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An Additional Structure in the Left Atrium in a Patient Undergoing Aortic Valve Replacement: Artifact or Something Else?
A 68-year-old, 42- kg, 149- cm woman presented with chief complaints of dyspnea and palpitations of 4 months' duration. Transthoracic echocardiography revealed severe aortic stenosis due to bicuspid aortic valve disease, with peak and mean gradients of 125 and 85 mmHg, respectively. Coronary angiography was normal. She denied a history of syncopal episodes, transient ischemic attack, or cerebrovascular accident. She was afebrile. Normal sinus rhythm was present. Transesophageal echocardiography (TEE) performed before cardiopulmonary bypass confirmed the preoperative diagnosis.Assessment of the MitraClip Procedure: Reassessing the Goals
THE MITRACLIP (Abbott Laboratories) was first implanted in 2003, was approved in Europe in 2008, and approved by the US Food and Drug Administration in 2013. The MitraClip procedure has reduced hospitalization and mortality compared to medical therapy, with either improved or similar outcomes compared with isolated mitral valve surgery.1-3 In the earlier and preliminary data, proponents of surgery highlighted less mitral regurgitation (MR) and fewer additional procedures after surgical correction of MR; however, the overall major cardiac adverse events were significantly lower (15% v 48%) for percutaneous procedures.A Rare Shunt
A 12-DAY-OLD girl (weight: 3 kg; height: 50 cm) presented to the authors’ institution in respiratory distress. The child was tachypneic (70 breaths/min), with an arterial oxygen saturation of about 65%-to- 70% on 3 L/min oxygen flow through a nasal cannula, and had signs of severe heart failure (Fig 1). Transthoracic echocardiography revealed situs solitus, levocardia, atrioventricular and ventriculoarterial concordant connections, normal systemic and pulmonary venous drainage, membranous pulmonary atresia, and an intact ventricular septum.Large Mass in the Left Atrium: The Usual Myxoma or Another Common Etiology?
A 64-YEAR-OLD, 82-kg, 183-cm man with heart failure with reduced ejection fraction and a remote history of coronary artery bypass graft surgery, mitral valve replacement, left atrial appendage ligation, and chronic atrial fibrillation treated with warfarin presented to the authors’ institution with worsening dyspnea on exertion, fatigue, and orthopnea. He denied chest pain, fever, chills, and palpitations. The physical examination revealed tachycardia and bilateral pitting edema in the lower extremities.Where Should We Leave the Wild “Raa Raa” During Cardiopulmonary Bypass?
THE PULMONARY artery catheter (PAC), the Raa Raa, the noisy, wild lion in a British stop-motion animated children's television program1 (Fig 1), also known as the Swan-Ganz catheter, is used frequently during cardiac surgery. The PAC might provide clinicians with important information on the preload, afterload, and contractility through the measured and derived parameters for risks stratification and guide perioperative management, particularly in patients with advanced heart failure, pulmonary hypertension, cardiogenic shock, and those who undergo heart and lung transplantation and left ventricular assist device implantation.A Five-Leaf Clover or an Exceptionally Rare Cause of Severe Aortic Insufficiency?
A 56-YEAR-old, 68- kg, 165- cm woman with a history of Crohn's disease presented to the authors’ institution with dyspnea and exercise intolerance of several months’ duration. More recently, her symptoms had progressed to occasional dyspnea at rest. She denied fever, chills, chest pain or pressure, palpitations, orthopnea, paroxysmal nocturnal dyspnea, syncope, and peripheral swelling. The physical examination was notable for a grade III of VI holodiastolic murmur. The electrocardiogram and laboratory analysis were noncontributory.Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients
A paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19.A New-Onset Mass in the Right-Sided Atrium in a Child After Cardiac Surgery: Unravelling the Diagnosis
A 2-year-old girl (weight: 9 kg, height: 82 cm) underwent an intracardiac repair. Preoperative transthoracic echocardiography revealed situs solitus, levocardia, left atrial isomerism, common atrium due to a large atrial septal defect, absent coronary sinus, 2 separate atrioventricular valves with a trivial left atrioventricular valve regurgitation due to a cleft in the anterior leaflet, and a dilated right ventricle with flattening of the interventricular septum due to volume overload (Fig. 1).Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study
The objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion.Porcine Orthotopic Cardiac Xenotransplantation: The Role and Perspective of Anesthesiologists
ON JANUARY SEVENTH, 2022, the first genetically modified porcine cardiac xenograft was transplanted into a patient at the University of Maryland Medical Center. As members of the xenotransplant team and division of cardiac anesthesiology at the University of Maryland School of Medicine, the authors here had a role in this historic event. Cardiac xenotransplantation could become a common occurrence if it proves to be a viable answer for the limited supply of donor hearts to treat end-stage heart failure.A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Failure
A 19-YEAR-OLD, 96 KG, 175 cm previously healthy man with COVID-19 pneumonia, sepsis, and adult respiratory distress syndrome was transferred from a community hospital to the authors’ institution for treatment with extracorporeal membrane oxygenation (ECMO). The patient had persistent hypoxemia and hypotension despite optimal mechanical ventilation and high-dose vasoactive drug support. He was cannulated for femoral-femoral venoarterial (VA) ECMO shortly after arrival in the intensive care unit. This intervention initially improved the patient's oxygenation and reduced his vasopressor requirements, but hypoxemia and hypotension recurred concomitant with ECMO suction events and reduced flow rates that were only transiently responsive to volume resuscitation and flow adjustment.Atrial Embolization after a Transcatheter Mitral Valve Replacement
MITRAL REGURGITATION (MR) IS the most prevalent form of valve disease, affecting about 10% of people over the age of 75 years and is associated with increased mortality.1,2 Management is dependent on the cause, pathophysiology, and predicted treatment efficacy. Although the historic gold standard for disease refractory to medical therapy is valve repair or replacement, over the last decade several transcatheter strategies have emerged, providing less invasive alternative options to elderly and frail patients at high risk for cardiac surgery.Aortic Valve Repair Using HAART 300 Geometric Annuloplasty Ring: A Review and Echocardiographic Case Series
Aortic valve repair (AVr) aims to preserve the native aortic leaflets and restore normal valve function. In doing so, AVr is a more technically challenging approach than traditional aortic valve replacement. Some of the complexity of repair techniques can be attributed to the unique structure of the functional aortic annulus (FAA), which, unlike the well-defined mitral annulus, is comprised of virtual and functional components. Though stabilizing the ventriculo-aortic junction (VAJ), a component of the FAA, is considered beneficial for patients with chronic aortic insufficiency (AI), the ideal AVr technique remains a subject of much debate.Dyspnea Declare Yourself! Decoding Doppler
AN APPRECIATION of the utility of echocardiographic Doppler spectral profile analysis in diagnosing cardiac pathology and guiding surgical intervention more than justifies an investment in obtaining proficiency in these skills. Given the relatively low incidence of significant complications associated with transesophageal echocardiographic examination, the facile use of both spectral and color Doppler principles to diagnose unusual pathology is essential. Doppler modalities are used to characterize blood flow, pressure gradients, chamber dimensions, and other anatomic and physiological parameters.Garden-Hose Mitral Regurgitation: A Variant That Can Result in Underestimation of Severity: A Multimodality Imaging Case Study
The quantitative assessment of mitral regurgitation (MR) by echocardiography has limitations. Cardiac magnetic resonance (CMR) imaging has an emerging role in the quantitation of MR, and preliminary studies indicate that CMR assessment may more accurately quantify MR and better correlate with postsurgical left ventricular reverse remodeling. The authors here report a case of MR in which multimodality imaging with CMR and transesophageal echocardiography was crucial in accurately diagnosing the severity of MR when transthoracic and provocative supine bike echocardiography underestimated the degree of MR in a unique variant known as “garden-hose” MR.Acute Cardiointestinal Syndrome Resulting From Postoperative Acute Biventricular Heart Failure
ACUTELY DECOMPENSATED HEART FAILURE (HF), if left untreated, causes organ hypoperfusion that can progress to irreversible and life-threatening multiorgan dysfunction. Cardiointestinal syndrome (CIS) is the result of both persistent venous congestion and hypoperfusion of the intestines as a result of biventricular HF.1 These mechanisms contribute to perturbations in normal intestine function that ultimately result in intestinal bacteria product translocation into the bloodstream.2 This translocation causes inflammatory cytokine production and sepsis, which depress myocardial function and eventually lead to biventricular heart failure, multiorgan failure, and death.Prospective Observational Trial of a Nonocclusive Dilatation Balloon in the Management of Tracheal Stenosis
TRACHEAL STENOSIS is a debilitating condition that is difficult to treat, requires multidisciplinary management, and yet often presents with severe respiratory compromise requiring urgent intervention. Emergency tracheostomy may be life-saving but impacts future definitive management by tracheal resection and reconstruction (TRR).1,2 Although considered the gold standard for the management of tracheal stenosis, TRR requires a high level of resources and still is associated with a significant rate of failure and restenosis.Is It a Residual Ventricular Septal Defect?
A 1-YEAR-OLD BOY (weight, 7.4 kg; height, 67 cm), with Trisomy 21 and a diagnosis of complete atrioventricular septal defect with tetralogy of Fallot, presented to the author's institution for intracardiac repair. Transthoracic echocardiography reported an ostium primum atrial septal defect, a nonrestrictive inlet-type ventricular septal defect, and anterosuperior deviation of the infundibular septum with a severe right ventricular outflow tract obstruction (peak pressure gradient of 75 mmHg). Intraoperative transesophageal echocardiography confirmed the findings (Fig.Assessing Skill Acquisition in Anesthesiology Interns Practicing Central Venous Catheter Placement Through Advancements in Motion Analysis
The study authors hypothesized that a combination of previously used (path length, translational motions, and time) and novel (rotational sum) motion metrics could be used to analyze learning curves of anesthesiology interns (postgraduate year 1) practicing central venous catheter placement in the simulation setting. They also explored the feasibility of using segmented motion recordings to inform deliberate practice.Mitral Regurgitation in Obstructive Hypertrophic Cardiomyopathy: Systolic Anterior Motion or a More Unusual Cause?
A 52-YEAR-OLD, 100-kg, 191-cm transitioned woman, receiving hormonal therapy, with a history of hypertension, hyperlipidemia, tobacco abuse, and known coronary artery disease, presented to a community hospital with recurrent chest pain and dyspnea. An electrocardiogram demonstrated new ST-segment elevation consistent with an anterior wall myocardial infarction. The patient was taken to the cardiac catheterization laboratory where drug-eluting stents were implanted in the left anterior descending and diagonal coronary arteries.Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With Endocarditis
A 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe aortic insufficiency presented to the authors’ institution with a 3-day history of “pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling. The patient previously was hospitalized on several occasions for the treatment of recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the treatment of a cephalic vein thrombosis. The physical examination was notable for sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard best at the left sternal border, bilateral lower extremity pitting edema, and red petechiae on both hands and feet.Third Atrial Chamber
A 10-MONTH-OLD BOY (weight: 5.8 kg; height: 66 cm; body mass index: 13) was taken to the cardiac catheterization laboratory before the creation of a bidirectional Glenn shunt. At 4 days of age, transthoracic echocardiography done for the evaluation of persistent cyanosis revealed heterotaxy (left atrial isomerism), situs ambiguous with levocardia, bilateral superior vena cava, atrial septal defect (9 mm), partial anomalous right pulmonary venous return to the morphologic right atrium, discordant atrioventricular connection and concordant ventriculoarterial connection, with a hypoplastic right ventricle.Dilated Coronary Sinus: The Usual Persistent Left Superior Vena Cava or a Less Common Etiology?
AN 84-YEAR-OLD MAN, 70 kg, 183 cm, with hypertension and left ventricular hypertrophy, presented to the authors’ institution with a history of progressive shortness of breath and abdominal distention. A large amount of ascites was present, necessitating biweekly paracentesis. The patient's functional capacity had significantly deteriorated. He described severe dyspnea associated with bending forward and standing from a sitting position. The physical examination was notable for cachexia, a grade- 3 holosystolic murmur heard best at the lower left sternal border, and a pulsating right upper quadrant.A Case of Transient Mitral Regurgitation: Not Everything Is Always What It Seems
Mitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and mortality. MR can be broadly classified into 2 different categories: primary and secondary MR. Primary MR usually is caused by leaflet abnormalities, whereas secondary MR is a chronic disease secondary to geometric distortion of both the annulus and subvalvular apparatus because of left ventricular remodeling. Without acute changes in loading conditions, myocardial blood flow, or rhythm disturbances, functional MR typically is not transient.Paravalvular Leak After Mitral Valve Replacement or Another Source for a Regurgitant Jet?
A 73-YEAR-OLD man (height: 169 cm, weight: 55kg), with a history of mitral valve repair, tricuspid annuloplasty, and Maze procedure, presented to the authors' emergency department with an 8-day history of profound fatigue. Multiple blood cultures grew Streptococcus dysgalactiae. Transesophageal echocardiography (TEE) showed vegetations on the anterior mitral valve leaflet and mild-to-moderate mitral regurgitation. He was started on intravenous antibiotics (ampicillin and clindamycin) for a diagnosis of infectious endocarditis, but he did not improve.
