Cause of profound hypoxemia following a bilateral bidirectional Glenn shunt: Clue suggested by agitated saline echo contrast

Following a bilateral bidirectional Glenn shunt, a child had persistent hypoxemia. Agitated saline contrast injection into the jugular vein during transesophageal echocardiography displayed a rapid appearance of saline particles in the cardiac chambers suggesting the presence of pulmonary arteriovenous malformations. However, the clinical picture was not in agreement and an angiographic contrast injection during an immediate cardiac catheterization revealed the underlying pathology which was immediately corrected surgically.

Use of Intracardiac Echocardiography to Evaluate Continuous-Flow Left Ventricular Assist Device Function in a Man With Obesity

Aortic insufficiency with recirculation can be difficult to diagnose echocardiographically in patients who have continuous-flow left ventricular assist devices. Transthoracic and transesophageal echocardiography can underestimate its severity; moreover, transesophageal echocardiography necessitates general anesthesia. We report the case of a 58-year-old man with obesity and end-stage nonischemic cardiomyopathy who, after 3 months of support with a continuous-flow left ventricular assist device, underwent intracardiac echocardiography to evaluate complications potentially associated with the device. The findings ruled out aortic insufficiency, preventing an unnecessary valvular intervention.

Application of transesophageal echocardiography in minimally invasive surgical closure of ventricular septal defects

We sought both to evaluate the clinical value of transesophageal echocardiography in minimally invasive surgical closure of ventricular septal defects and to evaluate the feasibility, safety, and efficacy of the surgical occlusion procedure. We selected 49 pediatric patients who had perimembranous ventricular septal defects as determined by preoperative transthoracic echocardiographic examination. After the patients were under general anesthesia, we used transesophageal echocardiography to determine the number of defects and their positions, shapes, and sizes, these last in order to choose the appropriate occluder. Under transesophageal echocardiographic monitoring and guidance, we introduced and deployed the occluder. The evaluation of therapy was performed by means of transesophageal echocardiography immediately after occluder release. All patients underwent follow-up transthoracic echocardiography within 2 to 5 postoperative days. Satisfactory occluder deployment was achieved in 38 patients. No death occurred. No occluder displacement or valve dysfunction was observed during the last transesophageal echocardiographic study. In addition, follow-up by transthoracic echocardiography showed improvement of left ventricular dimensions and ejection fractions. Our initial experience has been encouraging. Transesophageal echocardiography plays a crucial role in performing minimally invasive surgical closure of cardiac defects. It enables the feasible, safe, and effective closure of ventricular septal defects. However, larger sample sizes and longer-term follow-up are necessary for the accurate evaluation of this procedure's safety and effectiveness as an alternative to cardiopulmonary bypass surgery and transcatheter closure of congenital cardiac defects.

Echocardiographic myocardial imaging reveals segmental cardiomyopathy in Churg-Strauss syndrome

Cardiovascular involvement is the leading cause of morbidity and death in Churg-Strauss syndrome. Herein, we describe the case of a 47-year-old man with Churg-Strauss syndrome, in whom the use of novel echocardiographic techniques revealed segmental cardiomyopathy. Tissue Doppler and speckle-tracking imaging showed that both longitudinal and radial strain were impaired at the septal level and that the impairment of circumferential strain affected left ventricular torsion. Our case shows that advanced echocardiography with myocardial strain imaging in multiple vectors can identify systolic-diastolic abnormalities in a patient with myocardial infiltration and a normal left ventricular ejection fraction.

Detecting subclinical biventricular impairment in scleroderma patients by use of pulsed-wave tissue Doppler imaging

Systemic scleroderma is a disease that is characterized by excessive fibroblastic activity and collagen deposition in various organs, including the heart. We sought to evaluate the limits of biventricular function as derived noninvasively from pulsed-wave tissue Doppler imaging (TDI) of tricuspid and mitral annular motion in patients who had scleroderma.We enrolled 24 patients with scleroderma (study group; mean age, 49 +/- 11 yr; 20 women) and 24 healthy participants (control group; mean age, 51 +/- 9 yr; 19 women). Persons with cardiovascular risk factors were excluded. We obtained images by conventional echocardiography and by pulsed-wave TDI, measuring the respective peak systolic velocities (S, Sm) and peak early (E, Em) and late (A, Am) diastolic velocities. Mean Sm, mean Em, and mean Am were averages of the 4 measured sites (anterior, inferior, lateral, and septal). We calculated noninvasive estimates of left ventricular (LV) filling pressure by dividing E velocities (from the mitral inflow) by Em velocities (E/Em ratios).Biventricular regional Sm, regional LV myocardial Em, and ratios of myocardial Em/atrial component velocity (Em/Am) for the LV, and mean Sm, mean Em, and mean Em/mean Am ratios for the LV were significantly lower in the study group. The E/Em ratio was higher in the study group (7.3 +/- 2.6 vs 5.2 +/- 1.0, P = 0.01). Global LV systolic and diastolic function did not differ between the groups.Tissue Doppler imaging complements conventional echocardiography in detecting subclinical biventricular impairment in patients with scleroderma who have normal global measurements.

Impact of bicuspid aortic valve on complications and death in infective endocarditis of native aortic valves

We retrospectively investigated the impact of bicuspid aortic valve on the prognosis of patients who had definite infective endocarditis of the native aortic valve.Of 51 patients, a bicuspid aortic valve was present in 22 (43%); the other 29 had tricuspid aortic valves. On average, the patients who had bicuspid valves were younger than those who had tricuspid valves. Patients with a tricuspid valve had larger left atrial diameters and were more likely to have severe mitral regurgitation.Periannular complications, which we detected in 19 patients (37%), were much more common in the patients who had a bicuspid valve (64% vs 17%, P = 0.001). The presence of a bicuspid valve was the only significant independent predictor of periannular complications. The in-hospital mortality rate in the bicuspid group was lower than that in the tricuspid group; however, this figure did not reach statistical significance (9% vs 24%, P = 0.15). In multivariate analysis, left atrial diameter was the only independent predictor associated with an increased risk of death (hazard ratio, 2.19; 95% confidence interval, 1.1-4.5; P = 0.031).In our study, patients with infective endocarditis in a bicuspid aortic valve were younger and had a higher incidence of periannular complications. Although a worse prognosis has been reported previously, we found that infective endocarditis in a native bicuspid aortic valve is not likely to increase the risk of death in comparison with infective endocarditis in native tricuspid aortic valves.

Contrast echocardiography for right-sided heart conditions: case reports and literature review

Contrast echocardiography is recognized to be a safe, effective technique for evaluating the endocardial border and left ventricular function in patients who have suboptimal non-contrast echocardiograms. However, its use in diagnosing right-heart conditions is less well established. Herein, we report our experience with the use of contrast echocardiography for diagnosing 3 distinct right-sided heart conditions (hypokinesis of the right ventricular free wall, severe tricuspid regurgitation, and cardiac tamponade) in patients who had suboptimal echocardiograms. Further studies should be done to validate the use of contrast echocardiography for diagnosing right-heart conditions.

Perflutren microspheres for contrast echocardiography in a bloody pericardiocentesis

We report the cases of 2 patients who presented with clinical and echocardiographic evidence of cardiac tamponade. Therapeutic echocardiographic-guided pericardiocentesis yielded bloody fluid. In both patients, Definity perflutren lipid microspheres were used for echocardiographic contrast, which helped to assess the needle's location. To the best of our knowledge, this is the 1st reported use of perflutren microspheres for this purpose.