device closure despite having no residual shunt by echocardiography. Complex PFO did not increase risk of residual shunt or recurrent neurologic symptoms after device closure.

Accurate evaluation of the size, location and adjacent structure of an atrial septal defect (ASD) is very important in the selection of patients for further management. We directly compared the utility of transthoracic echocardiography, angiocardiography, balloon sizing, and intracardiac ultrasound (ICUS) in the detection of ASD. Twenty-one children underwent an ICUS study of ASD after routine clinical and laboratory studies. All patients had received transthoracic echocardiography (TTE), cardiac catheterization, cineangiography, and balloon sizing before the ICUS to evaluate the ASD. There was a significant correlation between the ICUS-derived ASD diameter and the other methods (p < 0.001). The balloon-sizing diameter was estimated by the equation: TTE diameter × 1.09 + 3.9 mm. There was a good correlation between the predicted and measured balloon-sizing diameter (r = 0.963; p < 0.001). It is worthwhile spending a few minutes to perform ICUS during cardiac catheterization since it will provide more detailed information on and high resolution images of atrial septal morphology, especially for patients undergoing transcatheter closure by device.

It has been reported that older patients with hypertrophic obstructive cardiomyopathy (HOCM) benefited the most from dual chamber (DDD) pacing. Since in older patients the distribution of septal hypertrophy and left ventricular (LV) cavity shape differs from that in younger patients, we decided to study the efficacy of DDD pacing on the reduction of LV outflow tract (LVOT) gradient in different patterns of septal hypertrophy. We compared HOCM patients with nonreversed septal curvature, thus preserving the elliptical LV cavity contour (common in the elderly), (group I) versus patients with reversed septal curvature, deforming the LV cavity to a crescent shape (common in the young), (group II). Eighteen HOCM patients were studied (11 patients in group I and 7 patients in group II). After implantation of a DDD pacemaker, the LVOT gradient was measured using Doppler echocardiography at various programmed AV delay intervals to determine the maximal percentage decrease of LVOT gradient from baseline. The measurement was repeated after at least a 6-month follow-up (chronic DDD pacing). The baseline LVOT gradient was comparable between groups (79 +/- 28 vs 81 +/- 25 mmHg, P = 0.92). The LVOT gradient reduction at acute DDD pacing was significantly greater in group I than group II (61 +/- 18% vs 23 +/- 10%, P = 0.0001). This difference in favor of the patients from group I was maintained at midterm follow-up (69 +/- 17% vs 40 +/- 17% P = 0.0076). In conclusion, patients with normal septal curvature and preserved elliptical LV cavity shape had a greater reduction of LVOT gradient after DDD pacing than patients with reversed septal curvature deforming LV cavity. The proposed criterion assessing the septal curvature may be useful to predict the efficacy of DDD pacing in the reduction of LVOT gradient.

Nummulites lyelli D'Archiac and Haime 1853, is described for the first time from photographs of both generations, using material from the species type locality at El-Mishgigah, in the El-Gharaq Formation exposed in the Fayum Depression. Nummulites praelyelli n.sp., described from the Mokattam Formation below the Citadel of Salah El Din, in the eastern part of Cairo, is interpreted to be the ancestor of Nummulites lyelli Archiac and Haime. The main ontogenetic trend in this newly identified lineage is a gradual change from tight to lax coiling during growth, whereas the opposite onotgenetic trend is found in the lineage of Nummulites gizehensis (Forskal) In this work, the group of Nummulites gizehensis and allied species is separated from the group of Nummulites lyelli, partly on this basis but definitively on the basis of granulation and septal morphology. We suggest that at the beginning of the Bartonian, Nummulites lyelli ecologically displaced the Late Lutetian Nummulites gizehensis in both sp...

The human lung at birth is not simply a miniaturized version of the adult one. A newborn lung has to undergo very marked structural changes in order to match adult morphology. We know that between 17 and 50 million alveoli are present at birth, whereas the lung of a man of 75 kg body weight contains around 300 million alveoli. Furthermore, the pulmonary microvasculature is completely restructured in the early postnatal period. Although this process markedly transforms septal morphology, very little is known about it. The late E. A. Boyden, an expert in structural pulmonary development, whose careful three-dimensional reconstructions of the developing lung represented pioneering work, seriously argued that the ‘alveoli’ counted at birth were saccules1. Therefore the alveolar stage of lung development has been placed after birth (Fig. 4.1). Recently Langston and co-workers2 have published a study on 42 fetal lungs showing that shallow alveoli were present sometimes as early as the 32nd or 34th week. At birth they counted on average 50 million alveoli, a finding which renewed the discussion about the degree of alveolization of the newborn human lung. Practically, this would mean that the human lung could be born in a more mature state than assumed so far. Nevertheless, these new data do not overthrow the fact that the bulk of alveoli develop after birth. Indeed, on average only 15–20% of their final number is present in the first days of postnatal life.

The parenthesomes of Sirobasidium magnum (Sirobasidiaceae) are composed of arrays of ampulliform vesicles from whose bases microfibrils connect to bands of striated material in the dolipore orifices. This septal morphology and the associated character of a yeast haplophase are comparable to that found in species of the Tremellaceae and Filobasidiaceae. The similarity of these basic characteristics in these three families supports their separation into the suborder Tremellineae (species of the Tremellales with regular dolipore/parenthesome septa and mycelial monokaryons are grouped in the suborder Exidiineae).