Faculty Bibliography

This paper provides a comprehensive overview of 3D transesophageal echocardiography still images and movies of mechanical mitral valves, mitral bioprostheses, and mitral valve repairs. Alongside these visual descriptions, the historical overview of surgical and percutaneous mitral valve intervention is described with the special emphasis on the incremental value of 3D transesophageal echocardiography (3DTEE). For each mitral valve intervention, 2D echocardiography, chest x-ray, and fluoroscopy images corresponding to 3DTEE are given. In addition, key references on echocardiographic imaging of individual valves and procedures are enumerated in accompanying figures and tables.

Background: Patients with severe aortic stenosis in the setting of low gradient and preserved left ventricular ejection fraction (LVEF) remain an area of clinical uncertainty. Methods: Retrospective chart review identified 209 patients who underwent transcatheter aortic valve replacement (TAVR) between September 2014 and September 2015. Of these patients, 3 (1.4%) were excluded due to procedural indication other than severe aortic stenosis and 41 (20%) were excluded due to reduced LVEF (<50%). Of the remaining 165 patients with aortic valve area <1 cm2, 77 (47%) had either a peak velocity <4.0 m2 or mean gradient <40 mmHg (LG group) and 88 (53%) had both peak velocity >4.0 m2 and mean gradient >40 mmHg (HG group) across the AV. Outcomes were defined by the valve academic research consortium 2 criteria when applicable and compared between the LG and HG groups via Fisher's exact test. Median follow-up was 367 days. Continuous data are shown as median [interquartile range] and categorical data are shown as proportions. Results: The 30-day mortality risk as assessed by Society of Thoracic Surgery score was not significantly different between the LG and HG groups (5.9% [3.5-8.1] vs 6.2% [4.4-7.6], p=0.45). There were no significant differences in outcomes (Table). Conclusion: In a high-volume center, patients undergoing TAVR for severe AS with LG preserved LVEF have no significant difference in adverse outcomes, both in-hospital and on 1-year follow-up, when compared to patients with HG preserved LVEF. (Figure Presented)

Aortic root thrombus is an uncommon complication of continuous-flow left ventricular assist devices (LVAD). We present the case of a 71-year-old man with ischemic cardiomyopathy who underwent destination therapy HeartMate II LVAD placement. Eighteen months later, he presented with a cerebrovascular accident followed by myocardial infarction. Transesophageal echocardiography revealed an aortic root thrombus spanning the left and noncoronary cusps and obliterating the left main coronary artery. We discuss the incidence, risk factors, and management of aortic root thrombus in LVAD patients. To our knowledge, this is the first report of three-dimensional echocardiography used to characterize an LVAD-associated aortic root thrombus.

Lipomatous atrial septal hypertrophy (LASH) is a histologically benign cardiac lesion characterized by excessive fat deposition in the region of the interatrial septum that spares the fossa ovalis. The etiology of LASH remains unclear, though it may be associated with advanced age and obesity. Because of the sparing of the fossa ovalis, LASH has a pathognomonic dumbbell shape. LASH may be mistaken for various tumors of the interatrial septum. Histologically, LASH is composed of both mature and brown (fetal) adipose tissue, but the role of brown adipose tissue remains unclear. In interventional procedures requiring access to the left atrium, LASH may interfere with transseptal puncture, as traversing the thickened area can reduce the maneuverability of catheters and devices. This may cause the needle to enter the epicardial space, causing dangerous pericardial effusions. LASH was once considered a contraindication to percutaneous device closure of atrial septal defects because of an associated increased risk for incorrect device deployment. However, careful attention to preprocedural imaging and procedural intracardiac echocardiography enable interventional cardiologists to perform procedures in patients with LASH without serious complications. In this review article, the authors describe anatomic and functional aspects of LASH, with emphasis on their roles in percutaneous interventions.

Contraindications to transesophageal echocardiography (TEE) include various esophageal pathologies, but compression of the esophagus by vertebral osteophytes is not listed in the current American Society of Echocardiography guidelines. We report a case of diffuse idiopathic skeletal hyperostosis (DISH) in an 81-year-old man who had incidentally been found to have extrinsic esophageal compression by cervical osteophytes prior to a proposed TEE. The incidence of esophageal perforation in patients with DISH and vertebral osteophytes is not well documented. We believe these patients are at increased risk of esophageal perforation during TEE, and thus, TEE may be relatively contraindicated in patients with DISH.

BACKGROUND: Individuals referred for stress testing to identify coronary artery disease may have nonobstructive atherosclerosis, which is not detected by stress tests. Identification of increased risk despite a negative stress test could inform prevention efforts. Abnormal ankle-brachial index (ABI) is associated with increased cardiovascular risk. HYPOTHESIS: Routine ABI testing in the stress laboratory will identify unrecognized peripheral arterial disease in some patients. METHODS: Participants referred for stress testing without known history of atherosclerotic disease underwent ABI testing (n = 451). Ankle-brachial index was assessed via simultaneous arm and leg pressure using standard measurement, automated blood-pressure cuffs at rest. Ankle-brachial index was measured after exercise in 296 patients and 30 healthy controls. Abnormal postexercise ABI was defined as a >20% drop in ABI or fall in ankle pressure by >30 mm Hg. RESULTS: Overall, 2.0% of participants had resting ABI /=1.40, and 5.5% had borderline ABI. No patient with abnormal or borderline ABI had an abnormal stress test. Participants who met peripheral arterial disease screening criteria (age >/=65 or 50-64 with diabetes or smoking) tended toward greater frequency of low ABI (2.9% vs 1.0%; P = 0.06) and were more likely to have borderline ABI (0.91 to 0.99; 7.8% vs 2.9%; P = 0.006). Postexercise ABI was abnormal in 29.4% of patients and 30.0% of controls (P not significant). CONCLUSIONS: Ankle-brachial index screening at rest just before stress testing detected low ABI in 2.0% of participants, all of whom had negative stress tests.

Congenital absence of left atrial appendage (LAA) is an extremely rare condition and its physiological consequences are unknown. We present two cases of incidental finding of a congenitally absent LAA in a 79-year-old male who presented for routine transesophageal echocardiogram (TEE) to rule out intracardiac thrombus prior to placement of biventricular implantable cardioverter-defibrillator and a 54-year old female who presented for TEE prior to radiofrequency ablation of atrial fibrillation. Characterization of patients with such an absence is important because congenitally absent LAA may be confused with flush thrombotic occlusion of the appendage. There are very few published reports of congenital absence of LAA. To our knowledge, our report is the first to demonstrate the congenital absence of LAA by 3D transesophageal echocardiography.

Carotid atherosclerosis is implicated in 20-30 % of strokes. However, the annual risk of stroke in patients with asymptomatic carotid stenosis is less than 5 %. Symptomatic carotid stenosis poses a greater risk for recurrent stroke with estimates as high as 15 % per year. This paper aims to raise awareness of populations at risk for carotid stenosis, the role of carotid screening and the sensitivity and specificity of various diagnostic modalities. The results of previous trials that support current guidelines for management of symptomatic and asymptomatic carotid stenosis will also be reviewed.