Accessory tricuspid valve (ATV) is a rare congenital anomaly that is often seen in complex congenital anomalies in children with very few reported cases in adults. We report a case of isolated ATV in an asymptomatic adult with no other congenital defects along with illustrative transesophageal echocardiographic 2D, 3D, high-resolution photo-realistic images.
We present a case of a 60 year old male who found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 hours and he was referred for TEE guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however the appendage was large and had a tongue like accessory lobe along with spontanous contrast on the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.
Introduction. The concept of ventricular anatomy as a single muscular band was initially described by Francisco Torrent-Guasp in 1972 1 and since then, there have been multiple novel contributions to the understanding of the morphology and function of the heart. To date, this concept has been supported and denied by multiple groups of professionals reflecting both the enthusiasm and resistance to the new concept of the single muscle band model. Currently, the single muscular band is the model that meets all the requirements to explain the performance of cardiac mechanics, and its distinctive feature to determine the characteristics of the structure.
A previously healthy 9-year-old girl was referred to us for the evaluation of a murmur on routine clinical examination. Routine electrocardiogram and chest X-ray were normal. The cardiac enzymes were normal. Combining ultrasound and CCTA, it was confirmed that the hemodynamics of the heart was a left-to-right shunt and that RVOT stole blood from the left ventricle through the single coronary artery (SCA).
A previously healthy 68-year-old woman presented to the outpatient clinic with a 2-month history of palpitation. Physical examination and laboratory findings were unremarkable. Her electrocardiogram showed sinus tachycardia with a heart rate of 115 beats/m. Transthoracic echocardiography (TTE) showed a normal ejection fraction with a huge mass in the left atrium (Figure 1a). Transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (MRI) were performed for further evaluation. TEE revealed a hyperechogenic, well-demarcated mass in the left atrium, that was attached to the interatrial septum and adjacent to the left pulmonary veins (Figure 1b, 1c,1d). Cardiac MRI revealed a heterogeneous left atrial mass located on the fossa ovalis, 58x52x54 mm in size and markedly hyperintense on a STIR sequence (Figure 1e). These findings were suggestive of a benign cardiac tumour such as myxoma or hemangioma. A decision for surgery was made and coronary angiography was performed which showed that the branch of the circumflex artery supplied and surrounded the mass in the form of a net (Figure 1e). The patient underwent complete excision of the mass (Figure 2a, 2b). Histopathological examination revealed a nested architecture of epitelioid cells, the nests are round or oval in shape and invested by an fibrovascular stroma. Tumor cells had centrally and eccentrically located round nuclei and cytoplasm ranging from finely granular to eosiniphilic. At immunohistochemical staining, the nests were positive for chromogranin A, negative for cytokeratin (Figure 2c, 2d, 2e, 2f). A diagnosis of paraganglioma was made. After an uneventful postoperative course, she was discharged home on postoperative day 6. Cardiac paraganglioma is a very rare neuroendocrine tumour and accounts for less than 1% of primary cardiac tumours (1,2). Approximately 10% of paragangliomas may be malignant, complete surgical resection remains the first-line treatment (3).
Objective: Peripartum cardiomyopathy (PPCM) diagnosis made by excluding identifiable causes of heart failure (HF) and occurs end of the pregnancy or during the postpartum period of five months. It presents a clinical HF spectrum with left ventricular systolic dysfunction. Background: The purpose of this study is to retrospectively evaluate the clinical characteristics, cardiac magnetic resonance (CMR) imaging features, and end-points consisting of left ventricle recovery, left ventricular assist device implantation, heart transplantation, and all-cause mortality. Method: Outpatient HF records between 2008 to 2021 were screened. Thirty-seven patients were defined as PPCM. Twenty-five patients had CMR evaluation at the time of diagnosis, and six patients were re-evaluated with CMR. Results: The mean age was 30.5±5.6 years, and the mean LVEF was 28.2±6.7%. In thirteen(35.7%) patients, LVEF recovered during the follow-up course. The median recovery time was 281(IQR [78-358]) days. LVEF on CMR was 35.3±10.5, and three patients exhibited late gadolinium enhancement(LGE) patterns. Sub-endocardial and mid-wall uptake pattern types were detected. 18(75%) patients met the Petersen left ventricle non-compaction cardiomyopathy(LVNC) criteria. Patients with NC/C ratio lower than 2.3 had lower LVEDVi and LVESVi (124.9±35.4,86.4±7.5, p=0.003;86.8±34.6,52.6±7.6, p=0.006), respectively. The median follow-up time was 2129 (IQR [911-2634]) days. The primary endpoint-free one-year survival was 88.9%(event rate 11.1%), and five-year survival was 75.7%(event rate 24.3%). Conclusion: In a retrospective cohort of PPCM patients, 35.7% of patients’ LVEF recovered, and the primary end-point of free-five-year survival was 75%. Twenty-five patients were assessed with CMR; three of four met the Petersen CMR-derived LVNC at initial evaluation.
Abernethy malformation, also known as congenital extrahepatic shunt, is a rare anomaly characterized by partial or complete diversion of the portal blood into the systemic venous circulation. The clinical manifestations of Abernethy malformation during childhood include neonatal cholestasis, failure to thrive, mental retardation, and other congenital defects. We report a case of Abernethy malformation Type Ⅱ in a 9-year-old boy whose left ventricle was slightly enlarged because of several major aortopulmonary collateral arteries but normal laboratory examinations five years earlier. The characteristics of congenital heart disease in patients with Abernethy malformation are discussed. We propose that enlargement of the left ventricular with systemic-pulmonary collateral circulation should raise the suspicion of Abernethy malformation.
Background Premature ventricular contraction (PVC) is a frequent kind of arrhythmia that affects around %1 of the general population. While PVC most frequently impairs ventricular function in structurally normal heart, retrograde ventriculo-atrial conduction can occur in people with PVC. These retrograde atrial activations may mimic pulmonary vein-derived atrial ectopies. As a result, PVC may raise the risk of AF by retrograde ventriculo-atrial conduction. The Four-Dimensional Automated Left Atrial Quantification (4D Auto LAQ) tool is a left atrial analytical approach that utilizes three-dimensional volume data to quantify the volume, as well as LA longitudinal and circumferential strains. The purpose of this study was to determine if clinical diagnosis of PVC is connected with abnormal LA function as determined by LA strain evaluation utilizing a 4D Auto LAQ compared to the healthy population. Methods The 58 patients with frequent PVCs and 53 healthy volunteers as a control group were enrolled in the study. Imaging was performed using the GE Vivid E95 echocardiography equipment (GE Healthcare; Vingmed Ultrasound, Horten, Norway) equipped with an M5S probe (frequency range: 1.5–4.6 MHz) and a 4V probe (frequency range: 1.5–4.0 MHz). Images were imported into and were selected for analysis using the EchoPAC203 software (GE Healthcare). The analysis mode was selected, followed by the volume and 4D Auto LAQ submodes. Following that, the sample point was positioned in the center of the mitral orifice in each of the three planes. The review function was used to acquire the LA parameters measured by 4D Auto LAQ, including volume and strain parameters. Results The maximum left atrial volume (LAVmax) and minimal left atrial volume (LAVmin) were signifcantly higher in the patient group (38.91 ± 9.72 vs. 46.31 ± 10.22, 17.75 ± 4.52 vs. 23.10 ± 7.13 respectively, all p values <0,001). On the other hand left atrial reservoir longitudinal strain (LASr), conduit longitudinal strain (LAScd), contraction longitudinal strain (LASct), reservoir circumferential strain (LASr-c), conduit circumferential strain (LAScd-c), and contraction circumferential strain (LASct-c) were signifcantly lower in patient group (26.64 ± 5.64 vs.19.16 ± 4.58, -19.53 ± 3.72vs.-11.28 ± 3.47, -10.34 ± 1.56 vs.-4.59 ± 1.49, 30.72 ± 4.04 vs.19.31 ± 2.60, -19.91 ± 1.78 vs. -13.38 ± 2.85,-15.89 ± 6.37vs.-9.24 ± 1.63 , respectively, all p values <0,001). Conclusions The present study found that premature ventricular complexes can lead to atrial remodeling as well as ventricular remodeling in patients with PVC and 4D LAQ technology can quantitatively examine left atrial function and determine these alterations early.
Objectives— Early screening and dynamic monitoring of pulmonary vascular disease (PVD) in bronchopulmonary dysplasia (BPD) high-risk infants is of great clinical significance. Pulmonary artery acceleration time (PAAT) is a reliable and non-invasive method for assessing PVD in children over 1 year, but to date, few studies have used PAAT to assess pulmonary hemodynamics of preterm infants, especially those with BPD. Through dynamic monitoring the main hemodynamic indicators reflected PVD after birth, this study aimed to assess the value of PAAT in evaluating early PVD in BPD infants. Methods— 81 preterm infants at risk of BPD were divided into BPD and non-BPD groups according to whether BPD occurred. Clinical characteristics, PAAT, right ventricular ejection time (RVET) and other main hemodynamic indicators at 4 different time points after birth were studied and compared. Results— PAAT and PAAT/RVET increased gradually within 72 hours after birth in the BPD group ( P < 0.05), but the curve tended to be flat over time after 72 hours( P > 0.05). At PMA32 and 36 weeks, the PAAT (49.7±4.8 vs.54.8±5.7, P=0.001; 50.0±5.3 vs.57.0±5.3, P=0.001) and PAAT/RVET (0.33 ± 0.04 vs. 0.35 ± 0.03, P=0.001; 0.34 ± 0.03 vs. 0.37 ± 0.04, P = 0.001) in BPD group were significantly lower than those in the non-BPD group. Conclusions— PAAT and PAAT/RVET in the BPD group infants showed different change patterns compared to non-BPD group infants. PAAT can be used as a noninvasive and reliable screening method for screening and dynamic monitoring of PVD in BPD high-risk infants.
Purpose: Left ventricular diastolic dysfunction (LVDD) is associated with poor outcomes in intensive care unit (ICU). Nonetheless, precise reporting of LVDD in COVID-19 patients is currently lacking and assessment could be challenging. Methods: We performed an echocardiography study in COVID-19 patients admitted to ICU with the aim to describe the feasibility of full or simplified LVDD assessment and its incidence. We also evaluated the association of LVDD or of single echocardiographic parameters with hospital mortality. Results: Between 06.10.2020 and 18.02.2021, full diastolic assessment was feasible in 74% (n=26/35) of patients receiving full echocardiogram study. LVDD incidence was 46% (n=12/26), whilst the assessment produced different results (incidence 81%, n=21/26). Nine patients were hospital-survivors (39%); incidence of LVDD (full assessment) was not different between survivors (n=2/9, 22%) and non-survivors (n=10/17, 59%; p=0.11). Also, the E/e’ ratio lateral was lower in survivors (7.4 [3.6] vs non-survivors 10.5 [6.3], p=0.03). We also found that s’ wave was higher in survivors (average, p=0.01). Conclusion: In a small single-center study, assessment of LVDD according to latest guidelines was feasible in three quarter of COVID-19 patients. Non-survivors showed a trend towards greater LVDD incidence; moreover, they had significantly worse s’ values (all) and higher E/e’ ratio (lateral).
Introduction: Pneumopericardium is a dreaded complication in esophageal carcinoma. Case description: We report a case of a 62 year old patient with past history of esophageal cancer with spontaneus pneumopericardium, without hemodynamic compromise. Admission echocardiogram that revealed a pneumopericadium with the presence of the “swirling bubbles” and the “air gap” sign. A small esophagopericardial fistula was postulated as the cause of the pneumopericardium. He underwent esophageal stent placement with resolution of the pneumopericardium. Discussion: Pneumopericardium is usually a sign of marked clinical deterioration in neoplasia and leads to patients’ death few weeks. Here we presented a case, in which a more fortunate and unusual outcome happened.
Introduction: Mitral annulus (MA) assessment is of utmost importance for the management of patients with mitral valve (MV) abnormalities and Three-dimensional transesophageal echocardiography (3D-TOE) has been the only reliable echocardiographic method for the evaluation of the mitral annulus by now. However, newer transthoracic echocardiography (TTE) probes have enabled to provide accurate measurements when TOE is contraindicated. The aim of this study is to assess the feasibility of 3D-TTE analysis of MA and the level of agreement with 3D-TOE measurements. Methods: A total of 121 consecutive patients were assessed with 3D-TTE and TOE. All MA parameters were retrospectively analyzed with the dedicated 4D-autoMVQ application. Bland-Altman analysis and intraclass correlation coefficient were used for the comparison and agreement between the two methods. Half of our patients had normal mitral valves and served as control group, while the other half had various mitral valve pathologies. Results: AutoMVQ analysis was not feasible in 11 out of 121 TTE examinations (91% feasibility) and in 4 out of 121 TOE examinations (96% feasibility). MA area and perimeter were slightly larger in TTE than those measured by TOE (12.7±3.6 vs 12.4±3.2cm2 for area and 12.7±1.7 vs 12.5±1.6cm for perimeter), however still showing strong correlation (r=0.942 and r=0.922 respectively). The majority of MV measurements were similar between the two methods with strong correlation (r>0.80). Conclusions: Assessment of the MV with 3D TTE with dedicated MVQ software is feasible and accurate, showing strong correlation and agreement with TOE measurements.
Background: In atrial fibrillation patients undergoing left atrial appendage occlusion with a Watchman device, surveillance imaging with a transesophageal echocardiogram (TEE) is typically performed at 45 days and 1 year to evaluate for device-related thrombus (DRT) and peri-device leak (PDL) before cessation of oral anticoagulation. The incidence of these complications is relatively low, and the ideal timing and duration of surveillance is unknown. We sought to evaluate the incidence of DRT and PDL after Watchman placement at 45 days and 1 year to determine the necessity of surveillance TEEs. Methods: We retrospectively analyzed 361 patients who received a Watchman device between January 2016 and January 2020. Baseline clinical and echocardiographic data, post-procedure antithrombotic therapy and surveillance echocardiographic data were collected from the NCDR LAAO Registry. Nested backward variable elimination regression was performed to derive independent predictors of the composite outcome of DRT and PDL. Results: A total of 286 patients who had post-procedure TEEs were included in the analysis. At 45 days, 9 patients had DRT (3.2%) and 44 patients had PDL (15.0%). At 1 year, 5 patients had DRT (5.6%) and 8 patients had PDL (8.9%). All DRT at 45 days was treated with continued anticoagulation while no change in protocol occurred with PDL. All DRT at 1 year occurred in new patients without prior thrombus. A history of prior transient ischemic attack (TIA) and thromboembolism were significantly associated with DRT or PDL at 1 year. Conclusions: We identified several patients with device-related complications at 45 days and 1 year despite appropriate device sizing and adequate use of antithrombotic therapy. The incidence of DRT increased from 45 days to 1 year and occurred in patients without prior thrombus. These findings highlight the importance of surveillance imaging and suggest the potential need for extended surveillance in select patients.
Background: Although Doppler evaluation using a multiplanar method is recommended to assess the severity of aortic stenosis (AS) with transthoracic echocardiography, evidence on the diagnostic significance of a non-apical method is limited. This study aimed to compare the use of the apical window (AW) with use of the right parasternal window (RW) method to evaluate AS severity and to examine the diagnostic significance of performing the RW method in addition to the AW method during the evaluation. Methods: This retrospective observational study included 287 consecutive patients (mean age: 79 ± 10 years; women, 56%) with severe AS (aortic valve area [AVA] ≤1.0cm 2). The severity of AS according to the AW method and that according to the RW for all subjects were compared, and the significance of performing the RW method in addition to the AW method was examined. Furthermore, we compared the concordance group, in which the AW and RW methods indicated matching in severity, and the discordant group, in which the AW and RW methods did not indicate matching severity. Results: Peak velocity (PV), mean pressure gradient (PG), and AVA were not significantly different between the AW and RW methods. Performing the RW method in addition to the AW method significantly decreased the number of low PG AS cases (mean PG <40 mmHg) from 71.1% to 65.0% and it increased the number of very severe AS cases (PV ≥5m/s) from 8.7% to 14.5%. Although, there was no significant difference in the Doppler angle (DA) observed using the AW method for the discordant group and the concordant group, the DA observed using the RW method was significantly smaller in the discordant group (8.8±8.2, 16.3±12.3 °, p<0.01). In the receiver-operating characteristic analysis, with the RW method, a DA of 8° was the cutoff value for discrepancies between the two groups. Conclusions: By performing the RW method in addition to the AW method to determine AS severity, different severity is observed in approximately 10% of cases. These results suggest that AS severity may be underestimated by using the AW method alone.
Background Right ventricular dysfunction is a major cause of heart failure and mortality in end-stage renal disease patients. Scarce data is available regarding the comparison of echocardiographic right ventricular function in end-stage renal disease patients on hemodialysis (HD) and peritoneal dialysis (PD). The aim of the study was to evaluate the long-term impacts of different dialysis modalities on right ventricular function assessed by conventional echocardiography, in end-stage renal disease patients with preserved left ventricular function. Methods The study included 120 patients grouped as follows: PD(n=40), HD with arterio-venous fistula (n=40) and healthy control subjects (n=40). Conventional echocardiography was performed in all patients. A classification of right ventricular function was defined in HD patients by using tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index (RV-MPI), fractional area change (FAC) and tricuspid lateral annulus systolic velocity (Sa) values. Correlation analysis was performed by using right ventricular dysfunction score, clinical and echocardiographic parameters. Results The mean age of the study population was 51.9±13.1 years and 47.5% were females. TAPSE and Sa velocity were found to be significantly lower and RV-MPI was significantly higher in patients undergoing HD, compared with control and PD patients. Logistic regression analysis showed that HD treatment was an independent risk factor for developing right ventricular dysfunction. Conclusion RV function was impaired in patients undergoing HD compared with patients on PD.
Prosthetic valve endocarditis with mechanical complications causing pulmonary edema is fatal, therefore it needs to be diagnosed early and should be treated surgically in emergency setting. Transesophageal echocardiogram is crucial for recognizing the mechanical complications, which can be encountered on daily practice, but the coexistence of complications occurring on different mechanism is rather uncommon. Herein, we report a 21-year-old gentleman presenting with acute heart failure, whose imaging tests showed a combination of dehiscence of mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm and hematoma causing right ventricular collapse.
Objective: To evaluate for cardiac involvement in recovered COVID-19 patients using cardiac magnetic resonance imaging (MRI). Methods: A total of 30 subjects recently recovered from COVID-19 and abnormal left ventricular global longitudinal strain were enrolled. Routine investigations, inflammatory markers and cardiac MRI were done at baseline with follow-up scan at 6 months in individuals with abnormal baseline scan. Additionally, 20 age-and sex-matched individuals were enrolled as healthy controls (HCs). Results: All 30 enrolled subjects were symptomatic during active COVID-19 disease and were categorized as mild: 11 (36.7%), moderate: 6 (20%) and severe: 13 (43.3%). Of the 30 patients, 16 (53.3%) had abnormal CMR findings. Myocardial edema was reported in 12 (40%) patients while 10 (33.3%) had LGE. No difference was observed in terms of conventional LV parameters however, COVID-19 recovered patients had significantly lower right ventricular (RV) ejection fraction, RV stroke volume and RV cardiac index compared to HCs. Follow-up scan was abnormal in 4/16 (25%) with LGE persisting in 3 patients. Myocardial T1 (1284 + 43.8 ms vs 1147.6 + 68.4 ms; P<0.0001) and T2 values (50.8+16.7 ms vs 42.6+3.6 ms; P=0.04) were significantly higher in post COVID-19 subjects compared to HCs. Similarly, T1 and T2 values of severe COVID-19 patients were significantly higher compared to mild and moderate cases. Conclusions: An abnormal CMR was seen in half of recovered patients with persistent abnormality in one-fourth at six months. Our study suggests a need for closer follow-up among recovered subjects in order to evaluate for long term cardiovascular sequalae.