Faculty Bibliography

Libman-Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syndrome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets. In this report, mitral valve LSE was visualized by real time 3D transesophageal echocardiography (TEE). 3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allows for an accurate determination of the size, shape, and location of the vegetations. (Echocardiography 2012;29:E100-E101).

Atrial fibrillation is a common, clinically significant arrhythmic disorder that results in increased risk of morbidity and mortality in affected patients. Atrial fibrillation is more prevalent among men compared with women and the risk for developing atrial fibrillation increases with advancing age. Ischaemic stroke is the most common clinical manifestation of embolic events from atrial fibrillation. While anticoagulation treatment is the preferred treatment, unfortunately, many patients have contraindications for anticoagulation treatment making this option unavailable to them. Previous data have shown that most thrombi that form in association with non-valvular atrial fibrillation occur in the left atrial appendage (LAA). It has been suggested that isolating the LAA from the body of the left atrium might reduce the risk of embolic events and that LAA obliteration may be a treatment option for patients with atrial fibrillation who are not candidates for anticoagulation treatment. Several procedures have been developed for isolation of the LAA, including surgical procedures as well as catheter-based ones. In this paper, we will review the currently available techniques, emphasizing the catheter-based ones. We will examine the increasing role of real-time three-dimensional transoesophageal echocardiography for appropriate screening and patient selection for these procedures, intra-procedural guidance, and follow-up care.

PURPOSE OF REVIEW: To describe cholesterol embolization syndrome (CES) and its risk factors, pathophysiology, clinical presentation, diagnosis and treatment. RECENT FINDINGS: To date, no specific diagnostic test (other than biopsy) for CES has been developed. Effective treatments for CES are yet to be developed. SUMMARY: CES (also referred to as cholesterol crystal embolization, atheromatous embolization or atheroembolism) occurs when cholesterol crystals and other contents of an atherosclerotic plaque embolize from a large proximal artery to smaller distal arteries, causing ischemic end-organ damage. Clinical manifestations of CES include constitutional symptoms (fever, anorexia, weight loss, fatigue and myalgias), signs of systemic inflammation (anemia, thrombocytopenia leukocytosis, high erythrocyte sedimentation rate, elevated levels of C-reactive protein, hypocomplementemia), hypereosinophilia, eosinophiluria, acute onset of diffuse neurologic deficit, amaurosis fugax, acute renal failure, gut ischemia, livedo reticularis and blue-toe syndrome. CES may occur spontaneously or after an arterial procedure. There is no specific laboratory test for CES. Retinal exam demonstrating Hollenhorst plaques supports the diagnosis of CES. Biopsy of target organs (usually skin, skeletal muscles or kidneys) is the only means of confirming the diagnosis of CES. Treatment consists of supportive care and general management of atherosclerosis and arterial ischemia

Esophageal perforation is the most feared complication of transesophageal echocardiography (TEE), although the overall risk is extremely low. We report a case of esophageal perforation in a 77-year-old woman who had no apparent contraindications to TEE. Chronic steroid therapy for symptoms of asthma as well as osteophytic changes of the cervical vertebrae contributed to her increased risk of perforation. Unlike in prior reports, the perforation in this case was fortuitously recognized rapidly due to ingestion of a carbonated beverage for evaluation of a hiatal hernia suspected during a subsequent transthoracic echocardiogram performed because of inadequate TEE images after a difficult intubation. The incidence of esophageal perforation in our series (1 in 5,000 TEEs, 0.02%) is similar to that reported in the literature. Early recognition and prompt surgical repair of the esophageal perforation led to favorable outcome in our patient

It is commonly postulated that neurologic complications of atrial myxomas are due to either direct tumor embolization or mycotic aneurysm of cerebral vasculature or rupture of mycotic aneurysms of cerebral arteries. However, the authors report the case of 63-year-old woman with a large left atrial myxoma whose progressive left-sided weakness was due to a different neurologic mechanism, namely, multiple bleeding cavernous malformations, which were visualized by magnetic resonance imaging of the brain. Cerebral cavernous malformations coexist with mesenchymal anomalies of other organs, including the liver, kidneys, and retinas. To the best of the authors' knowledge, this is only the second reported case of coexistent cerebral cavernous malformations and atrial myxoma

Anteriorly displaced right coronary artery (RCA) and anomalous origin RCAs occur in approximately 1% and 0.1% of adult patients, respectively, and are the leading cause of incomplete coronary angiography and prolonged procedure times. We present a case in which anteriorly displaced RCA occlusion resulted in an acute inferior-posterior-right ventricular myocardial infarction complicated by complete atrioventricular block and hypotension. Failure to image the RCA resulted in considerable delay in reperfusion time with fibrinolysis. The authors discuss the most frequent anatomic locations of ectopic RCAs and suggest an algorithm to be employed when an ectopic RCA cannot be imaged with conventional diagnostic catheters. Contrary to popular belief, the search for an ectopic RCA has <90 degrees boundaries limited to the anterior third of the right sinus and anterior half of the left sinus.

BACKGROUND: There are currently no standardized three-dimensional (3D) transesophageal echocardiographic (TEE) views of the interatrial septum and atrial septal defects (ASDs). Without a standardized approach, it is difficult to ascertain the important anatomic relationships (such as the location of the aortic rim of an ASD), to perform relevant measurements (such as the size of an ASD or the size of its rims), or to guide the deployment of catheters and devices during atrial septal closure. METHODS: Using a 3D TEE matrix-array transducer, 706 TEE studies were performed over a 14-month period. The purpose of the study was to develop a standardized protocol for anatomically correct orientation of 3D TEE images of the interatrial septum and ASDs. RESULTS: Among 706 TEE studies, there were 23 patients with ASDs, representing 3.3% of the study population. Eighteen patients had secundum ASDs, two had primum ASDs, and three had sinus venosus ASDs of the superior vena cava type. A protocol for properly orienting 3D TEE images of the interatrial septum and ASDs was developed. When the images are acquired at an angle of 0 degrees , the septum is properly oriented by the tilt-up-then-left maneuver. The initial 3D TEE image in first tilted up to reveal the right atrial side of the septum. Then the image is tilted 180 degrees around its vertical axis to reveal the left atrial side of the septum; the aortic rim is on the left, the superior vena cava on the top, and the right-sided pulmonary vein ostia on the right side of the screen. For acquisitions at a higher angle, the rotate-left-in-z-axis maneuver is used. The image is first tilted up to reveal the right atrial side of the septum, as in the tilt-up-then-left maneuver. The image is then rotated counterclockwise in the z axis until the superior vena cave is at 12 o'clock. Finally, the image is tilted 180 degrees around its vertical axis to reveal the left atrial side of the septum. CONCLUSIONS: The use of standardized tilt-up-then-left and rotate-left-in-z-axis maneuvers enhances the diagnosis of ASDs, ascertains the important anatomic relationships of ASDs to surrounding structures, and facilitates communication between echocardiographers obtaining 3D TEE images and interventional cardiologists or cardiac surgeons performing ASD closures

BACKGROUND: Two-dimensional and Doppler echocardiography are standard methods to assess the severity of pulmonic insufficiency (PI). However, methods to define severity of