Faculty Bibliography

Transesophageal echocardiography is essential in guiding the surgical approach for patients with obstructive hypertrophic cardiomyopathy. Septal hypertrophy, elongated mitral valve leaflets, and abnormalities of the subvalvular apparatus are prominent features, all of which may contribute to left ventricular outflow tract obstruction. Surgery aims to alleviate the obstruction via an extended myectomy, often with an intervention on the mitral valve and subvalvular apparatus. The goal of intraoperative echocardiography is to assess the anatomic pathology and pathophysiology in order to achieve a safe intraoperative course and a successful repair. This guide summarizes the systematic evaluation of these patients to determine the best surgical plan.

Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. In this article, the authors describe the crucial role of two- and three-dimensional transesophageal echocardiography in the pre- and postprocedural assessment and intraprocedural guidance of percutaneous left atrial appendage (LAA) occlusion procedures. Although recent advances have been made in the field of systemic anticoagulation with the novel oral anticoagulants, these medications come with a significant risk for bleeding and are contraindicated in many patients. Because thromboembolism in atrial fibrillation typically arises from thrombi originating in the LAA, surgical and percutaneous LAA exclusion/occlusion techniques have been devised as alternatives to systemic anticoagulation. Currently, surgical LAA exclusion is typically performed as an adjunct to other cardiac surgical procedures, which limits the number of eligible patients. Recently, several percutaneously delivered devices for LAA exclusion from the systemic circulation have been developed, some of which have been shown in clinical trials to reduce the risk for thromboembolism. These devices use an either purely endocardial LAA occlusion approach, such as the Watchman and Amulet procedures, or both an endocardial and a pericardial (epicardial) approach, such as the Lariat procedure. In the Watchman and Amulet procedures, a transseptally delivered structure composed of nitinol is placed in the LAA orifice, thereby excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA.

The technique of mechanical circulatory support or the site of cannulation may affect transvalvular flow. We describe early failure of a mitral bioprosthesis in a patient with temporary left ventricular assist device support, likely from thrombosis. Salvage with transcatheter mitral valve replacement was attempted. Temporary mechanical circulatory support strategies that maximize flow across a new bioprosthesis should be sought to avoid early valvular thrombosis.

Purpose of Review: Atrial fibrillation (AF) is the most common arrhythmia in humans. It is a major cause of morbidity and mortality as it impairs cardiac function and is a major risk of embolic stroke. Traditionally, thromboembolic risk of AF has been treated with system anticoagulation with intravenous, intramuscular, or oral anticoagulants. Although the novel oral anticoagulants (NOACs) have revolutionized stroke risk reduction in AF patients, they are associated with a significant risk of bleeding and may be contraindicated in certain patients. Embolic events in AF typically originate from thrombi that form within the left atrial appendage (LAA), especially in nonvalvular AF. Both surgical and percutaneous LAA closure techniques have been devised as alternatives to systemic anticoagulation. As surgical LAA closure is typically performed as an adjunct to other cardiac surgeries, the amount of eligible patients for this type of therapy may be limited. Recent Findings: Excluding the LAA from the systemic circulation may reduce the risk of thromboembolism in AF. Recent technologic advances have led to the development of several percutaneously delivered devices that can occlude or exclude the LAA from systemic circulation. These devices may be purely endocardially delivered such as the Watchman (Boston Scientific, Maple Grove, MN) and Amulet (St. Jude Medical, Minneapolis, MN), or both endocardially and pericardially delivered such as the Lariat (Sentre-HEART, Palo Alto, CA). During Amulet and Watchman procedures, a transseptally delivered device composed of nitinol is placed in the LAA orifice, subsequently excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA. Their use is steadily increasing in worldwide either through routine clinical use of approved devices or within clinical trials. Summary: In this review, we describe the various devices available for percutaneous LAA closure, and the indispensable role of real-time transesophageal echocardiography in the periprocedural assessment and intraprocedural guidance of percutaneous LAA occlusion procedures.

BACKGROUND: Pulmonary artery intimal spindle cell sarcomas are rare and carry with them a poor prognosis and high rate of recurrence. In extremely rare cases, this tumor can infiltrate the pulmonic valve and manifest as adult-onset pulmonic stenosis. CASE PRESENTATION: We report an unusual case of a patient with symptomatic, adult-onset severe pulmonic stenosis who was referred for possible balloon valvuloplasty but was subsequently found to have pulmonary artery intimal sarcoma infiltrating the pulmonary valve leading to progressive exertional dyspnea. CONCLUSION: The presence of adult-onset pulmonic stenosis should prompt the clinician to investigate further as most cases of pulmonic stenosis are congenital in nature and present early in life. Careful diagnostic evaluation in concert with multimodal imaging should take place to arrive at the correct and challenging diagnosis of sarcoma-induced adult-onset severe pulmonic stenosis. Given the poor prognosis and rapid progression of disease, early diagnosis is crucial.

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.