Journal of the American Society of Echocardiography - Articles in Press

Left Atrial Phasic Volumes Are Modulated by the Type Rather Than the Extent of Left Ventricular Hypertrophy - Corrected Proof

Suzanne Eshoo, Chris Semsarian, David L. Ross, Liza Thomas — 2010-03-12

Background: The aim of this study was to evaluate whether maximal left atrial (LA) volume and phasic atrial function would be further altered in patients with hypertrophic cardiomyopathy (HCM) compared with patients with systemic hypertension (HT) with similar left ventricular (LV) mass. LA enlargement on echocardiography has been documented in HCM and moderate or severe HT, both conditions causing LV hypertrophy.Methods: Thirty-five patients with HCM were compared with patients with HT matched for LV mass and normal controls matched for age and gender. Maximal, minimal, and pre-“p” LA biplane and real-time 3-dimensional volumes and LA phasic function were evaluated. Atrial function was estimated by LA ejection force, atrial fraction, and A′ velocity.Results: Maximal, minimal, and pre-“p” LA volumes were significantly increased in the HCM group compared with the HT group and controls. Additionally, LA phasic volumes demonstrated that conduit volume and total, passive, and active emptying fractions were decreased in the HCM group. Despite similar LV mass, the HCM group had a higher incidence of abnormal diastolic filling (60% vs 34%, P = .001).Conclusions: Patients with HCM appeared to have larger LA volumes, poorer LA function, and greater severity of diastolic dysfunction compared with those with HT having comparable LV mass. LA changes may be due to coexistent atrial myopathy associated with other pathophysiologic aspects of HCM, including outflow obstruction, mitral regurgitation, and myocardial fibrosis in HCM.

Passive Leg-Raise Is Helpful to Identify Impaired Diastolic Functional Reserve During Exercise in Patients With Abnormal Myocardial Relaxation - Corrected Proof

2010-03-12

Background: The aim of this study was to demonstrate the usefulness of leg raise in identifying lower diastolic functional reserve to exercise.Methods: One hundred fifty-four patients with abnormal left ventricular relaxation on Doppler mitral inflow with preserved left ventricular ejection fractions were enrolled. After resting evaluations, Doppler echocardiographic measurements were repeated during passive leg raise and graded supine bicycle exercise.Results: Patients were divided into 3 groups according to resting E/e′ ratio and its response to leg raise: group IA (persistent E/e′ < 15 [n = 112]), group IB (change to E/e′ ≥ 15 after leg raise [n = 19]), and group II (persistent E/e′ ≥ 15 [n = 23]). Group II had lower S′, e′, and diastolic reserve index values during exercise compared with group IA but not with group IB. Group IB had higher E/e′ ratios during exercise and lower diastolic functional reserve index values accompanied by lower exercise capacity compared with group IA.Conclusion: Passive leg raise might be helpful in identifying a subgroup with lower diastolic functional reserve and lower exercise capacity among patients with abnormal relaxation.

A New Simple Method to Estimate Pulmonary Regurgitation by Echocardiography in Operated Fallot: Comparison With Magnetic Resonance Imaging and Performance Test Evaluation - Corrected Proof

2010-03-04

Background: The aim of this study was to assess a novel transthoracic echocardiographic method to estimate the severity of pulmonary regurgitation (PR) in patients with surgically repaired tetralogy of Fallot.Method: In 63 patients with operated tetralogy of Fallot, PR was evaluated by vena contracta width, jet deceleration, PR index, pressure half-time, and a new index, referred to as Pulmonary Regurgitation Index by M-mode echocardiography (PRIME), which is the systolic-to-diastolic variation in right pulmonary artery diameter. The results were matched to PR fraction (PRF) assessed by cardiovascular magnetic resonance imaging. PRIME cutoff values for selecting patients with mild, moderate, and severe PR were identified by maximizing PRIME sensitivity and specificity. Nonlinear regression by 3-parameter logistic function was used to estimate PRF by PRIME.Results: The sensitivity and specificity of PRIME were high for all diagnostic targets: PRF ≥15% versus <15%, PRF ≥25% versus <25%, and PRF >40% versus ≤40%. The nonlinear regression model showed a good correlation between PRF and PRIME (R2 = 0.95).Conclusion: PRIME is a simple and accurate method to estimate PR by transthoracic echocardiography in patients with operated tetralogy of Fallot.

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.

Can Isovolumic Acceleration Be Used in Clinical Practice to Estimate Ventricular Contractile Function? Reproducibility and Regional Variation of a New Noninvasive Index - Corrected Proof

2010-03-04

Background: Myocardial acceleration during isovolumic contraction (IVA) has been validated as a relatively load-insensitive noninvasive index of contractility. Its feasibility, reproducibility, and variation between segments have not been studied in detail, and thus its utility in clinical practice has not been established.Methods: We analyzed myocardial velocity loops (median frame rate 182 s−1) from 20 young volunteers (10 men, aged 25.7 ± 2.9 years), 20 patients with type 2 diabetes (14 men, aged 64.1 ± 8.5 years), and 20 patients with heart failure (17 men, aged 64.6 ± 7.7 years). Long-axis IVA was measured in all walls at the annulus and in basal and mid-ventricular segments. Intraobserver reproducibility for 1 observer in all subjects and interobserver reproducibility among 3 observers in 10 subjects from each group were assessed.Results: In control subjects, subjects with diabetes, and subjects with heart failure, the feasibility of measuring IVA was 97%, 89%, and 82%, respectively; intraobserver reproducibility was 12%, 18%, and 30%, respectively (pooled coefficients of variation); and mean interobserver reproducibility was 23%, 21%, and 28%, respectively. IVA was lower in the mid-ventricular segments by 24% to 43% compared with the annulus, and IVA was higher in the right than the left ventricle (P < .001). IVA of the medial mitral annulus discriminated those with heart failure from those with diabetes and controls, and had acceptable intraobserver reproducibility across groups (mean coefficient of variation 13%).Conclusion: IVA may be used as a research tool if it is measured at the medial mitral annulus, but its clinical applicability is hampered by low reproducibility, especially in patients with impaired left ventricular function in whom it would otherwise be most useful.

Recovery of Function After Acute Myocardial Infarction Evaluated by Tissue Doppler Strain and Strain Rate - Corrected Proof

2010-03-04

Background: The aim of this study was to investigate the changes and time course of recovery of regional myocardial function within the first week following successful primary coronary intervention in patients with first-time ST-segment elevation myocardial infarctions using myocardial deformation analysis, which is more quantitative and thus more objective than the wall motion score.Methods: Thirty-one consecutive patients admitted with ST-segment elevation myocardial infarctions were studied on days 1, 2, 3, and 7 using strain and strain rate tissue Doppler echocardiography.Results: The mean peak troponin T level was 7.0 μg/L, and 15 patients had anterior and 16 had inferior infarct localization. Peak systolic strain rate and end-systolic strain increased significantly on day 2, both in segments with moderately reduced function (−0.6 to −1.0 s−1 vs −8% to −15%, P < .001) and in severely reduced function (−0.2 to −1.0 s−1 vs 1% to −12%, P < .001), but there were no further changes. Mean wall motion score in infarct related segments decreased significantly from day 1 to day 2 (2.7 to 2.4, P = .001) and from day 3 to day 7 (2.3 to 2.2, P = .001).Conclusions: Recovery of regional function after ST-segment elevation myocardial infarction occurred within 2 days and could be detected by wall motion score, strain rate, and strain. However, strain and strain rate were better discriminative parameters for the changes in function as well as being better to assess near normalization on day 2. This could have a clinical impact on early management in patients who undergo percutaneous coronary intervention.

Predicting Heart Failure Hospitalization and Mortality by Quantitative Echocardiography: Is Body Surface Area the Indexing Method of Choice? The Heart and Soul Study - Corrected Proof

2010-03-04

Background: Echocardiographic measurements of left ventricular (LV) mass, left atrial (LA) volume, and LV end-systolic volume (ESV) predict heart failure (HF) hospitalization and mortality. Indexing measurements by body size is thought to establish limits of normality among individuals varying in body habitus. The American Society of Echocardiography recommends dividing measurements by body surface area (BSA), but others have advocated alternative indexing methods.Methods: Echocardiographic measurements were collected in 1024 ambulatory adults with coronary artery disease. LV mass, LA volume, and LV ESV were calculated using truncated ellipse method and biplane method of disk formulae. Comparison between raw measurements and measurements divided by indexing parameters was made by hazard ratios per standard deviation increase in variable and c-statistics for BSA, BSA0.43, BSA1.5, height, height0.25, height2, height2.7, body weight (BW), BW0.26, body mass index (BMI), and BMI0.27.Results: Mean LV mass was 192 ± 57 g, mean LA volume was 65 ± 24 mL, and mean LV ESV was 41 ± 26 mL. Average height was 171 ± 9 cm, average BSA was 1.94 ± 0.22 m2, and average BMI was 28.4 ± 5.3 kg/m2. At an average follow-up of 5.6 ± 1.8 years, there were 148 HF hospitalizations, 71 cardiovascular (CV) deaths, and 269 all-cause deaths. There was excellent correlation between raw measurements and those indexed by height (r = 0.98-0.99), and moderate correlation between raw measurements and those indexed by BW (r = 0.73-0.94). C-statistics and hazard ratios per standard deviation increase in indexed variables were similar for HF hospitalization, CV mortality, and all-cause mortality. There were no significant differences among indexing methods in ability to predict outcomes.Conclusion: The choice of indexing method by parameters of BSA, height, BW, and BMI does not affect the clinical usefulness of LV mass, LA volume, and LV ESV in predicting HF hospitalization, CV mortality, or all-cause mortality among ambulatory adults with coronary artery disease. Continued use of BSA to index measurements of LV mass, LA volume, and LV ESV is acceptable.

Automated Border Detection for Assessing the Mechanical Properties of the Carotid Arteries: Comparison with Carotid Intima–Media Thickness - Corrected Proof

Michael Luc, Tamar Polonsky, Georgeanne Lammertin, Kirk Spencer — 2010-03-04

Background: Although carotid intima–media thickness (CIMT) assesses the structural properties of the carotid artery, it does not assess the mechanical properties of the vessel.Methods: The carotid arteries of 71 adult patients were evaluated with CIMT, and automated border detection computed vessel stiffness, compliance, elasticity, and distensibility.Results: CIMT and mechanical properties were differentially affected by traditional cardiac risk factors, with age dominating for CIMT, and age, diabetes, and smoking dominating for mechanical variables. There was a moderate linear correlation between CIMT and the distensibility coefficient (r = −0.54), but there were weak associations with other parameters of dynamic vessel function. When patients were separated into risk groups, the mechanical vascular parameters' classification frequently differed from the CIMT classification. This was particularly notable for patients with intermediate CIMT values, who were reclassified as low or high risk by mechanical parameters 45% of the time.Conclusion: We found that it is feasible to assess the cross-sectional area of the carotid artery using automatic border detection, which allows a novel method of determining carotid mechanical properties. These functional characteristics are often discordant with CIMT, suggesting that mechanical properties may be an important adjunct to the CIMT when evaluating the carotid artery.

Functional Anatomy of Tricuspid Regurgitation in Patients with Systemic Right Ventricles - Corrected Proof

2010-03-02

Objective: Although the functional anatomy of mitral regurgitation has been thoroughly studied and is strongly predictive of postoperative outcome, the functional anatomy of tricuspid regurgitation (TR) in patients with systemic right ventricles has not been described.Methods: We measured the indices of tricuspid valve deformation, right ventricular remodeling and function, and brain natriuretic peptide (BNP) concentrations in a series of 42 patients (mean age 20.8 ± 3.7 years) with systemic right ventricles after atrial switch for complete transposition of the great arteries.Results: TR was present in 34 patients. It was associated with predominant annular dilatation in 5 patients (14.7%), valvular prolapse in 14 patients (41.1%), and systolic leaflet tethering in 15 patients (44.1%). Compared with patients with valve prolapse, patients with leaflet tethering had greater end-systolic right ventricular cavity area (21.1 ± 3.6 cm2 vs 27.3 ± 7.9 cm2; P < .05), lower right ventricular fractional area change (0.40 ± 0.09 vs 0.34 ± 0.09, P < .05), and higher BNP levels (14.6 ± 13.5 pg/mL vs 25 ± 24.3 pg/mL, P < .05). Intermediate values were observed in patients with annular dilatation (23.9 ± 5.6 cm2; 0.37 ± 0.05 pg/mL and 19.0 ± 0.07 pg/mL, respectively).Conclusion: Three distinct types of TR, caused by predominant annular dilatation, valve prolapse, and valve tethering, were apparent in patients with systemic right ventricles. They were associated with diverse severity of right ventricular dysfunction and BNP activation. Further studies are needed to assess the impact of variable functional anatomy of the systemic tricuspid valve on the outcome of medical and surgical therapies.

Authors' Reply - Corrected Proof

Woo-In Yang, Jong-Won Ha — 2010-03-02

To the Editor: We thank Dr. Fayssoil for his interest in and important comments about our article. Our study was designed to investigate parameters that can predict adverse outcomes in patients with hypertrophic cardiomyopathy, including cardiac magnetic resonance parameters, and we found that left atrial (LA) volume index was independently associated with cardiovascular outcomes in patients with hypertrophic cardiomyopathy.

Percutaneous Closure of a Mitral Perivalvular Leak Using Three Dimensional Real Time and Color Flow Imaging - Corrected Proof

Kenneth D. Horton, Brian Whisenant, Steve Horton — 2010-02-12

The role of echocardiography, including three-dimensional (3D) echocardiography, during interventional procedures in the cardiac catheterization laboratory is continuing to expand as interventional cardiologists perform more catheter-based interventions. Echocardiography often complements angiographic imaging of cardiac structures and sometimes provides additional information not available by angiography and fluoroscopy. The closure of perivalvular leaks using catheter-based techniques is one of the areas in which 3D echocardiography can be helpful. This case report describes the use of 3D real-time and color flow imaging during the closure of a mitral perivalvular leak. Three-dimensional echocardiography was used to assess the leak prior to intervention and the success of the intervention at the completion of the case.

Traumatic Tricuspid Regurgitation Caused by Myocardial Laceration: A Three-Dimensional Echocardiographic Study - Corrected Proof

2010-02-11

A 19-year-old man was admitted for severe traumatic tricuspid regurgitation (TR) 4 months after a traffic accident. Transthoracic echocardiography revealed severe TR, with an abnormal chordal structure. Three-dimensional echocardiography showed widely lacerated right ventricular endocardium involving many subvalvular components. In this case of traumatic TR, three-dimensional echocardiography was useful not only for its diagnosis but also in providing important information for surgical decision making.

Diffuse Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance Predicts Significant Intraventricular Systolic Dyssynchrony in Patients With Non-Ischemic Dilated Cardiomyopathy - Corrected Proof

2010-02-11

Background: Left ventricular dyssynchrony and myocardial fibrosis are common findings in patients with nonischemic dilated cardiomyopathy (NDCM). The aim of this study was to investigate the association between myocardial fibrosis and intraventricular systolic dyssynchrony (DYS-sys) in patients with NDCM.Methods: Thirty-nine patients with NDCM and sinus rhythm were enrolled. Intraventricular DYS-sys was evaluated using Doppler tissue imaging, and cardiac fibrosis was assessed with cardiovascular magnetic resonance imaging with a 17-segment cardiac model. Each segment was graded on a 2-point scale (segmental fibrosis score): 0 = absence of late gadolinium enhancement, and 1 = presence of late gadolinium enhancement. A cardiac fibrosis index was calculated as 17/(17 − sum of fibrotic segments). Receiver operating characteristic analysis was performed to determine the utility of the cardiac fibrosis index to predict intraventricular systolic dyssynchrony.Results: Patients with DYS-sys had larger left atrial size (P = .004) and left ventricular end-systolic (P = .028) and end-diastolic (P = .034) volumes and lower tricuspid annular Doppler tissue imaging peak systolic velocities (P = .037) compared with patients without DYS-sys. A cardiac fibrosis index ≥ 1.4 predicted significant DYS-sys with 92% sensitivity and 60% specificity (area under the receiver operating characteristic curve, 0.703; 95% confidence interval, 0.512-0.893; P = .035). Patients with cardiac fibrosis indexes ≥ 1.4 (group 1) had larger left ventricular end-systolic (P = .044) and end-diastolic (P = .034) volumes than those with cardiac fibrosis indexes < 1.4 (group 2). Nine of 11 patients (82%) in group 1 and 6 of 28 patients (21%) in group 2 had significant DYS-sys (Pearson's χ2 = 12.169, P < .0001). Logistic regression analysis revealed that cardiac fibrosis index ≥ 1.4 (odds ratio, 11.2; 95% confidence interval, 1.72-71.4; P = .012) was an independent predictor of DYS-sys.Conclusion: Patients with NDCM and prominent cardiac fibrosis have significant DYS-sys. The cardiac fibrosis index is a useful tool to predict DYS-sys.

Acquired Pulmonary Vein Stenosis: One Problem, Two Mechanisms - Corrected Proof

Anna M. Booher, David S. Bach — 2010-02-08

Until the last decade, acquired pulmonary vein (PV) stenosis in the adult population was a rare finding, caused by neoplasm or inflammatory conditions such as sarcoidosis or fibrosing mediastinitis. With the increased use of catheter-based ablation for the treatment of atrial fibrillation, PV stenosis is increasingly recognized as a complication of this procedure. Additionally, PV stenosis has been described as a rare complication of cardiac surgery. This report describes two cases of PV stenosis, one acquired as a result of multiple left atrial ablation procedures and the other after surgical cannulation of the right upper PV.

Left Atrial Volume Index: A Predictor of Adverse Outcome in Patients With Hypertrophic Cardiomyopathy - Corrected Proof

Abdallah Fayssoil — 2010-02-08

To the Editor: I read with great interest the report by Yang et al on the value of the left atrial (LA) volume index for predicting adverse outcome in patients with hypertrophic cardiomyopathy. The article raises the following concerns.

Transthoracic and Transesophageal Echocardiography for the Indication of Suspected Infective Endocarditis: Vegetations, Blood Cultures and Imaging - Corrected Proof

2010-02-08

Background: The aim of this study was to investigate the ability of transthoracic echocardiography (TTE) to detect vegetations and the relationship between blood cultures and transesophageal echocardiography (TEE).Methods: Five hundred eleven TTE and TEE pairs performed to evaluate endocarditis were retrospectively analyzed. Vegetation on TTE, prosthetic valve, change in regurgitation, and blood cultures were correlated with vegetation on TEE.Results: TTE detected 45% of vegetations seen on TEE. There was no difference for prosthetic valves. Prosthetic valves (odds ratio, 1.7; P = .03) and increased regurgitation (odds ratio, 1.7; P = .01) were associated with vegetations on TEE; staphylococcal bacteremia and fungemia were not. Negative blood cultures were associated with negative results on TEE (P < .0001), but 27% of patients with prosthetic valves had culture-negative endocarditis or nonbacterial thrombotic endocarditis, and 6% had abscesses missed by TTE.Conclusion: This study demonstrates a limited capacity of TTE to detect vegetations. TEE may be an appropriate initial study to evaluate prosthetic valves. TEE for culture-negative endocarditis deserves further study.

High Resolution Speckle Tracking Dobutamine Stress Echocardiography Reveals Heterogeneous Responses in Different Myocardial Layers: Implication for Viability Assessments - Corrected Proof

2010-02-08

Background: Speckle-tracking echocardiography (STE) can be used to quantify wall strain in 3 dimensions and thus has the potential to improve the identification of hypokinetic but viable myocardium on dobutamine stress echocardiography (DSE). However, if different myocardial layers respond heterogeneously, STE-DSE will have to be standardized according to strain dimension and the positioning of the region of interest. Therefore, the aim of this study was to create a high-resolution model for ejection time (ET) strain and tissue flow in 4 myocardial layers at rest, during hypoperfusion, and during dobutamine challenge to assess the ability of STE-DSE to detect deformation and functional improvement in various layers of the myocardium.Methods: In 10 open chest pigs, the left anterior descending coronary artery was constricted to a constant stenosis, resulting in 35% initial flow reduction. Fluorescent microspheres were used to measure tissue flow. High-resolution echocardiography was performed epicardially to calculate ET strain in 4 myocardial layers in the radial, longitudinal, and circumferential directions using speckle-tracking software. Images were obtained at rest, during left anterior descending coronary artery constriction (hypoperfusion), and during a subsequent dobutamine stress period.Results: Dobutamine stress at constant coronary stenosis increased flow in all layers. ET strain increased predominantly in the midmyocardial layers in the longitudinal and circumferential directions, whereas subendocardial strain did not improve in either direction.Conclusion: Dobutamine stress influences ET strain differently in the various axes and layers of the myocardium and only partially in correspondence to tissue flow. Longitudinal and circumferential functional reserve opens the potential for the specific detection of midsubendocardial viable tissue by high-resolution STE.

Contrast Guided Two-Dimensional Echocardiography for Needle Localization During Pericardiocentesis: A Case Report - Corrected Proof

Jeffrey M. Schussler, Paul A. Grayburn — 2010-02-01

The authors present a case of pericardial effusion that was percutaneously drained using agitated saline for echocardiographic contrast guidance. This technique can safely confirm the location of a pericardiocentesis needle in the pericardial space prior to tract dilation and insertion of the pericardial drainage catheter. In this instance, this technique prevented the inadvertent placement of the pericardiocentesis catheter in the right ventricle.

Supravalvar Mitral Ring With Complete Atrioventricular Septal Defect: A Case Report and Three-Dimensional Echocardiography Evaluation - Corrected Proof

Levi J. Novero, Eliot R. Rosenkranz, Richard E. Kardon — 2010-02-01

Supravalvar mitral ring (SVMR) is a rare cause of congenital mitral stenosis. It can occur in isolation but often coexists with other cardiac anomalies, such as a ventricular septal defect or left-sided obstructive lesions. Conversely, a complete atrioventricular septal defect (AVSD) is a much more common anomaly. An AVSD may be associated with other major cardiac defects, such as tetralogy of Fallot, transposition of the great arteries, or double-outlet right ventricle. The authors describe what they believe is the first case of SVMR and complete AVSD occurring together; the SVMR was diagnosed by two-dimensional echocardiography, and its morphology could be more accurately delineate using three-dimensional echocardiography.

Ventricular Septal Rupture and Right Ventricular Free Wall Dissection After Inferior Myocardial Infarction: A Case Report and Review of the Literature - Corrected Proof

Gernot Schram, Btissama Essadiqi, Michel Doucet, Denis Bouchard, Robert Amyot — 2010-01-27

Ventricular septal rupture (VSR) with dissection of the right ventricular free wall is an extremely rare complication after inferior myocardial infarction. Mortality is 100% without surgical treatment. The optimal surgical strategy remains unclear because of the limited number of cases, but repair of VSR alone might be equally effective as repair of VSR and right ventricular free wall reconstruction. Transesophageal echocardiography is an important adjunct to transthoracic echocardiography to establish the diagnosis.

Are All Ventricular Septal Defects Created Equal? - Corrected Proof

Daniela Lax, Rajan D. Bhatt, Scott E. Klewer, Vincent L. Sorrell — 2010-01-25

The authors report the occurrence of infective endocarditis in a 32-year-old man with a ventricular septal defect and a left ventricular–to–right-atrial shunt who adhered to the revised 2007 American Heart Association guidelines for infective endocarditis. The patient had received antibiotic prophylaxis prior to multiple previous dental procedures. At a recent dental evaluation for fillings, he was informed that he no longer needed prophylaxis. Fatigue and fevers developed 1 week later, and he was treated with an oral course of ciprofloxacin. The symptoms recurred, and blood cultures grew Streptococcus viridans. A 7-mm vegetative mass was seen on the septal leaflet of the tricuspid valve during transesophageal echocardiography. This report raises the concern that patients with ventricular septal defects and left ventricular–to–right-atrial shunts are at higher risk for endocarditis and may require antibiotic prophylaxis.

Real-Time Three Dimensional Echocardiography in the Postoperative Follow-Up of Type-A Aortic Dissection—A Case Report - Corrected Proof

2009-12-04

Aortic dissection is a fearful complication with extremely high mortality in young patients with Marfan syndrome. Successful aortic emergency surgery increases the life expectancy of these patients, yet it does not prevent disease progression and late complications. Therefore, long-term imaging follow-up of both reconstructed and chronically dissected aortic segments is mandatory. This case report illustrates the potential role of real-time three-dimensional echocardiography as a supplement to conventional postoperative follow-up in aortic dissection that provides valuable spatial and functional information.

Coronary Sinus Obstruction by Primary Cardiac Lymphoma as a Cause of Dyspnea Due to Significant Diastolic Dysfunction and Elevated Filling Pressures - Corrected Proof

2009-12-04

A 52-year-old woman presented with severe dyspnea of 2 weeks' duration. Echocardiography showed an enlarged left atrium but normal global left ventricular systolic function. However, a huge, irregularly shaped mass at the dilated coronary sinus that extended into the right atrium was noted. Mitral inflow showed restrictive physiology and the E/E' ratio was significantly elevated, suggesting elevated left ventricular filling pressures. Echocardiography-guided biopsy was performed, and a diagnosis of primary cardiac lymphoma (diffuse large B-cell type) was made. After the first cycle of chemotherapy, the patient's symptom was markedly improved. A follow-up echocardiogram showed complete removal of the mass and a change in left ventricular filling pattern from restrictive to relaxation abnormality with decreased E/E'. The present case demonstrates a rare cause of diastolic dysfunction due to coronary sinus obstruction by tumor infiltration. Diastolic dysfunction caused by coronary sinus obstruction was improved after the tumor was resolved by chemotherapy.

Echocardiographic Features of Double-Outlet Right Atrium and Straddling Tricuspid Valve with Intact Ventricular Septum: A Rare Cardiac Anomaly Associated with Pulmonary Atresia and Single Coronary Artery Ostium - Corrected Proof

Rebecca S. Beroukhim, Tal Geva — 2009-11-12

Double-outlet right atrium is a rare congenital cardiac anomaly previously described in association with atrioventricular canal defect. Straddling tricuspid valve is another uncommon anomaly that is almost always associated with a ventricular septal defect. We report the echocardiographic features of a newborn with double-outlet right atrium associated with pulmonary atresia, intact ventricular septum, and right coronary artery ostial atresia. Alternatively, the anatomy can be interpreted as straddling tricuspid valve with intact ventricular septum. The echocardiographic findings were confirmed by cardiac catheterization.

A Right Atrial Mass, Patent Foramen Ovale, and Indwelling Central Venous Catheter in a Patient With a Malignancy: A Diagnostic and Therapeutic Dilemma - Corrected Proof

2009-11-02

A 33-year-old woman with a history of gestational trophoblastic disease presented for investigation of a right atrial mass. She had been receiving chemotherapy administered via a Port-a-Cath system for 2 months prior to presentation. On transesophageal echocardiography and magnetic resonance imaging, she was found to have a mass attached to the right atrial free wall, with a segment projecting across a patent foramen ovale. Because of the risk for an embolic event, the mass was surgically removed and the patent foramen ovale repaired. Pathology showed an organized thrombus. This case emphasizes the need for high suspicion for thrombus when a right atrial mass is found in a patient with a hypercoagulable state due to underlying malignancy who has a central venous catheter.

An Unusual Case of Dissecting Aneurysms Involving Both Coronary Sinuses of Valsalva - Corrected Proof

Ravi S. Math, Anita Saxena, Praloy Chakraborty, Srikrishna M. Reddy, A. Bisoi — 2009-11-02

A 16-year-old boy with a progressive history of dyspnea and palpitations was diagnosed to have rupture of the right and left coronary sinuses on transthoracic echocardiography. The right coronary sinus had ruptured and dissected into the interventricular septum from its base up to the left ventricular apex and all around the lateral wall of the left ventricle up to the base of the papillary muscles. The left coronary sinus was also ruptured, and the rupture was contained by a false aneurysm that dissected into the roof of the left atrium from the aortomitral intervalvular fibrosa. The involvement of multiple coronary sinuses is extremely rare.

Incidental Finding by Two-Dimensional Echocardiography of a Mycotic Pseudoaneurysm of the Ascending Aorta After Orthotopic Heart Transplantation - Corrected Proof

Federico Ronco, Sinan Simsir, Lawrence Czer, Huai Luo, Robert J. Siegel — 2009-11-02

Mycotic pseudoaneurysm of the ascending aorta is a rare and potentially fatal complication of cardiac surgery, particularly in immunosuppressed heart transplantation patients. In this case, a 70-year-old man who underwent heart transplantation 4 months earlier was incidentally found to have a large pseudoaneurysm of the ascending aorta at the level of the aortic suture line. Surgical repair of the pseudoaneurysm was undertaken, and cultures from the pseudoaneurysm were found to be positive for Aspergillus fumigatus.

Diagnosis of Inferior Sinus Venosus Atrial Septal Defects Using Transthoracic Three-Dimensional Echocardiography - Corrected Proof

2009-10-15

The authors report the cases of 2 patients with symptoms and signs related to severe pulmonary hypertension. Two-dimensional echocardiography demonstrated defects in the posterior portion of the atrial septum. Transthoracic three-dimensional echocardiography clearly showed inferior sinus venosus atrial septal defects and their relationships with the inferior vena cava, the pulmonary vein, and the muscular border of the fossa ovalis. These 2 cases not only elucidate the potential value of transthoracic three-dimensional echocardiography in delineating the structural characteristics of unusual interatrial shunting but also remind clinicians to be aware of this potentially treatable cardiac defect during workup for pulmonary hypertension.