Journal of the American Society of Echocardiography - Articles in Press

HeartMate II Ventricular Assist Device Thrombosis—An Echocardiographic Approach to Diagnosis: Can Doppler Evaluation of Flow Be Useful? - Corrected Proof

2010-07-26

A 68-year-old man was admitted to the hospital 4 months after HeartMate II ventricular assist device implantation, because his clinical status had deteriorated and his levels of lactate dehydrogenase and free hemoglobin had increased. Transthoracic echocardiography performed at admission revealed decreased basic diastolic continuous flow velocity with a pulsatile increase in flow velocity during ventricular contraction in both inflow and outflow cannulas. Twelve hours after beginning lytic therapy, basal diastolic continuous flow velocity had increased, and the amplitude between diastolic and systolic flow velocity had decreased. The clinical status of the patient improved, and his lactate dehydrogenase decreased. A decrease in basal diastolic flow may be a valuable marker of flow disturbance in continuous flow ventricular assist devices.

The Incremental Prognostic Value of Echocardiography in Asymptomatic Stage A Heart Failure - Corrected Proof

2010-07-26

Objective: This multicenter study consisted of echocardiographic examination of subjects with stage A heart failure (HF) with cardiovascular risk factors and normal electrocardiogram and clinical examination results to (a) define whether stage A subjects with risk factors are really free of functional or structural cardiac abnormalities and (b) assess the impact of the presence of risk factors and incremental value of echocardiographic parameters in the prediction of progression of HF or in the development of cardiovascular events.Methods: A total of 1097 asymptomatic subjects underwent echocardiographic examination as a screening evaluation in the presence of cardiovascular risk factors. Left ventricular (LV) dysfunction, both systolic (ejection fraction) and diastolic (transmitral flow velocity pattern), was evaluated according to standard criteria. The subjects were divided according to different criteria: the presence of one or more risk factors, presence or absence of LV systolic dysfunction, and presence or absence of LV diastolic dysfunction. A follow-up period of 26 ± 11 months was performed, observing primary (cardiac death, myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, acute pulmonary edema, stroke, and transient ischemic attack) and secondary (cardiologist-made diagnosis of HF and HF hospitalization) end points.Results: The multivariate analysis for independent predictors of primary end points showed that age (P = .001), gender (P = .02), dyslipidemia (P = .01), obesity (P = .001), and systolic dysfunction (P = .048) represented the significant predictors. The multivariate logistic regression analysis for independent predictors of secondary end points showed that gender (P = .02), LV systolic dysfunction (P = .01), and LV diastolic dysfunction (P < .01) represented the significant predictors. The multivariate analysis for independent predictors of combined end points showed that only age (P < .003), gender (male: P < .001), obesity (P < .04), and systolic dysfunction (P < .001) represented the significant predictors. Echocardiography showed a high incremental value in the detection of systolic LV dysfunction and the prediction of cardiovascular events during follow-up in subjects with at least two risk factors.Conclusion: This study demonstrated that preclinical functional or structural myocardial abnormalities could be detected by echocardiography in asymptomatic subjects with two or more cardiovascular risk factors and without electrocardiogram abnormalities (stage A of HF classification). The presence or absence of LV systolic dysfunction or LV diastolic dysfunction, as demonstrated by echocardiography, has an incremental value to cardiovascular risk factors in predicting both the evolution toward more severe HF stage C and the occurrence of cardiovascular events.

Quantitative Evaluation of Coronary Artery Wall Echogenicity by Integrated Backscatter Analysis in Kawasaki Disease - Corrected Proof

2010-07-26

Background: Coronary artery wall echogenicity increases on echocardiograms during the acute phase of Kawasaki disease (KD). According to this background, echogenicity of the coronary artery wall in patients with KD is quantified by using integrated backscatter (IB) analysis.Methods: IB analysis is a quantitative method for evaluating echogenicity. We examined the value of IB in the wall of the left anterior descending coronary artery and compared it with that in adjacent intracardiac blood as a measure of background. The difference between these values is represented as corrected IB for the coronary artery wall.Results: Corrected IB for the coronary artery wall was higher in patients with KD than in controls (KD with pre-immunoglobulin therapy vs. controls: 27.4 ± 5.3 dB vs. 22.0 ± 3.5 dB, P < .05) and in patients with coronary enlargement after intravenous immunoglobulin (with vs. without coronary enlargement, 29.2 ± 5.2 dB vs. 24.1 ± 5.5 dB, P < .05).Conclusion: The magnitude of IB from the coronary artery wall reflects the effectiveness of immunoglobulin therapy. Furthermore, this method and its value might be useful to predict the occurrence of coronary enlargement in patients with KD.

Comparison between Different Speckle Tracking and Color Tissue Doppler Techniques to Measure Global and Regional Myocardial Deformation in Children - Corrected Proof

2010-07-23

Background: Myocardial deformation parameters obtained by speckle-tracking echocardiography (STE) and color Doppler tissue imaging (CDTI) using two different ultrasound systems and three different software packages were compared.Methods: Apical four-chamber, short-axis grayscale, and color Doppler tissue images were prospectively acquired using Vivid 7 and iE33 ultrasound systems in 34 children and then analyzed using EchoPAC and QLAB (STE) and SPEQLE (CDTI).Results: Measurement of myocardial deformation was feasible for all three modalities. Longitudinal strain (ε) measurements showed the lowest intraobserver and interobserver variability (intraobserver and interobserver coefficients of variation, 9% and 8% for EchoPAC, 5% and 6% for QLAB, and 14% and 16% for SPEQLE). In addition, longitudinal ε had a small bias and narrow limits of agreement when comparing different techniques. The coefficients of variation of circumferential ε by EchoPAC and QLAB were 12% and 11% (intraobserver) and 9% and 13% (interobserver), respectively. Circumferential ε by STE had a small systematic bias but relatively narrow limits of agreement. The reproducibility of radial ε measurements using STE was low, while CDTI ε provided better performance (intraobserver and interobserver coefficients of variation for radial posterior ε, 12% and 24% for EchoPAC, 39% and 56% for QLAB, and 12% and 14% for SPEQLE). Radial ε was on average 50% lower using QLAB compared with EchoPAC and SPEQLE. Systolic strain rate values obtained by STE were lower compared with CDTI-derived values. The limits of agreement for strain rate values among the three modalities were wide, and intraobserver and interobserver variability was poor for all three modalities.Conclusions: Some deformation measurements (e.g., longitudinal and circumferential ε) are comparable among different ultrasound machines and software packages, whereas others are significantly different (e.g., radial ε and strain rate). This study stresses the need for an industry standard for these techniques.

Hypertrophy Pattern and Regional Myocardial Mechanics Are Related in Septal and Apical Hypertrophic Cardiomyopathy - Corrected Proof

2010-07-22

Background: Hypertrophic cardiomyopathy (HCM) is associated with considerable phenotypic heterogeneity. Previous studies have shown a relationship between the degree and location of hypertrophy and the prognosis of patients. The aim of this study was to compare left ventricular (LV) circumferential and longitudinal regional mechanics in patients with septal HCM and apical HCM to study the relationship between hypertrophy and function as assessed by myocardial mechanics.Methods: Seventy-two patients with HCM (27 with apical HCM, 45 with septal HCM) were compared with 25 clinically normal and age-matched subjects. Myocardial mechanics were assessed using Velocity Vector Imaging, which extracts myocardial motion estimates from B-mode clips by tracking user-defined points and feature tracking. The Velocity Vector Imaging software generated data on global and regional systolic and diastolic longitudinal and circumferential strain, strain rate, and rotational angle velocities. One-way analysis of variance with post hoc multiple comparisons was used among the three groups.Results: Normal subjects had relatively uniform strain and strain rates for all LV segments. Compared with the normal group, patients with septal HCM had decreased LV regional longitudinal strain rates and strain at both the basal and mid septal and lateral segments (all P < .01). Compared with patients with apical HCM, those with septal HCM had higher LV circumferential strain rates and strain at the basal and mid segments (P < .05 to P < .01). There were significant differences in rotational velocities at the mid segments among the three groups (P < .05 to P < .001).Conclusions: Patients with HCM have abnormalities in myocardial mechanics that are related to the site of abnormal myocardial hypertrophy.

The Impact of Preexisting Myocardial Remodeling on Ventricular Function Early after Tetralogy of Fallot Repair - Corrected Proof

2010-07-22

Background: Twenty-three patients (median age 23 months) who underwent Fallot's tetralogy repair were investigated prospectively to detect a possible association between histopathologic myocardial remodeling and echocardiographic findings of systolic or diastolic ventricular dysfunction.Methods: Intraoperatively resected infundibular bands and subendocardial biopsy samples from the right ventricle (RV) and left ventricle were obtained for histopathologic evaluation. Tissue Doppler echocardiographic interrogation of the ventricles was performed before surgery and in the postoperative period.Results: Histopathologic data revealed hypertrophy of the RV cardiomyocytes and increased interstitial collagen in both ventricles. Mean values of RV isovolumic acceleration decreased significantly at the third evaluation compared with the preoperative values (P = .006). RV myocardial fibrosis greater than 8.3% was associated with a probability of altered E' of at least 0.7 (odds ratio = 2.31).Conclusion: Preoperative histologic myocardial remodeling influenced the postoperative RV function in this group of patients with late repair. Further studies are necessary to evaluate the myocardium in younger patients and to define its influence in the long-term follow-up.

An Intriguing Co-Existence: Atrial Myxoma and Cerebral Cavernous Malformations: Case Report and Review of Literature - Corrected Proof

2010-07-22

It is commonly postulated that neurologic complications of atrial myxomas are due to either direct tumor embolization or mycotic aneurysm of cerebral vasculature or rupture of mycotic aneurysms of cerebral arteries. However, the authors report the case of 63-year-old woman with a large left atrial myxoma whose progressive left-sided weakness was due to a different neurologic mechanism, namely, multiple bleeding cavernous malformations, which were visualized by magnetic resonance imaging of the brain. Cerebral cavernous malformations coexist with mesenchymal anomalies of other organs, including the liver, kidneys, and retinas. To the best of the authors' knowledge, this is only the second reported case of coexistent cerebral cavernous malformations and atrial myxoma.

Comparison of Echocardiographic Single-Plane vs Biplane Method in the Assessment of Left Atrial Volume and Validation by Real Time Three-Dimensional Echocardiography - Corrected Proof

2010-07-22

Background: The American Society of Echocardiography recommends calculating left atrial (LA) biplane volume because of its greater accuracy and prognostic value over LA diameter. However, biplane methods are not always feasible. The aim of this study was to assess the correlation between the echocardiographic LA biplane and single-plane volumes and their agreement in the classification of LA size when American Society of Echocardiography cutoffs are applied.Methods: Two-dimensional echocardiography was performed on the participants of the population-based Cardiovascular Abnormalities and Brain Lesions study. LA volume was calculated by the biplane area-length and single-plane modified Simpson's methods and validated against three-dimensional echocardiography.Results: The study sample consisted of 527 participants (mean age 69.6 ± 9.7 years; 61.9% women). Both single-plane and biplane LA volumes correlated well with three-dimensional echocardiography (r = 0.93, P < .001). The correlation between the single-plane and biplane methods was excellent (r = 0.95, P < .001; intraclass correlation coefficient, 0.92; 95% confidence interval, 0.80–0.96). Categorical agreement between the single-plane and biplane methods was modest (κ = 0.51; 95% confidence interval, 0.45–0.57; disagreement rate, 26.0%), mainly because of overestimation by the single-plane method. The correction of the single-plane volume by a regression equation improved the agreement (κ = 0.70; 95% confidence interval, 0.64–0.76), but misclassifications remained in 14.0% of cases.Conclusions: Single-plane and biplane LA volume measurements have strong correlations, but their agreement for categorical classification is suboptimal. Specific cutoff points should be developed for the single-plane method.

Ventricular Prosthesis Embolization During Transapical Aortic Valve Implantation: The Role of Transesophageal Echocardiography in Diagnosis and Management - Corrected Proof

2010-07-22

The authors present the case of an 81-year-old patient with severe aortic stenosis who experienced left ventricular embolization of an aortic bioprosthesis during transapical aortic valve implantation. The authors discuss reasons for prosthesis embolization and reinforce the attention to technical details and the widespread use of multimodality imaging techniques. In this context, transesophageal echocardiography appears indispensable in the detection and management of procedure-related complications.

The Feasibility of Velocity Vector Imaging by Transesophageal Echocardiography for Assessment of Elastic Properties of the Descending Aorta in Aortic Valve Disease - Corrected Proof

2010-07-22

Background: Velocity vector imaging (VVI) is a novel two-dimensional speckle-based imaging technique for evaluation of tissue deformation. The aim of this study was to determine the feasibility and variability of VVI for the assessment of aortic strain, distensibility, and stiffness in patients with aortic valve disease.Method: Eighty-five patients (mean age 66 ± 11 years) with aortic stenosis (AS) or aortic regurgitation (AR) were examined in the operating room before the operation using transesophageal echocardiography (TEE). The two-dimensional short-axis images and M-mode recordings of the descending aorta were acquired simultaneously with the invasive blood pressure measurement in the radial artery. The TEE images were analyzed off-line using VVI software.Results: In comparison with patients with AS, patients with AR displayed significantly higher circumferential strain (7.6% ± 4.5% vs. 3.7% ± 1.9%, P < .001) and distensibility (27.1 ± 12.8 kPa-110-3 vs. 17.2 ± 7.2 kPa-110-3, P < .001) by VVI and distensibility (32.8 ± 16.7 kPa-110-3 vs. 21.7 ± 10.6 kPa-110-3, P < .004) by M-mode. Stiffness was higher in AS than AR, as measured by VVI (13.3 ± 6.0 vs. 10.5 ± 6.0, P < .01) and M-mode (11.2 ± 6.1 vs. 10.4 ± 9.1, P < .048). The correlations between VVI and M-mode distensibility (r = 0.84) and stiffness (r = 0.84) were both highly significant (P < .0001). The VVI strain measurements showed low inter- and intraobserver variability with intraclass correlations greater than 0.95 and coefficients of variation less than 10%.Conclusion: VVI-derived strain, distensibility, and stiffness differ significantly between AR and AS and correlate strongly with the corresponding M-mode–derived parameters. VVI is a feasible method for the assessment of the elastic properties of the descending aorta with low variability and has the advantage of incorporating the entire aortic wall circumference in the analysis, consequently accounting for local variations in the elastic properties of the aorta.

Acute Occlusion of a Bileaflet Mechanical Mitral Valve Prosthesis Resulting from External Cardiac Compression - Corrected Proof

2010-07-22

A 45-year-old woman with a history of rheumatic mitral disease underwent valve replacement. After surgery, the patient became hemodynamically unstable. A transesophageal echocardiogram showed an underfilled left ventricle with a clot impinging on the lateral aspect of the left ventricle and a malfunctioning mitral valve prosthesis. After evacuation of the clot in the operating room, the mitral valve prosthesis began functioning normally. The prosthesis malfunction resulted from external cardiac compression. This dynamic device malfunction was replicated when the surgeon compressed the lateral aspect of the heart. To our knowledge, this dynamic form of leaflet dysfunction from external compression has not been described. This case highlights the importance of closely evaluating prosthetic valve function in the setting of hemodynamic deterioration.

A Depression in Left Ventricular Diastolic Filling following Prolonged Strenuous Exercise is Associated with Changes in Left Atrial Mechanics - Corrected Proof

2010-07-02

Background: Standard marathon running can result in a depression of left ventricular (LV) diastolic function during early recovery. Left atrial (LA) mechanics are integral in maintaining an early diastolic pressure gradient as well as being responsive to changes in LV diastolic function, and therefore the detailed assessment of LA mechanics may provide further insight. The aim of this study was to determine the impact of prolonged strenuous exercise on mechanics of the left atrium and the association with changes in LV diastolic function.Methods: Myocardial speckle-tracking echocardiograms of the left atrium and left ventricle were obtained prior to, immediately after, and 6 hours after the completion of a marathon (42.2 km) in 17 healthy adult men. Speckle tracking was used to determine peak atrial deformation, early diastolic deformation rate, and contractile function, including atrial activation time. LA volumes throughout the cardiac cycle were also assessed to provide reservoir, conduit, and booster pump volumes. Diastolic assessment of the left ventricle included peak early diastolic strain rate, late diastolic strain rate, and standard indices. Temporal assessment of LV “twist” and “untwist” was also evaluated.Results: All 17 subjects completed the marathon (mean finishing time, 209 ± 19 minutes; range, 173-241 minutes). Although contractile function was significantly increased, there was a reduction in early diastolic deformation rate that was correlated with reduced atrial deformation. Atrial activation time was significantly increased after the race. All LV indices of diastolic function were reduced in early diastole, whereas late diastolic function was increased after the race. LV torsion was significantly reduced at end-systole and significantly elevated in the isovolumic period and early diastole, after the race. All indices returned toward baseline at 6 hours after exercise.Conclusions: This study demonstrates transient changes in LV diastolic relaxation following prolonged exercise that appear to have a direct impact on subsequent LA deformation. The impact of reduced LA preload on these findings and the delay in LA activation time requires further exploration.

Multi-Modality Imaging of an Unusual Congenital Left Ventricular Diverticulum - Corrected Proof

James L. Hoffman, Shaji C. Menon, Melanie D. Everitt, Phillip T. Burch — 2010-07-02

The authors describe the case of a newborn presenting with a pulsatile abdominal mass that was subsequently diagnosed as a large congenital muscular left ventricular diverticulum. This case illustrates the role of multimodality imaging in the diagnosis and surgical planning of this rare congenital heart disease. The diverticulum was managed with surgical resection without the use of cardiopulmonary bypass. Unlike in previous case reports, this patient did not have any associated intracardiac defect.

Isolated Left Ventricular Apical Hypoplasia: A Newly Recognized Unclassified Cardiomyopathy - Corrected Proof

2010-06-30

We describe two relatively asymptomatic cases diagnosed with the newly recognized unclassified cardiomyopathy, isolated left ventricular apical hypoplasia. The disease has been described mainly in cardiac magnetic resonance, whereas this study presents the echocardiographic characteristics of this new cardiomyopathy.

Percutaneous Closure of a Left Atrial Appendage Pseudoaneurysm - Corrected Proof

2010-06-30

Atrial dissections and pseudoaneurysms are rare complications of cardiac surgery. The authors describe the case of a patient after mitral valve replacement who presented with a left atrial appendage pseudoaneurysm. This case represents the first known closure of an atrial pseudoaneurysm with a percutaneous septal occluder device.

An Unnatural History of Left Ventricular Pseudoaneurysm? - Corrected Proof

Andrew K. Chen, Noah Rosenthal, Eric Nyberg, Brian D. Hoit — 2010-06-21

We report the case of a 79-year-old woman with a history of methicillin-resistant Staphylococcus aureus bacteremia and purulent pericarditis with subsequent subxiphoid pericardiostomy and formation of a large left ventricular pseudoaneurysm (LVPA) that has been medically managed. Long-term survival after pseudoaneurysm formation has traditionally been thought to be unusual without operative intervention. Computed tomography (CT), three-dimensional reconstructed CT, and echocardiographic images documenting the progression of the LVPA are presented over the course of the patient's follow-up. This case highlights the natural history of LVPA and the utility of multimodal imaging in allowing accurate assessment of LVPA anatomy.

Thrombosed Aneurysm of the Left Sinus of Valsalva Presenting as an Intramyocardial Mass - Corrected Proof

2010-06-07

Aneurysms of the sinuses of Valsalva are uncommon in clinical practice. Most are congenital, but secondary causes are also recognized. Congenital aneurysms of the left sinus of Valsalva are particularly rare. The authors report a fatal case in which a nonruptured aneurysm of the left sinus of Valsalva dissected into the interventricular septum and presented as heart failure. The concurrent presence of dilated cardiomyopathy and the mechanisms that may have led to it are discussed on the basis of the anatomic and histologic features found at autopsy.

Spontaneous Resolution of Severe Mitral Regurgitation in a Patient with a Flail Mitral Valve - Corrected Proof

Ihab Asmer, Salim Adawi, Moshe Y. Flugelman, Avinoam Shiran — 2010-06-04

Flail mitral valve usually causes severe mitral regurgitation, which may lead to left ventricular dysfunction if left uncorrected. The authors present a case of flail posterior mitral valve leaflet and severe mitral regurgitation in which mitral valve adaptation led to enlargement of the anterior mitral valve leaflet, decrease in mitral regurgitation, and reverse left ventricular remodeling without any need for surgery.

The Seabed-like Appearance of Atherosclerotic Plaques: Three-Dimensional Transesophageal Echocardiographic Images of the Aortic Arch Causing Cholesterol Crystal Emboli - Corrected Proof

2010-05-31

Cholesterol crystal embolism (CCE) is a rare but important complication of endovascular procedures or anticoagulation therapy. An 84-year-old man was referred to the Gunma University Graduate School of Medicine with the diagnosis of acute myocardial infarction. After successful emergency coronary angioplasty, his serum creatinine level increased continuously. A subsequent skin biopsy confirmed that the patient had CCE. Transesophageal echocardiography (TEE) clearly demonstrated the mobile mass protruding from the complex atheroma. Three-dimensional TEE provides more precise and attractive volumetric images of the atherosclerotic plaque than two-dimensional TEE. In addition, the findings of this case revealed contrast media-induced nephropathy and CCE as possible causes of renal dysfunction after endovascular procedures.

Torn Atrial Septum during Transcatheter Closure of Atrial Septal Defect Visualized by Real-Time Three-Dimensional Transesophageal Echocardiography - Corrected Proof

2010-05-17

Transcatheter closure of atrial septal defects (ASDs) has become an accepted and reliable procedure. Although various complications have been recognized, tear of the atrial septal rim is a rare complication. We report a case of atrial septal rim tear that was diagnosed during the procedure by real-time three-dimensional transesophageal echocardiography (TEE). The device was successfully implanted 3 months after the initial intervention. RT3D TEE is more useful for displaying the entire shape of the defect and its spatial relationship (RT3D) with its neighboring structures compared with conventional two-dimensional echocardiography. By using both two-dimensional and RT3D TEE images, especially in cases with complicated ASD morphology, both the echocardiologist and interventionalist gain valuable information on the morphology of the ASD before and during the procedure.

Composite Hodgkin and Non-Hodgkin Lymphoma of the Mitral and Aortic Valves - Corrected Proof

2010-05-10

A 58-year-old man with a remote history of diffuse large B-cell lymphoma (DLBCL), status post chemotherapy, radiation, and peripheral blood stem cell transplantation, presented with splenic nodular sclerosis classical Hodgkin lymphoma. He was found to have aortic and mitral valve mass lesions. The mitral valve mass showed typical histologic and immunophenotypic features of nodular sclerosis classical Hodgkin lymphoma, whereas the aortic valve mass and aortic mitral curtain tissue showed DLBCL with necrosis. Both tumors were Epstein-Barr virus positive and were clonally related; however, they were not related to his DLBCL from 14 years prior. This is the first case report of a patient with a composite lymphoma affecting two cardiac valves.

Utility of Three-Dimensional Transesophageal Echocardiography: Anatomy, Mechanism, and Severity of Regurgitation in a Patient with an Isolated Cleft Posterior Mitral Valve - Corrected Proof

Patric Biaggi, Matthias Greutmann, Andrew Crean — 2010-05-10

Echocardiographic assessment of a 72-year-old woman revealed a posterior mitral valve prolapse with an unusual central regurgitation jet. The use of three-dimensional (3D) transesophageal echocardiography elucidated the mismatch between morphologic and color Doppler echocardiographic findings: There was a cleft in the posterior mitral valve in addition to the posterior mitral valve prolapse. This case illustrates that the use of high-quality real-time 3D transesophageal echocardiography (including 3D color Doppler) facilitates the understanding of the anatomy and the mechanism and severity of regurgitation in complex mitral valve pathology and is clearly superior to two-dimensional TEE alone.

Electrical Dissociation Within the Left Atrium and Left Atrial Appendage Diagnosed With Transesophageal Echocardiography - Corrected Proof

Tasneem Z. Naqvi, Reza Rafie, David Cesario — 2010-05-03

The authors describe the case of a 79-year-old man with prior mitral valve repair and a maze procedure who developed recurrent atrial fibrillation, in whom transesophageal echocardiography revealed an accessory lobe of the left atrial appendage in sinus rhythm when the remaining body of the left atrial appendage was in atrial fibrillation or flutter. Electrophysiology confirmed dissociated rhythm within the left atrium. This case emphasizes the need for careful Doppler interrogation of the left atrial appendage and its lobes to look for dissociated atrial rhythm.

Transesophageal Echocardiography of a Dislodged Left Atrial Appendage Thrombus and Its Subsequent Surgical Removal During Coronary Artery Bypass Graft Surgery - Corrected Proof

Rob C. Tanzola, Brian Milne, Andrew Hamilton — 2010-04-19

Left atrial appendage (LAA) thrombus is a common finding in patients with atrial fibrillation and a major source of emboli that cause strokes. The incidental finding of an LAA thrombus during cardiac surgery is an infrequent finding during routine intraoperative echocardiography, and optimal management is not well defined. A case of a large, incidentally discovered LAA thrombus that became mobile on initiation of cardiopulmonary bypass in a patient undergoing coronary artery bypass graft surgery is presented. Intraoperative transesophageal echocardiography diagnosed the thrombus, discovered its dislodgement from the LAA, and very interestingly demonstrated its surgical removal. This case demonstrates the ability of intraoperative transesophageal echocardiography to alter surgical management and provides support for its routine use in cases in which LAA thrombi are likely.

Biventricular Pacing as Bridge to Rapid Recovery in Infancy - Corrected Proof

2010-04-01

The authors present the unique case of an 8-month-old baby diagnosed with severe left ventricular failure of unknown etiology. Due to a lack of organ availability for this age, a mechanical assist device and assessment for cardiac transplantation were not offered. Subsequent comprehensive echocardiographic dyssynchrony assessment and the presence of left bundle branch block were suggestive of response to cardiac resynchronization therapy. Dual-chamber epicardial pacing was initiated, resulting in prompt marked clinical and echocardiographic improvement, which continued until complete normalization of cardiac function. The pacing system was safely turned off 6 months after its implantation. In conclusion, cardiac resynchronization therapy should be considered as a treatment option even in infancy, regardless of the etiology of disease and/or patient age.

Contrast Enhanced Transesophageal Echocardiographic Guidance of Left Atrial Appendage Closure Device Implantation - Corrected Proof

Michael L. Main, George G. Latus, Anthony Magalski, Kenneth C. Huber — 2010-04-01

The percutaneous implantation of a left atrial appendage closure device offers an alternative to chronic oral anticoagulation in patients with nonvalvular atrial fibrillation and concomitant risk factors for stroke. Transesophageal echocardiography plays a key role in defining left atrial appendage anatomy and in guiding device implantation. The authors describe a case in which contrast-enhanced transesophageal echocardiography was critically important in spatially resolving the borders of the left atrial appendage, which ultimately led to successful device implantation with cessation of warfarin therapy.

Dislocation of Amplatzer Septal Occluder Device After Closure of Secundum Atrial Septal Defect - Corrected Proof

2010-03-04

Atrial septal defect transcatheter occlusion techniques have become an alternative to surgical procedures. With the increasing use of this new technology, several complications have been identified. The authors present the case of a patient who was admitted to the hospital for primary percutaneous closure of a secundum atrial septal defect. On routine follow-up examination 24 hours after implantation, transthoracic echocardiography revealed a partial dislocation of the occluder into the right atrium. The patient was referred for cardiosurgical treatment. Strict selection criteria and the choice of the device may help reduce the incidence of complications such as dislocation of the occluder into the right atrium following the percutaneous device closure of an atrial septal defect.