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

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

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

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.

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

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

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

Tissue Urate Crystal StudyPI: 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

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

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

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.

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

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

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.

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.

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

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Thank you!Dr Gill and Dr Simkin