BMJ Heart Asia Latest Issue

Direct medical cost of newly diagnosed stable coronary artery disease in Hong Kong

2013-01-02T23:34:41-08:00

Background

Stable coronary artery disease (CAD) affects approximately 7% of the population of Hong Kong and is associated with substantial healthcare costs.

Objective

We aimed to evaluate the first-year direct medical cost for a patient with newly diagnosed stable CAD at a tertiary care public hospital in Hong Kong and to identify CAD-related resource consumption pattern among different patient subgroups.

Methods

89 consecutive patients with newly diagnosed stable CAD at our institution from January 2007 to December 2009 were retrospectively analysed. Direct medical costs including hospitalisation, clinic visits, diagnostic tests, laboratory tests, invasive procedures and medications were calculated for 1 year after diagnosis. Mann-Whitney tests were performed to compare median costs in patients with and without hypertension, diabetes mellitus and hyperlipidaemia, and in patients undergoing coronary intervention and those who were not.

Results

The mean first-year total direct medical cost of newly diagnosed stable CAD per patient was US$11 477. Hospitalisation was the dominant cost item accounting for 29.2% of the total cost. The total cost for patients who underwent invasive coronary procedure was higher than those treated medically alone (US$14 787 vs US$6121, p<0.001). Hyperlipidaemia was associated with higher incremental costs than hypertension and diabetes mellitus (p<0.001). (1US$=7.8HK$).

Conclusions

Huge healthcare expenses are incurred in the first year of stable CAD diagnosis from the perspective of the local public healthcare system. Healthcare costs are highest among patients with hyperlipidaemia and those undergoing invasive coronary procedures (even discounting costs for procedural consumables). Strategies for cost saving and preventive measures should be implemented to lower healthcare expenditure associated with CAD.

A luminance-based heart chip assay for assessing the efficacy of graft preservation solutions in heart transplantation in rats

2013-01-17T20:39:37-08:00

Objective

We developed a novel luciferase-based viability assay for assessing the viability of hearts preserved in different solutions. We examined whether this in vitro system could predict heart damage and survival after transplantation in rats.

Design

By our novel system, preserved heart viability evaluation and transplanted heart-graft functional research study.

Setting

University basic science laboratory.

Interventions

Isolated Luciferase-transgenic Lewis (LEW) rat cardiac-tissue-chips were plated on 96-well tissue-culture plates and incubated in preservation solutions at 4°C. Viability was measured as photon intensity by using a bio-imaging system. Heart-grafts preserved in University of Wisconsin (UW), extracellular-trehalose-Kyoto (ETK), Euro-Collins (EC), histidin-tryptophan-ketoglutarat solution (HTK), lactated Ringer's (LR) or normal saline solution were transplanted cervically by using a cuff-technique or into the abdomens of syngeneic wild-type LEW rats by using conventional microsurgical suture techniques.

Main outcome measures

Imaging an evaluation of preservation heart-graft and functional analysis.

Results

Cardiac-tissue-chips preserved with UW, HTK or ETK solution gave higher luminance than those preserved with EC, LR or normal saline (p<0.03). After 24 h of preservation of hearts in each solution at 4°C, the beating of the isolated hearts was evaluated. The success rate, evaluation of beating, of cervical heart transplants using UW and ETK solution exceeded 70%, but those using other preservation solutions were lower (UW: 100%, ETK: 75%, EC: 42.86%, HTK: 14.29%, normal saline: 0%). Histological analysis of cervical heart-grafts after 3 h preservation by myeloperoxidase (MPO), zona occludens-1(ZO-1), and caspase-3 immunostaining revealed different degrees of preservation damage in all grafts.

Conclusions

Our novel assay system is simple and can test multiple solutions. It should therefore be a powerful tool for developing and improving new heart-graft preservation solutions.

Coronary arteriovenous malformation presenting with acute myocardial infarction

Ng, C. T., Wong, A., Cheah, F.-K., Ching, C. K. — 2013-01-22T23:06:10-08:00

A patient presented to the Emergency Department with sudden-onset chest tightness associated with diaphoresis and dyspnoea. Electrocardiogram revealed ST depression over the lateral leads and cardiac enzymes were elevated, consistent with Non-ST Elevation Myocardial Infarction.

Invasive coronary angiography showed a large left main coronary artery (LM) that was aneurysmal, with thrombus near the ostium of left circumflex artery (LCx) (figure 1, see online supplementary video A). CT angiography confirmed an arteriovenous malformation (figure 2) arising from an aneurysmal LM coronary artery (see online supplementary figure S1) and draining into the right atrium (see online supplementary figure S2), with a thrombus at the proximal portion causing mild narrowing of the origin of the LCx (see online supplementary figure S3); the right coronary artery and left anterior descending artery were normal.

Figure 1

Invasive coronary angiogram showing aneurysmal left main coronary artery, with thrombus near the...

Coronary artery fistula draining into pulmonary artery and optimal management: a review

Rippel, R. A., Kolvekar, S. — 2013-01-25T08:21:28-08:00

Coronary artery fistula is a rare congenital malformation of high variability. The disease is illustrated with a description of a case example. The management of patients with coronary artery fistulas remains controversial. Both spontaneous regression and life threatening complications have been described. The fistula can be ligated or embolised; however, there are no long term outcome data regarding management. Intraoperative risk of myocardial infarction is less than 5% and death rate varies between 0% and 6%. Due to a small number of cases being described in the literature and a lack of evidence on optimal management, further research is needed in order to determine the best treatment options.

Stenting of left main coronary artery stenosis: A to Z

Dash, D. — 2013-01-25T08:21:28-08:00

For several decades, coronary artery bypass grafting (CABG) has been considered as the gold standard treatment of unprotected left main coronary artery (LMCA) disease. The marked improvement in technique and technology makes percutaneous coronary interventions (PCIs) feasible for patients with unprotected LMCA stenosis. The recent introduction of drug-eluting stents (DESs), together with advances in periprocedural and postprocedural adjunctive pharmacotherapies, has improved outcomes of PCIs of these lesions. Recent studies comparing efficacy and safety of PCIs using drug-eluting stents and CABG revealed comparable results in terms of safety and a lower need for repeat revascularisation for CABG. Patient selection for both the techniques directly impacts clinical outcome. Despite improvement in stent technology and operator experience, management can be challenging especially in LMCA bifurcation lesions and, therefore, an integrated approach combining advanced devices, tailored techniques, adjunctive support of physiological evaluation, and adjunctive pharmacological agents should be reinforced to improve clinical outcome.

Case report of an anomalous single azygos venous coil insertion to reduce the defibrillation threshold in a patient with a right-sided deltopectoral ICD implant

Moran, D. P., Bhutta, U., Yearoo, I., Keelan, E., O'Neill, J., Galvin, J. — 2013-03-05T18:21:12-08:00

Implantable cardiac defibrillators (ICDs) reduce the incidence of sudden death in persons at high risk for lethal arrhythmias. The life-saving potential of ICDs depends on their ability to effectively deliver an adequate current density through a sufficient proportion of the ventricular myocardium to terminate ventricular fibrillation. High defibrillation thresholds (DFTs) are an important contributing factor to mortality in ICD recipients.1

High DFTs are more common in patients with right-sided implants, as well as patients on amiodarone, patients with hypertrophic cardiomyopathy and patients with large chest size.

Some patients require right-sided ICD implants because of left innominate vein occlusion. A number of strategies have been described to improve the DFT in these patients, including using higher output devices, avoiding DFT raising drugs and using alternate vectors.

The use of an extra coil in the superior vena cava (SVC), coronary sinus, azygos vein and hemiazygos vein have all...

Saccular aneurysm of left main coronary artery

Vijay, J., Salahuddin, S., Faizal, A. — 2013-03-05T18:21:12-08:00

A 48-year-old woman with no traditional coronary risk factors, presented to our hospital with a recent anterior ST elevation myocardial infarction which had been thrombolysed, from a local hospital. Her physical examination and routine investigations were unremarkable. A coronary angiogram (figure 1) revealed a saccular aneurysm arising from the left main coronary artery (LMCA). There were no stenotic lesions noted at the aneurysm site or elsewhere. A coronary intravascular ultrasound study demonstrated a wide-mouthed aneurysm in the LMCA measuring 3.5x4.5 mm, with no thrombus within (figure 2).

Figure 1

Coronary angiography images in the cranial (A) and caudal (B) projections showing a saccular aneurysm arising from the left main coronary artery.

Figure 2

Intravascular ultrasound images of proximal left main coronary artery (LMCA) (A) and distal LMCA with aneurysm (B).

Coronary artery aneurysms, are...

A septal branch playing the role of a right coronary artery

Chinikar, M., Sadeghipour, P. — 2013-03-07T20:00:08-08:00

A 56-year-old woman was hospitalised in our emergency department with a new onset chest pain and exertional dyspnoea. Her pain had started 3 weeks earlier and its severity had apparently aggravated. She reported to have an elevated blood pressure during the last 5 years which was controlled by Captopril 25 mg three times a day. At physical exam, her blood pressure was 135/95 mm Hg, and her heart rate and respiratory rate were 65 bpm and 15, respectively. Her cardiac exam was quite normal. Her ECG, showed a 0.05 mV ST depression on the inferior leads. She had a normal left ventricular ejection fraction on her echocardiography, and apart from a mild hypokinesia of the inferior wall, no other abnormality was reported. She had undergone an electrographic exercise stress test which was positive. She was a candidate for coronary angiography. At the left injection, a long septal branch was first noted. Subsequent views showed...

An unusual cause of tall R wave in lead V1: cardiac lipoma

Cagli, K., Tok, D., Basar, F. N. — 2013-03-07T20:00:08-08:00

A 59-year-old woman was admitted with atypical chest pain. Surface electrocardiography showed sinus rhythm with tall R wave in lead V1, northwest axis, clockwise rotation and suspicious left anterior fascicular block (figure 1). Echocardiography revealed a heterogeneous mass in the interventricular septum with protrusion into the right ventricular (RV) cavity and normal left and RV wall thickness. MRI suggested the diagnosis of lipoma involving the septum (figure 2). Close follow-up was decided as treatment strategy.

Figure 1

Surface ECG of the patient.

Figure 2

Axial T1 weighted magnetic resonance image suggesting the presence of benign lipoma (arrow) in the interventricular septum that has the same signal intensity as fat tissue.

Tall R wave in V1 may be present in different cardiac abnormalities such as posterior myocardial infarction, RV hypertrophy, hypertrophic cardiomyopathy, left septal...

Refractory cardiogenic shock following idiopathic giant cell myocarditis in a 19-year-old woman

Viana-Tejedor, A., Sousa, I., Bueno, H., Fernandez Aviles, F. — 2013-03-07T20:00:08-08:00

Clinical case

A 19-year-old woman with no medical history except for facial acne treated with tetracyclines during the previous year presented to the emergency room referring 1-week history of worsening muscle weakness, palpitations and exertional dyspnoea. Physical examination revealed a tachycardic (130 bpm), tachypnoeic and hypotensive (blood pressure 90/50 mm Hg) thin woman with fever of 38.5°C, rash and jugular vein distention.

An ECG showed sinus tachycardia with 0.5 mm elevation of the ST segment in the anterior and inferior leads. In laboratory studies, she had leukocytosis with neutrophilia and eosinophilia and mild rise of troponin I (4.8 µg/l), creatine kinase (524 U/l) and transaminases (aspartate aminotransferase of 765 U/l and alanine aminotransferase of 658 U/l). An echocardiogram revealed severe biventricular dysfunction with global hypokinesia and circumferential mild pericardial effusion. Signs of heart failure were found on her chest x-ray. In this clinical situation, we treated her with dobutamine, but she started to develop sustained ventricular...

Knots in the cath lab, an embarrassing complication of radial angiography

Gupta, P. N., Praveen, G. K., Ahmed, S. Z., Kumar, B. K., V S, S. — 2013-03-08T19:45:42-08:00

Most case reports or series describe knots in the venous system such as knots of Swan-Ganz catheters, pacing wires or thermodilution catheters. Knots during radial angiography are relatively rare. Here we describe a simple method of unravelling a radial knot via the femoral route, together with a review of the literature on knots in the catherisation laboratory and the techniques to deal with them.

Association of statin therapy with ventricular arrhythmias among patients with acute coronary syndrome

2013-03-11T23:25:52-07:00

Background

In addition to lowering cholesterol, statins stabilise atherosclerotic plaques and can potentially reduce the incidence of ventricular arrhythmias. We tested the hypothesis that prior statin therapy is associated with a lower incidence of inhospital ventricular arrhythmias among patients with acute coronary syndrome (ACS).

Methods

The study population consisted of 2007 patients (mean age 64 years, 67.5% male) enrolled in the Thai Registry of Acute Coronary Syndrome, a prospective, multicentre, nationwide, observational study of patients with ACS. Patients were categorised as either statin users or non-users according to their reports of statin use before enrolment at their initial presentation. The primary endpoint was inhospital ventricular arrhythmias. The secondary endpoint was a composite endpoint of inhospital ventricular arrhythmias or inhospital cardiac death. A propensity-adjusted multivariate model was developed to assess the effects of statin use on the primary and secondary endpoints.

Results

During a mean hospital stay of 7 days, a total of 96 patients (4.8%) died; 82 (4.1%) of the deaths were due to cardiac causes. The primary and secondary endpoints were reached in 163 patients (8.1%) and 194 patients (9.7%), respectively. A total of 525 patients (26.2%) had used statins prior to hospitalisation. After adjusting for the propensity scores and other relevant covariates, statin use was associated with lower risks of the primary (adjusted OR 0.505, 95% CI 0.276 to 0.923) and secondary endpoints (adjusted OR 0.498, 95% CI 0.276 to 0.897).

Conclusions

The use of statins is associated with a reduced incidence of ventricular arrhythmias among patients with ACS.

Spectacular migration of a central venous catheter into the pulmonary artery

Hara, T., Sata, M. — 2013-03-26T19:48:10-07:00

A 44-year-old woman consulted us with local swelling at the insertion site of a central venous port system. She had been undergoing chemotherapy for advanced gastric cancer via a totally implantable central venous catheter system for 9 months. Physical examination was normal except for the local swelling. Chest x-ray demonstrated disappearance of the catheter from the connection site of its subcutaneous port. An unexplained abnormal linear structure was found in the mediastinal shadow (figure 1).

Figure 1

Chest x-ray. Focused view of the mediastinal shadow. Red arrows indicate an unexplained abnormal linear structure.

She underwent contrast-enhanced CT, which revealed a complicatedly looped catheter structure extending from the main pulmonary trunk to the bilateral pulmonary arteries (figure 2). Fortunately, no obvious adhesion or thrombus formation around the catheter could be observed. We diagnosed that the central venous catheter had detached itself from...

Tobacco imagery in Bollywood films: 2006-2008

Nazar, G. P., Gupta, V. K., Millett, C., Arora, M. — 2013-04-16T16:55:22-07:00

Objective

To estimate exposure to tobacco imagery in youth-rated Bollywood films, and examine the results in light of recent developments in India's film rating system.

Methods

Content coding of 44 top grossing Bollywood films (including 38 youth-rated films) released during 2006–2008 was undertaken to estimate tobacco occurrences and impressions.

Results

Out of the 38 youth-rated (U and U/A) films coded, 50% contained tobacco imagery. Mean tobacco occurrences were 1.9, 2.9 and 13.7 per U, U/A and adult (A) rated films, respectively. Top grossing youth-rated films delivered 1.91 billion tobacco impressions to Indian cinema audiences.

Conclusions

Half the youth-rated Bollywood films contain tobacco imagery resulting in large population level exposure in India, relative to other countries. Measures to reduce youth exposure to tobacco imagery through films, such as restricting access through the rating system, will complement other tobacco control measures.

Apical ballooning syndrome precipitated by dobutamine stress testing

Yu, A. F., Mitter, S. S., Chaudhry, H. W. — 2013-04-16T20:26:47-07:00

A 52-year-old man with a history of hypertension, insulin-dependent diabetes mellitus and hyperlipidaemia was referred for a dobutamine stress echocardiogram as part of a pre-renal transplant evaluation. The baseline echocardiogram showed normal systolic function with no wall-motion abnormalities (see videos 1 and 2). At peak dobutamine infusion, he developed severe abdominal pain associated with deep T-wave inversions in leads aVR and V1 and 0.5 mm ST-segment elevations in leads I and aVL (figure 1). The echocardiogram revealed akinesis of the left ventricular apex with apical ballooning (figure 2; videos 3 and 4).

Figure 1

Baseline EKG (A). Immediate post-infusion EKG (B) showing 0.5–1 mm ST-segment elevations in leads I and aVL.

Figure 2

Standard parasternal long axis and apical four chamber views obtained during a dobutamine stress echocardiogram. Baseline images (A) show normal left ventricular systolic function....

Coexistence of arrhythmogenic right ventricular cardiomyopathy and coronary artery disease in a patient with ventricular tachycardia: a highly unusual combination

Shalganov, T. N., Stoyanov, M. K., Genova, K. Z. — 2013-04-26T06:02:42-07:00

A middle-aged patient with arterial hypertension and dyslipidaemia presented with a 10-year history of recurrent sustained monomorphic ventricular tachycardia (VT) provoked by exertion or emotional affect (figure 1A). He had been treated with propafenone and amiodarone. Four years before, the standard 12-lead and modified Fontaine ECG in sinus rhythm were normal, as was the echocardiogram. VT of different morphology was reproducibly induced and terminated with programmed right ventricular (RV) pacing (figure 1B). Coronary angiography showed three-vessel coronary artery disease (figure 2A,B). The operator thought this was the cause of the VT and implanted three intracoronary stents. RV angiography was not performed. Treatment with amiodarone was continued.

Figure 1

(A) The clinical ventricular tachycardia (VT). Note that the morphology is right bundle branch block and is unusual for a VT of right ventricular origin. (B) Induction of sustained monomorphic VT of...

Improvement of the stunned lung in a case of pulmonary thromboembolism after embolectomy

Nakamura, S., Kumita, S., Mizuno, K. — 2013-04-29T18:56:52-07:00

A 46-year-old man was referred to our department with dyspnoea associated with precordial T-wave inversions on a 12-lead ECG and an increased level of d-dimer. Enhanced CT of the chest revealed multiple thrombi in the pulmonary arteries and right side of the heart, with one occluding the left pulmonary artery and another almost occluding the right pulmonary artery (figure 1A, arrows). The patient immediately underwent surgical embolectomy and the thrombi were successfully extracted. Tc-99m macro aggregated albumin pulmonary perfusion scintigraphy 10 days after the embolectomy (acute phase) showed little perfusion to the lower lobe and lingular segment of the left lung or to the medial and lower lobes of the right lung (figure 1B). The patient had an uneventful postoperative course but showed shortness of breath on mild exertion at discharge. Follow-up pulmonary perfusion (3 months after the embolectomy; chronic phase) showed improvement in the...

Complications of coronary intervention: device embolisation, no-reflow, air embolism

Dash, D. — 2013-04-30T03:17:56-07:00

The introduction of drug-eluting stents, better equipment, stronger antiplatelet drugs, and higher levels of operator experience has led to markedly improved patency rates for complex percutaneous coronary interventions (PCIs). The evolving techniques of contemporary PCI have been unable to completely eliminate complications. However, rigorous preventive measures pre-empt the appearance of complications. During traversal of severely diseased coronary arteries and manipulating equipment, particularly devices with detachable components, the opportunity for loss or embolisation of material in the coronary circulation presents itself. Device embolisation is associated with periprocedural myocardial infarction and emergent referral to surgery, particularly if the device is not retrieved. The coronary no-reflow phenomenon is a feared complication of PCI. It is associated with a worse prognosis and has been shown to be an independent predictor of death, myocardial infarction and impaired left ventricular function. Air embolism can be prevented by flushing of catheters during equipment exchanges.

Destructive bacterial endocarditis of critically stenotic aortic valve with transformation to florid aortic regurgitation with massive abscess presenting without septic symptoms

Murdoch, D., Jayasinghe, R., Kulkarni, V. — 2013-04-30T03:17:56-07:00

A 74-year-old woman with known critical aortic stenosis presents to hospital with acute, severe dyspnoea.

The patient had presented 3 months earlier with dyspnoea on exertion. Critical calcific aortic stenosis was diagnosed on echocardiography with an aortic valve area of 0.44 cm² and mean pressure gradient of 54 mm Hg (figure 1A). She was referred to a cardiac surgeon for aortic valve replacement, but was initially managed conservatively.

Figure 1

(A) Previous transthoracic echocardiogram demonstrating severe aortic stenosis. Presenting chest x-ray shows pulmonary oedema (B) and initial telemetry monitoring documented intermittent complete heart block (C). Transthoracic echocardiogram with two pedunculated masses on the aortic valve, consistent with vegetations (D). Transoesophageal echocardiogram (E–H) with large, bulging abscess (E, white arrows); severe aortic regurgitation (F) and communication between the abscess and the ascending aorta (G,H).

She was afebrile. Pulse was 120 bpm; BP 90/30. On auscultation, there were...

Complications of coronary intervention: abrupt closure, dissection, perforation

Dash, D. — 2013-05-03T20:56:56-07:00

The introduction of drug-eluting stents (DESs) and superior anticoagulation has successfully improved the safety and patency rates of complex percutaneous coronary interventions (PCIs). The evolving techniques of contemporary PCI have been unable to completely eliminate coronary injury and mechanical complications. Primary causes for abrupt closure include dissection, thrombus formation and acute stent thrombosis. Initial treatment for abrupt closure includes balloon redilatation, optimisation of activated clotting time (ACT) and deployment of stent to stabilise a dissection. Coronary perforation is one of the most challenging and feared complications of PCI. It is most frequently due to distal wire or balloon/stent oversizing and should be fixed with balloon occlusion. Covered stent may be needed for large perforation in major proximal vessels. Perforations in small or distal vessels not resolving with balloon occlusion may be managed by coil or Gelfoam embolisation. Referral to emergency coronary artery bypass surgery (CABG) should be an option in case perforations do not seal.

Clinical characteristics associated with high on-treatment platelet reactivity of patients undergoing PCI after a 300 mg loading dose of clopidogrel, measured by thrombelastography

Hou, X.-M., Han, W.-Z., Qiu, X.-B., Fang, W.-Y. — 2013-05-09T22:49:02-07:00

Background

Dual antiplatelet therapy with clopidogrel and aspirin is the standard of care for patients undergoing percutaneous coronary intervention (PCI).

Objective

To determine the clinical characteristics associated with high on-treatment platelet reactivity (HPR) of patients undergoing PCI after a 300 mg loading dose of clopidogrel, measured by thrombelastography (TEG).

Methods and results

394 consecutive patients were enrolled in this prospective observational study. All had been receiving aspirin 100 mg/day for more than 7 days, but were clopidogrel naïve. A 300 mg loading dose of clopidogrel was given more than 12 h before the procedure. The cut-off point for HPR was defined as ≥70% adenosine-5-diphosphate-induced aggregation. The prevalence of HPR was 21% as measured by TEG. More women than men (41.7% vs 27.1%, p=0.01) were found in the HPR group. Raised glycosylated haemoglobin (HbA1c) was more prevalent in the HPR group than in the group with normal on-treatment platelet reactivity (NPR) (45.2% vs 30.0%, p=0.009). Patients with HPR had a higher level of total plasma cholesterol (4.8±1.5 mmol/l vs 4.3±1.1 mmol/l, p=0.002) and low-density lipoprotein cholesterol (2.8±1.1 mmol/l vs 2.5±0.9 mmol/l, p=0.022) than those with NPR. Multivariable logistic regression analysis showed that female gender (OR=3.175, 95% CI 1.428 to 7.059, p=0.005) and raised HbA1c (OR=1.911, 95% CI 1.066 to 3.428, p=0.03) independently predicted the occurrence of HPR.

Conclusions

Despite pretreatment with aspirin and a 300 mg loading dose of clopidogrel, 21% patients undergoing PCI exhibited HPR measured by TEG. A raised level of HbA1c and female gender independently predicted the findings.

Correction

2013-05-16T23:28:57-07:00

Association of statin therapy with ventricular arrhythmias among patients with acute coronary syndrome

Apiyasawat S, Sritara P, Ngarmukos T, Sriratanasathavorn C, Kasemsuwan P.

The funding information of this paper was incorrect. It should be the following:

The study was supported by the Heart Association of Thailand under the Royal Patronage, the project of Higher Education Research Promotion and National Research University Development, Office of the Higher Education Commission, Ministry of Education, Thailand, and unrestricted fund from Sanofi Aventis (Thailand) Ltd.

An uncommon picture of endomyocardial fibrosis: no embolism yet

Gupta, P. N., Kunju, S. M., Vishwanathan, S., Thomas, J. M., Kumar, B. R. — 2013-05-21T23:18:51-07:00

We present here a review of the various gradings of endomyocardial fibrosis from autopsy (Shaper's types). Echocardiography accurately delineates the extent of fibrosis of either the right or left ventricle and we have illustrated a typical classical case. We have images of the same patient from 2010, 2011 and 2012 and so we use this to illustrate the echocardiographic gradings.