Faculty Bibliography

Mitral regurgitation (MR) is one of the most commonly encountered valvular lesions in clinical practice. MR can be either primary (degenerative) or secondary (functional) depending on the etiology of MR and the pathology of the mitral valve (MV). Echocardiography is the primary diagnostic tool for MR and is key in determining this etiology as well as MR severity. While clinicians usually turn to 2 Dimensional echocardiography as first-line imaging, 3 Dimensional echocardiography (3DE) has continually shown to be superior in terms of describing MV anatomy and pathology. This review article elaborates on 3DE techniques, modalities, and advances in software. Furthermore, the article demonstrates how 3DE has reformed MR evaluation and has played a vital role in determining patient management.

BACKGROUND:Studies have demonstrated the value of transthoracic echocardiogram (TTE) diastolic parameters in predicting left atrial appendage (LAA) thrombus; however, these studies have been small. We aim to clarify the relationship between TTE diastolic parameters, in particular average e', and LAA thrombus or sludge. METHODS:A case-control review was conducted of subjects with non-valvular atrial fibrillation (n = 2263) who had undergone TEE (transesophageal echocardiogram) and had a TTE within 1 year of TEE. Cases of LAA sludge or thrombus were matched to controls by age, sex, left ventricular ejection fraction (LVEF), and anticoagulation status. RESULTS:Forty-three subjects (mean age 73 ± 12, 65% male, LVEF 47%, 44% on anticoagulation) with LAA sludge or thrombus were identified. Compared to matched controls, average TTE e' (7.3 ± 2.1 cm/s vs 8.7 ± 2.1 cm/s, P < 0.001) and the E:e' ratio (15 ± 7 cm/s vs 12 ± 5 cm/s; P = 0.005) were significant predictors of LAA sludge or thrombus. Average TTE e' value of >11 cm/s had 100% sensitivity for ruling out LAA sludge or thrombus. CONCLUSION/CONCLUSIONS:In individuals with atrial fibrillation, average e' >11 cm/s on TTE is a promising independent predictor of the absence of LAA sludge or thrombus on TEE.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) for low gradient (LG) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) remains an area of clinical uncertainty. METHODS:Retrospective review identified 422 patients who underwent TAVR between September 4, 2014 and July 1, 2016. Procedural indication other than severe AS (n = 22) or LVEF <50% (n = 98) were excluded. Outcomes were defined by valve academic research consortium two criteria when applicable and compared between LG (peak velocity <4.0 m/s and mean gradient <40 mmHg; n = 73) and high gradient (HG) (n = 229) groups. The LG group was further categorized as low stroke volume index (SVI) (n = 41) or normal SVI (n = 32). Median follow-up was 747 days [interquartile range 220-1013]. RESULTS: = 0.39). CONCLUSION/CONCLUSIONS:Patients with preserved LVEF undergoing TAVR for severe AS with LG, including LG with low SVI, have no significant difference in adverse outcomes when compared to patients with HG.

Partial anomalous pulmonary venous return (PAPVR) comprises a group of congenital cardiovascular anomalies associated with pulmonary venous flow directly or indirectly into the right atrium. Scimitar syndrome is a variant of PAPVR in which the right lung is drained by right pulmonary veins connected anomalously to the inferior vena cava. Surgery is the definitive treatment for scimitar syndrome. However, it is not always necessary as many patients are asymptomatic, have small left-to-right shunts, and enjoy a normal life expectancy without surgery. We report multimodality imaging in four adults with scimitar syndrome and the implications for management of this rare syndrome.

Echocardiography has become a critical tool in clinical cardiology in evaluating cardiac physiology and diagnosing cardiac disease states. However, imaging artifacts are commonly encountered and often lead to misdiagnoses of life-threatening diseases, such as aortic dissection and ventricular thrombus. It is, thus, critical for clinicians to understand these artifacts to avoid these misdiagnoses and protect patients from undue intervention. Artifacts can be broken down into two categories: those from violation of ultrasound system assumptions and those from interference by external equipment and devices. This review article discusses the most commonly encountered artifacts by category, explains their physical mechanisms, elaborates on their most common presentations, and instructs clinicians on how to avoid their misinterpretation.

Vascular complications from transradial percutaneous coronary intervention (PCI) are rare. We report an unusual case of stridor after PCI due to brachiocephalic artery perforation, pseudoaneurysm formation, and development of a large mediastinal hematoma with tracheal compression. Endovascular repair of the brachiocephalic artery was achieved with covered stent placement at the neck of the pseudoaneurysm. This case highlights the importance of careful guide catheter placement from the right radial approach. Ultimately, rapid diagnosis of vascular perforation, appropriate airway management, and prompt endovascular repair of the injured vessel is critical to the successful management of this life-threatening condition.