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Noninvasive Assessment With Transthoracic Echocardiography in End-Stage Heart Failure
Heart failure is a common cardiac condition that carries a substantial risk of morbidity and mortality despite advances in management. Echocardiography plays a central role in its diagnosis, elucidation of mechanisms, and detailed hemodynamic analysis. In this E-Challenge, the authors review a few transthoracic echocardiographic findings that yield insights into the hemodynamics.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.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.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.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).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.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.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.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.Progressive Dyspnea and Exercise Intolerance Four Months After Left Ventricular Outflow Tract Radiofrequency Ablation for Frequent Premature Ventricular Contractions
A 52-year-old, 62-kg, 155-cm woman with essential hypertension and tobacco use disorder underwent left ventricular outflow tract (LVOT) radiofrequency ablation for frequent premature ventricular contractions (PVCs) after presenting to the emergency department following a near-syncopal episode associated with hypotension and atypical chest pain. Four months after the procedure, she returned to the electrophysiology clinic complaining of progressive dyspnea on exertion, worsening exercise intolerance, and orthostatic dizziness.Renal-Resistive Index for Prediction of Acute Kidney Injury in the Setting of Aortic Insufficiency
Acute kidney injury (AKI) is a common postoperative complication after cardiac surgery with cardiopulmonary bypass (CPB), and leads to significant morbidity, mortality, and cost. Although early recognition and management of AKI may reduce the burden of renal disease, reliance on serum creatinine accumulation to confidently diagnose it leads to a significant and important delay (up to 48 hours). Hence, a search for earlier AKI biomarkers is warranted. The renal-resistive index (RRI) is a promising early AKI biomarker that reflects intrarenal arterial pulsatility as reflected by the peak systolic and end-diastolic blood velocities divided by the peak systolic velocity.Multiple Color Doppler Flow Jets Into The Atria in a Child With Heterotaxy Syndrome
A nine-month-old girl (weight: 7.92 kg; height: 70 cm) was taken to the operating room for the creation of a bilateral bidirectional Glenn shunt and atrial septectomy. Patent ductus arteriosus stenting had been done when the child was four days old. Transthoracic echocardiography showed heterotaxy (left atrial isomerism) with situs inversus, discordant atrioventricular and concordant ventriculoarterial connections (ventricular ‘noninversion’), a large ventricular septal defect, membranous pulmonary atresia with a hypoplastic main pulmonary artery, confluent branch pulmonary arteries, aorta anterior and to the right of the pulmonary artery, and bilateral superior vena cava with no bridging vein.Myocardial Bridge or Something Else?
In this E-Challenge, the authors report on a patient with symptoms of exertional dyspnea and angina, scheduled to have surgical unroofing of an identified myocardial bridge (MB). An MB is very common in patients with hypertrophic cardiomyopathy (HCM). Intraoperative transesophageal echocardiography with provocative maneuvers revealed the patient had a systolic anterior motion of the mitral valve with septal contact and resulting outflow tract obstruction despite the notable absence of significant basal septal hypertrophy.A Retrocardiac Echolucency
A 92-year-old woman with a past medical history of hypertension and heart failure with preserved ejection fraction presented to the authors’ institution after a fall. She was found to have multiple rib fractures, with a right-sided pneumothorax and a pulmonary contusion. She was admitted for further monitoring, chest tube placement, and pain management. On the third day after admission, she became acutely hypotensive with worsening abdominal distention. Bedside transthoracic echocardiography (TTE) demonstrated a normal biventricular systolic function and a well-defined retrocardiac echolucency anterior to the descending thoracic aorta, which was suggestive of a localized pericardial effusion (Fig 1, A; Video 1).An Unusual Cause of Profound Tricuspid Annular Dilatation Resulting in Severe Regurgitation
A 69-YEAR-OLD, 69-kg, 178-cm man with hypertension, paroxysmal atrial flutter-fibrillation, heart failure with reduced ejection fraction, active substance use disorder (cocaine and marijuana), and a seven-year history of hemodialysis-dependent end-stage kidney disease presented to the authors’ institution for evaluation of atypical chest pain. The patient was treated with dialysis three times per week through a right brachiocephalic arteriovenous fistula (AVF). The patient described left-sided chest pain that occurred approximately three hours into each dialysis session that resolved when treatment was completed.A Mass in the Left Ventricular Outflow Tract After Mitral Valve Replacement
A 34-year-old woman presented with a four-year history of shortness of breath and dyspnea on exertion that had worsened over the preceding six months. The patient had a stroke two years before her current presentation but had no residual neurologic deficits. Transthoracic 2 two-dimensional echocardiography revealed severe mitral stenosis (peak/mean gradients = 21/14 mmHg), with a mitral valve area of 0.7 cm2 by the pressure-half time method, and calcific thickened mitral valve leaflets with commissural fusion and subvalvular thickening.
