Faculty Bibliography

BACKGROUND:Diagnosis and management of multivalve disease could be challenging for clinicians. Rheumatic heart disease is a well-known etiology of multivalve disease. CASE SUMMARY/METHODS:A 51-year-old male with a history of rheumatic heart disease was referred to rule out infectious endocarditis. Three-dimensional (3D) transesophageal echocardiography (TEE) showed significant stenosis of the tricuspid valve, moderate tricuspid regurgitation, rheumatic mitral valve disease, and a bicuspid aortic valve. DISCUSSION/CONCLUSIONS:Transthoracic echocardiography is the modality of choice for evaluation of cardiac valves and quantification of cardiac chambers. However, due to the complex nature of multivalve disease, using a complementary imaging technique such as 3D TEE becomes crucial in many patients. Tricuspid stenosis as the dominant valvular lesion in rheumatic heart disease is rare and almost always occurs in the presence of mitral valve disease. We present a unique case of rheumatic heart disease with the involvement of mitral and tricuspid valves in the presence of a bicuspid aortic valve, in which tricuspid stenosis is the predominant lesion. We also discuss the important role of cardiac imaging and 3D TEE in patient decision making. TAKE-HOME MESSAGES/CONCLUSIONS:Tricuspid stenosis as the dominant valvular lesion in rheumatic heart disease is rare and almost always occurs in the presence of mitral valve disease. Transthoracic echocardiography remains the modality of choice for evaluation of the tricuspid valve. 3D TEE can play an important role in reaching a final management decision.

• LAAO devices are used for patients with AF intolerant of anticoagulation. • Periprocedural multimodality imaging is crucial for successful device deployment. • LAAs with bifid morphologies are uncommon and pose procedural challenges. • We describe closure of a bifid LAA using 2 side-by-side lobe-and-disk devices.

Left atrial appendage occlusion (LAAO) has emerged as an important intervention for stroke prevention in patients with non-valvular atrial fibrillation (AF) who are unable to tolerate long-term anticoagulation. The development of advanced imaging technologies and techniques, such as 3D echocardiography with multiplanar reconstruction (MPR), multidetector computed tomography (MDCT), 3D intracardiac echocardiography (ICE), 3D printing, and simulation, has revolutionized pre-procedural planning, intra-procedural guidance, and post-procedural surveillance, ensuring improved precision and outcomes. Transesophageal echocardiography (TEE) remains a foundational imaging modality for assessing LAA morphology, excluding thrombi, and obtaining accurate measurements for device sizing. Recent advances in 3D TEE and MPR techniques enable enhanced visualization of complex LAA anatomies, improving device selection and procedural planning. Multidetector computed tomography has a growing role, offering high-resolution 3D reconstructions for detailed anatomical assessment. Additionally, its applications in 3D printing and virtual device simulation provide patient-specific insights, facilitating optimal device sizing and improving procedural efficiency. Intra-procedurally, 3D ICE has gained traction as a valuable alternative to TEE. With its real-time imaging capabilities and high spatial resolution, 3D ICE allows precise guidance during transseptal puncture and device deployment while reducing the need for general anesthesia. Post-procedurally, both TEE and MDCT play critical roles in assessing device stability and identifying complications such as device-related thrombus and peri-device leak. This review highlights the evolving role of multimodality imaging in LAAO, including innovations such as 3D ICE, 3D printing, and simulation. It also reviews recent literature to establish state-of-the-art imaging practices, providing a comprehensive discussion of imaging applications across pre-, intra-, and post-procedural phases to optimize outcomes and minimize complications in LAAO.

Structural, architectural, contractile or electrophysiological alterations may occur in the left atrium (LA). The concept of LA cardiopathy is supported by accumulating scientific evidence demonstrating that LA remodeling has become a cornerstone diagnostic and prognostic marker. The structure and the function of LA and left atrial appendage (LAA) which is an integral part of the LA, are key elements for a better understanding of multiple clinical conditions, most notably atrial fibrillation (AF), cardioembolism, heart failure and mitral valve diseases. Rational use of various imaging modalities is key to obtain the relevant clinical information. Accordingly, this clinical consensus document from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists and cardiac imagers for the best practice of imaging LA and LAA for the diagnosis, management and prognostication of the patients.

BACKGROUND/UNASSIGNED:There is controversy about risk of malignant arrhythmias and stroke in patients with apical aneurysms in hypertrophic cardiomyopathy (HCM). OBJECTIVES/UNASSIGNED:The aim of this study was to estimate the associations of aneurysm size and major HCM risk factors with the incidence of lethal and potentially lethal arrhythmias and to estimate incidence of unexplained stroke. METHODS/UNASSIGNED:In 108 patients (age 57.4 ± 13.5 years, 37% female) from 3 HCM centers, we assessed American Heart Association/American College of Cardiology guidelines risk factors and initial aneurysm size by echocardiography and cardiac magnetic resonance imaging and assessed outcomes after median 5.9 (IQR: 3.7-10.0) years. RESULTS/UNASSIGNED:and also without risk factors VT, VF, or SCD occurred in only 2.5%. Clinical atrial fibrillation (AF) was prevalent, occurring in 49 (45%). Stroke was commonly associated with AF. Stroke without conventional cause had an incidence of 0.5%/year. Surgery in 19% was effective in reducing symptoms. VT ablation and surgery were moderately effective in preventing recurrent VT. CONCLUSIONS/UNASSIGNED:Risk factors and aneurysm size were associated with subsequent VT, VF, or SCD. Patients with aneurysms in the lowest tercile of size have a low cumulative 5-year risk. Clinical AF occurred frequently. Stroke prevalence in absence of known stroke etiologies is uncommon and comparable to risk of severe bleeding.

BACKGROUND:Latent left ventricular outflow tract obstruction (LVOTO) is an important cause of symptoms in patients with hypertrophic cardiomyopathy (HCM) but can be challenging to provoke. OBJECTIVES AND METHODS/OBJECTIVE:To examine the value of postprandial resting and stress echocardiography and utilization of invasive or enhanced drug therapies (surgical myectomy, alcohol septal ablation, disopyramide, and mavacamten) in patients with postprandial LVOTO. Consecutive HCM patients without LVOTO underwent routine and postprandial echocardiography at rest, with provocation (Valsalva and standing) and after symptom-limited treadmill stress. RESULTS:Among 252 patients (mean age, 58 years, 39% women), postprandial LVOT gradients were higher compared with routine echocardiography at rest (median, 9.0 [0-38.0] vs 0 [0-14.0] mm Hg; P < .0001) and with provocation (18.5 [0-70.3] vs 1.5 [0-41.0] mm Hg; P < .0001). Postprandial exercise stress echocardiogram (PPXSE) gradients were higher in a subset of 44 patients who underwent both postprandial and fasting stress echocardiography (47.0 [5.3-81.0] vs 17.5 [0-46.0] mm Hg; P < .0001). In total, 49 (19.5%) patients achieved the ≥50 mm Hg threshold under routine conditions (rest/provocation); 90 (35.7%) additional patients achieved postprandial gradients ≥50 mm Hg (rest/provocation/exercise), 38 (15.1%) with PPXSE alone. A total of 71 patients were treated with 91 invasive or enhanced drug therapies, 32 (45.1%) of whom had gradients ≥50 mm Hg only after eating (rest/provocation) and 8 (11.3%) only with PPXSE, with symptom relief in the majority. CONCLUSIONS:Postprandial echocardiography was useful at unmasking LVOTO in more than one-third of patients who did not have high gradients otherwise. Eating before echocardiography is a powerful provocative tool in the evaluation of patients with HCM.

Marantic endocarditis is defined as a sterile endocarditis that is rarely encountered in clinical practice. This case series illustrates five cases of marantic endocarditis. All cases were diagnosed on trans thoracic echocardiography and verified on transesophageal echocardiography. The first three cases occur in the setting of antiphospholipid syndrome; the last two occur in the setting of advanced malignancy. Two cases were treated successfully with anticoagulation, while two others required valvular surgery. One case resulted in mortality. The treatment course of these five patients mirrors certain patterns described in the literature.

BACKGROUND/UNASSIGNED:Clot-in-transit is associated with high mortality, but optimal management strategies remain uncertain. The aim of this study was to compare the outcomes of different treatment strategies in patients with clot-in-transit. METHODS/UNASSIGNED:This is a retrospective study of patients with documented clot-in-transit in the right heart on echocardiography across 2 institutions between January 2020 and October 2023. The primary outcome was a composite of in-hospital mortality, resuscitated cardiac arrest, or hemodynamic decompensation. RESULTS/UNASSIGNED:=0.067). CONCLUSIONS/UNASSIGNED:In this study of CBT in patients with clot-in-transit, CBT or systemic thrombolysis was associated with a significantly lower rate of adverse clinical outcomes, including a lower rate of death compared with anticoagulation alone driven by the CBT group. CBT has the potential to improve outcomes. Further large-scale studies are needed to test these associations.

• RHD is a rare cause of severe valvular AS. • Rheumatic MS typically accompanies rheumatic AV disease. • 2D and 3D echocardiography are essential in the assessment of rheumatic AS. • CCT has become crucial in planning therapeutic procedures for AS.

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.