Journal of the American Society of Echocardiography - Articles in Press

Anomalies Associated With a Prominent Azygos Vein on Echocardiography in the Pediatric Population - Corrected Proof

Rajesh Punn, Inger Olson — 2010-02-08

Background: Prominent azygos veins (PAVs) have been described with interrupted inferior venae cavae (IVCs) with heterotaxy. At the authors' institution, cases of PAVs with uninterrupted IVCs have been noted. The aim of this study was to determine the occurrence rate of PAVs and associated lesions by echocardiography.Methods: All patients with PAVs were collected; those with interrupted and uninterrupted IVCs were assigned to groups 1 and 2. Normal controls were assigned to group 3.Results: Among 15,849 patients from January 1, 2001, to March 31, 2008, 55 (0.3%) had PAVs, 42 (76%) in group 1 and 13 (24%) in group 2. Heterotaxy was prominent in group 1, whereas patients in group 2 had no heterotaxy. Patients in group 2 had more structurally normal hearts than those in group 1 (46% vs 14%, P < .01), partial anomalous pulmonary venous return, and one single ventricle. IVC measurements were the same in groups 2 and 3 (P = .65).Conclusions: This study demonstrates that a PAV without IVC interruption is not associated with heterotaxy. Patients with PAVs should be carefully examined for partial anomalous pulmonary venous return.

Chromosomal Abnormalities and Neuromuscular Disorders Predict Severity and Outcome of Noncompaction in Addition to Cardiac Comorbidities - Corrected Proof

Claudia Stöllberger, Josef Finsterer — 2010-02-08

To the Editor: The following questions and concerns need to be answered to put Punn and Silverman's findings in perspective.

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.

Left Atrial Electromechanical Conduction Time Can Predict Six-Month Maintenance of Sinus Rhythm After Electrical Cardioversion in Persistent Atrial Fibrillation by Doppler Tissue Echocardiography - Corrected Proof

2010-02-08

Background: The purpose of this study was to determine whether atrial electromechanical conduction time (EMT) measured by echocardiography can predict 6-month maintenance of sinus rhythm (SR) after electrical cardioversion in patients with atrial fibrillation (AF).Methods: Fifty-three patients with persistent AF (>1 month) who had successful cardioversion and 30 controls with SR were prospectively enrolled. SR maintenance was assessed during 6-month follow-up. EMT was measured as the time interval from the onset of the P wave on electrocardiography to the peak of the late diastolic wave from the septal and lateral mitral annulus (EMT-S and EMT-L, respectively) and the lateral tricuspid annulus (EMT-T) on tissue Doppler echocardiography.Results: Compared with controls, left atrial (LA) volume index, P-wave duration, and EMT were significantly larger in patients with AF (all P values < .001). In patients with AF, the duration of AF (P = .71) and P-wave duration (P = .24) were not different between the SR maintenance group (n = 23) and the AF recurrence group (n = 30), and there was a trend toward increased LA volume index in the AF recurrence group (47.0 ± 12.4 vs 45.3 ± 12.6 mL/m2, P = .07). EMT-S and EMT-L were significantly larger in the AF recurrence group (131.4 ± 20.9 vs 116.3 ± 15.5 ms, P = .005, and 152.2 ± 15.7 vs 128.9 ± 13.8 ms, P < .001, respectively), but not EMT-T. EMT-S and EMT-L were related to LA volume index (r = .36, P = .008, and r = .33, P = .02, respectively). On multivariate logistic regression analysis, only EMT-L was an independent predictor of identifying patients who remained in SR (P < .001), and the sensitivity and specificity for the prediction of 6-month maintenance of restored SR were 82.6% and 83.3% using a cutoff value of EMT-L ≤ 138.0 ms (odds ratio, 0.862; 95% confidence interval, 0.788-0.942; P = .001).Conclusion: LA EMT was significantly prolonged in patients with recurring AF, indicating significantly depressed atrial conduction in enlarged LA, and can predict 6-month maintenance of SR after electrical cardioversion.

Reliability of Visual Assessment of Global and Segmental Left Ventricular Function: A Multicenter Study by the Israeli Echocardiography Research Group - Corrected Proof

2010-02-08

Background: The purpose of this multicenter study was to determine the reliability of visual assessments of segmental wall motion (WM) abnormalities and global left ventricular function among highly experienced echocardiographers using contemporary echocardiographic technology in patients with a variety of cardiac conditions.Methods: The reliability of visual determinations of left ventricular WM and global function was calculated from assessments made by 12 experienced echocardiographers on 105 echocardiograms recorded using contemporary echocardiographic equipment. Ten studies were reread independently to determine intraobserver reliability.Results: Interobserver reliability for visual differentiation between normal, hypokinetic, and akinetic segments had an intraclass correlation coefficient of 0.70. The intraclass correlation coefficient for dichotomizing segments into normal versus other abnormal was 0.63, for hypokinetic versus other scores was 0.26, and for akinetic versus other scores was 0.58. Similar results were found for intraobserver reliability. Interobserver reliability for WM score index was 0.84 and for left ventricular ejection fraction was 0.78. Similar values were obtained for the intraobserver reliability of WM score index and ejection fraction. Compared to angiographic data, the accuracy of segmental WM assessments was 85%, and correct determination of the culprit artery was achieved in 59% of patients with myocardial infarctions.Conclusion: Among experienced readers using contemporary echocardiographic equipment, interobserver and intraobserver reliability was reasonable for the visual quantification of normal and akinetic segments but poor for hypokinetic segments. Reliability was good for the visual assessment of global left ventricular function by WM score index and ejection fraction.

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.

Prospective Assessment of Fetal Cardiac Function With Speckle Tracking in Healthy Fetuses and Recipient Fetuses of Twin-to-Twin Transfusion Syndrome - Corrected Proof

2010-02-08

Background: The aim of this study was to assess speckle tracking–derived fetal cardiac function in a normal population and in recipient fetuses of twin-to-twin transfusion syndrome (TTTS).Methods: A case-control study was conducted of 59 uncomplicated singleton pregnancies and 17 recipient fetuses of TTTS. Peak systolic strain, strain rate, velocity, and displacement were calculated, corrected for gestational age, and compared between patients with TTTS and controls.Results: The feasibility of speckle tracking was 83% in controls but only 61% in patients with TTTS. Myocardial velocity and displacement increased over gestation, and regional differences were present within each wall and between walls. Strain and strain rate were stable within each wall but were higher in the right ventricle than in the left ventricle and septum. Right ventricular strain was decreased in patients with TTTS compared with controls (0.75 ± 0.34 vs 1.00 ± 0.37 multiples of the median, P = .04).Conclusion: The feasibility of speckle tracking is low when imaging conditions are challenging, but it can identify right ventricular failure in selected patients with TTTS.

Sequential Changes of Longitudinal and Radial Myocardial Deformation Indices in the Healthy Neonate Heart - Corrected Proof

2010-02-08

Background: Significant hemodynamic changes, including preload and afterload modifications, occur during the transition from the fetal to the neonatal environment. The ductus arteriosus closes, pulmonary vascular resistance decreases, and pulmonary blood flow increases. Strain rate (SR) and strain (ε) have been proposed as ultrasound indices for quantifying regional wall deformation. This study was designed to determine if these indices can detect variations in regional deformation between early and late neonatal periods.Methods: Data were obtained from 30 healthy neonates (15 male). The initial study was performed at a mean age of 20.1 ± 14 hours (exam 1) and the second at 31.9 ± 2.9 days (exam 2). Apical and parasternal views were used to quantify regional left ventricular (LV) and right ventricular (RV) longitudinal and radial SR and ε, and systolic, early, and late diastolic values were calculated from these curves. A paired-samples t test was performed comparing the two groups.Results: Compared with exam 1, LV radial deformation showed significant reductions in peak systolic ε in the basal and mid segments (51 ± 15% vs 46 ± 9%, P < .01). LV longitudinal deformation behaved similarly, showing significant peak systolic ε reductions in all measured segments. Systolic SR showed reductions only in the basal and apical segments of the lateral wall and in the mid portion of the inferior wall (−1.9 ± 0.5 vs −1.7 ± 0.3 s−1 and −1.9 ± 0.4 vs −1.7 ± 0.2 s−1, respectively, P = .03). RV longitudinal free and inferior wall systolic SR and ε values were significantly higher in exam 2.Conclusions: LV peak systolic ε decreases in exam 2 were possibly due to afterload increase and preload decrease. The lower RV initial deformation indices could be attributed to increased afterload caused by physiologic pulmonary hypertension or immature RV contractile properties. SR seemed to be a more robust index than ε and less influenced by preload and afterload hemodynamic alteration.

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.

The Relative Atrial Index (RAI)—A Novel, Simple, Reliable and Robust Transthoracic Echocardiographic Indicatory of Atrial Defects - Corrected Proof

2010-01-25

Background: The detection of atrial septal defects (ASDs) and other shunts is sometimes difficult on transthoracic echocardiography. In addition, the quantitative assessment of right-heart volume loading as an indicator of significant shunting can be difficult, with subjective estimation commonly used. Thus, the initial aim of this study was to test the accuracy of a simple, noninvasive index using atrial area dimensions to detect the presence of an ASD. Subsequently, the index was used to assess the degree of normalization and remodeling of atrial size following percutaneous ASD device closure.Methods: The relative atrial index (RAI) was derived from standard apical 4-chamber views as right atrial area divided by left atrial area. RAI was calculated in patients with previously diagnosed secundum atrial defects (n = 219) with no concomitant lesions and then compared with those calculated in age-matched controls (n = 219). 101 of the 219 patients with secundum atrial defects underwent percutaneous device closure. Measurements were obtained before and 1 day after percutaneous closure as well as in the early (mean, 124 days) and late (mean, 390 days) stages of follow-up.Results: The mean RAI in patients with ASDs (1.23 ± 0.23) was significantly higher than that in the age-matched normal control group (0.78 ± 0.1) (P < .0001). The mean RAI in patients with ASD was also significantly higher than that in the general population (0.81 ± 0.15) (P < .0001). Receiver operating characteristic curve analysis suggested that a nominal RAI cutoff value of >0.92 predicted patients with ASDs versus matched controls with 99.1% sensitivity and 90.5% specificity. After percutaneous closure, significant atrial remodeling occurred immediately, with a reduction in the mean RAI at day 1 to 0.93 ± 0.16 (P < .0001) and complete normalization at early follow-up to 0.81 ± 0.12.Conclusion: The RAI, a novel and simple transthoracic parameter, reliably identifies patients with possible atrial shunting. The resolution of right atrial enlargement occurs remarkably early after percutaneous ASD closure, as demonstrated by this novel parameter.

Normal Rotational, Torsion and Untwisting Data in Children, Adolescents and Young Adults - Corrected Proof

2010-01-25

Background: Left ventricular (LV) torsion and untwisting are important components of LV performance, but there is little information on the effect of age, particularly in younger populations.Methods: LV rotation and LV rotation rate, torsion, recoiling, and untwisting were measured in normal subjects (n = 111) aged 3 to 40 years (mean age, 19.3 years) using speckle-tracking imaging.Results: LV torsion increased with age because of the augmentation of apical LV rotation, but this disappeared when normalized by LV length. Although peak LV torsion and apical LV rotation increased with age, the normalized peak torsion rate decreased. As well, the peak untwisting rate decreased with age and was enhanced when normalized by LV length. Younger hearts demonstrated greater untwisting and recoiling of the apex during isovolumic relaxation and early diastole. The time difference between apical and basal events decreased with advancing age.Conclusion: The heart maintains a constant LV torsion and LV rotation profile when normalized by length and cardiac cycle. Younger hearts tend to twist, untwist, and deform faster.

Ventricular Rotation Is Independent of Cardiac Looping: A Study in Mice With Situs Inversus Totalis Using Speckle-Tracking Echocardiography - Corrected Proof

2010-01-25

Background: The authors conducted an ultrasound interrogation of a mutant mouse model with a Dnah5 mutation to determine whether cardiac mechanics may be affected by reversal of cardiac situs. This mutant is a bona fide model of primary ciliary dyskinesia, with surviving homozygous mice showing either situs solitus (SS) or situs inversus totalis (SI).Methods: High-frequency ultrasound interrogations of 27 neonatal and infant Dnah5 mutant mice, 16 with SS and 11 with SI, were conducted using an ultra-high-frequency biomicroscope. Electrocardiographic and respiratory gating were used to reconstruct high-resolution two-dimensional cines at 1,000 Hz, with speckle-tracking echocardiography used to further analyze midchamber and apical rotation.Results: All SS mice exhibited the expected counterclockwise apical rotation as viewed caudocranially, and surprisingly, the same counterclockwise motion was also observed in SI mice. Speckle-tracking analysis confirmed counterclockwise systolic rotation in both SS and SI mice, and this increased in magnitude from the subepicardium to the endocardium and from the papillary muscles to the apex. The magnitude of apical endocardial rotation was not different for SS and SI mice (5.64 ± 0.75° and 5.76 ± 1.90°, respectively, P = .93). The anatomic segments responsible for the largest components of apical endocardial systolic rotation differed between the SS and SI hearts (P = .004). In both, the two largest contributors to rotation were offset 180° from each other, but the anatomic regions differed between them. In SS hearts, maximal regional rotation occurred at the anterior mid-septum and posterolateral free wall, while in SI hearts, it was derived from the posterior septum and the anterolateral free wall. Analysis by episcopic fluorescence image capture histology of representative SI and SS mice showed normal intracardiac and segmental anatomy ({S,D,S} or {I,L,I}) without intracardiac defects.Conclusions: These results show that mirror-image cardiac looping did not result in mirror-image rotation of the morphologic left ventricle. These findings suggest that further studies are warranted to evaluate whether fiber orientation and cardiac mechanics may be abnormal in individuals with reversal of cardiac situs. The results of this study indicate that cardiac looping and myofiber orientation may be independently regulated.

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.

Application of the Appropriateness Criteria for Echocardiography in an Academic Medical Center - Corrected Proof

2010-01-18

Background: The authors examined the feasibility of application of the American College of Cardiology Foundation's appropriateness criteria for transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) at a large tertiary care practice.Methods: Indications for consecutive TTE and TEE were determined by chart review and classified according to the guidelines as appropriate, inappropriate, or uncertain or, for situations not addressed in the document, nonclassifiable.Results: Of the 529 studies reviewed, 469 were appropriate, 23 inappropriate, 1 uncertain, and 36 nonclassifiable. Inappropriate and nonclassifiable studies were more commonly TTE than TEE (P < .001). Inappropriate studies were more common in outpatients than inpatients (P < .001). Nonclassifiable cases included assessment after radiofrequency ablation (33.3%) and preoperative evaluation (8.3%). Disagreement between observers in selection of the criterion was present in 30.8%.Conclusions: Although the study was conducted retrospectively, only 4.7% of classifiable studies were inappropriate. The reproducibility of classification was moderate, and 6.8% of studies were not classifiable. Areas for improvement of the criteria were identified.

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.

Isolated Tricuspid Valve Libman-Sacks Endocarditis and Valvular Stenosis: Unusual Manifestations of Systemic Lupus Erythematosus - Corrected Proof

Ali Reza Moaref, Sasan Afifi, Sheema Rezaian, Gholam Reza Rezaian — 2009-10-16

The most common valves involved in systemic lupus erythematosus are the mitral and aortic valves. Although isolated tricuspid valve involvement is quite rare, the authors report such a case. A 42-year-old woman presented with exertional dyspnea and was found to have a cardiac murmur. Echocardiography showed a stenotic tricuspid valve with vegetations on all 3 cusps. No other valvular vegetation could be detected. Concomitant tricuspid regurgitation was noted too. Blood culture results were negative. Clinical findings and serologic tests confirmed the diagnosis of systemic lupus erythematosus. The patient was successfully treated with prednisolone and hydroxychloroquine, and follow-up echocardiography showed the disappearance of the vegetations.

Intraoperative Stress Cardiomyopathy - Corrected Proof

Edward Gologorsky, Angela Gologorsky — 2009-10-15

The authors discuss and present transesophageal echocardiographic images of intraoperative tako-tsubo cardiomyopathy in a female patient under general anesthesia. Intraoperative transesophageal echocardiography was performed in an attempt to manage a sudden episode of hypotension and mild pulmonary edema coincidental with surgical incision. The suspected diagnosis of stress cardiomyopathy was confirmed by computed tomographic angiography and cardiac catheterization. The patient made a complete recovery. This case report stresses the utility of transesophageal echocardiography in the differential diagnosis of intraoperative hypotension and suspected acute coronary syndrome.

Systemic Air Embolization Originating from a Pleural Air Leak via a Left Ventricular Assist Device Cannula Anastomosis Site - Corrected Proof

2009-10-15

A patient presented with cardiogenic shock, and a left ventricular assist device (LVAD) was inserted. Transthoracic echocardiography demonstrated air in the left side of the heart whenever the patient coughed. A chest x-ray and computed tomography of the chest did not reveal a pneumothorax. Air appeared to enter the left atrium (LA) around the LA cannula. The working diagnosis was a right pleural tear with intermittent passage of air from the pleural space (supra-atmospheric during coughing) into the LA (around the cannula), which contained a large-bore LVAD cannula on -40 mm Hg suction. This was confirmed by inserting a right-sided chest drain, and no air appeared during coughing. This case demonstrates an unusual complication of LVAD use (systemic air embolization) and highlights the point of variable physiology during dynamic versus static imaging procedures.

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.

Double Mitral Valve Imaging - Corrected Proof

Ozcan Ozeke, Cemal Ozbakir, Emre Nuri Gunel — 2009-09-27

Double-orifice mitral valve is an uncommon anomaly of the mitral valve with a single fibrous annulus with 2 orifices opening into the left ventricle. Three major types of this anomaly are recognized: (1) the eccentric or hole type (accounting for about 85%), (2) the central or bridge type (about 15%), and (3) duplicate mitral valve, which involves 2 mitral valve annuli and valves, each with its own set of leaflets, commissures, chordae, and papillary muscles. However, some echocardiographic artifacts also may lead to interesting appearances. The duplicating of cardiac valves by refraction of the ultrasound beam or mirror images has rarely been reported. The authors present the duplication of a moving mitral valve associated with an echocardiographic refraction artifact.