Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS/RESULTS:The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.

The increase of intravenous drug use has led to an increase in right-sided infective endocarditis and its complications including septic pulmonary embolism. The objective of this study was to compare the outcomes of tricuspid valve (TV) operations in patients with drug-use infective endocarditis (DU-IE) complicated by septic pulmonary emboli (PE). Hospitalizations for DU-IE complicated by septic PE were identified from the National Inpatient Sample from 2002 to 2019. Outcomes of patients who underwent TV operations were compared with medical management. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as in-hospital mortality, myocardial infarction, stroke, cardiogenic shock, or cardiac arrest. An inverse probability of treatment weighted analysis was utilized to adjust for the differences between the cohorts. A total of 9,029 cases of DU-IE with septic PE were identified (mean age 33.6 years), of which 818 patients (9.1%) underwent TV operation. Surgery was associated with a higher rate of MACE (14.5% vs 10.8%, p <0.01), driven by a higher rate of cardiogenic shock (6.1% vs 1.2%, p <0.01) but a lower rate of mortality (2.7% vs 5.7%, p <0.01). Moreover, TV operation was associated with an increased need for permanent pacemakers, blood transfusions, and a higher risk of acute kidney injury. In the inverse probability treatment weighting analysis, TV operation was associated with an increased risk for MACE driven by a higher rate of cardiogenic shock and cardiac arrest, but a lower rate of mortality when compared with medical therapy alone. In conclusion, TV operations in patients with DU-IE complicated by septic PE are associated with an increased risk for MACE but a decreased risk of mortality. Although surgical management may be beneficial in some patients, alternative options such as percutaneous debulking should be considered given the higher risk.

Rhythm control strategies in patients with esophageal varices and atrial arrhythmias pose a unique challenge. The left atrium should be imaged for a thrombus prior to attempting cardioversion or ablation, but the presence of varices is a relative contraindication for transesophageal echocardiography. We present a safe, novel technique of evaluating for left atrial thrombus with simultaneous transesophageal echocardiography and esophagogastroduodenoscopy using slim probes in a patient with large, high-risk esophageal varices, and symptomatic atrial flutter with rapid ventricular rates despite medical therapy.

Echocardiography is the preferred initial imaging method for assessment of cardiac masses. Cardiac magnetic resonance (CMR) imaging, with its excellent tissue characterization and wide field of view, may provide additional unique information. We evaluated the predictive value of echocardiography and CMR imaging parameters to identify tumors and malignancy and to provide histopathologic diagnosis of cardiac masses. Fifty patients who underwent CMR evaluation of a cardiac mass with subsequent histopathologic diagnosis were identified. Echocardiography was available in 44 of 50 cases (88%). Echocardiographic and CMR characteristics were evaluated for predictive value in distinguishing tumor versus nontumor and malignant versus nonmalignant lesions using histopathology as the gold standard. The Wilcoxon rank-sum test was used to compare the 2 imaging methods' ability to provide the correct histopathologic diagnosis. Parameters associated with tumor included location outside the right atrium, T2 hyperintensity, and contrast enhancement. Parameters associated with malignancy included location outside the cardiac chambers, nonmobility, pericardial effusion, myocardial invasion, and contrast enhancement. CMR identified 6 masses missed on transthoracic echocardiography (4 of which were outside the heart) and provided significantly more correct histopathologic diagnoses compared to echocardiography (77% vs 43%, p <0.0001). In conclusion, CMR offers the advantage of identifying paracardiac masses and providing crucial information on histopathology of cardiac masses.

Aneurysms of the branches of the coronary arteries are rare. We report a case of a right coronary artery aneurysm with aneurysmal dilation and thrombosis of the sinoatrial nodal branch presenting as a right atrial mass. The patient underwent multiple imaging evaluations before coronary CT angiography diagnosed aneurysm and thrombosis of the sinoatrial nodal branch.

Intravenous agitated saline injection is useful in identifying right-to-left shunting at the atrial or intrapulmonary level. Anomalous systemic venous drainage to the left atrium is a rare but easily correctable cause of right-to-left shunting which, if left undiagnosed, may have serious consequences, including meningitis and pyogenic brain abscesses. This case illustrates an unusual cause of right-to-left shunting and the utility of venous microbubble injection in its diagnosis. (Echocardiography 2011;28:E39-E41)