Faculty Bibliography

Tricuspid regurgitation (TR) is an uncommon and underdiagnosed complication of blunt chest trauma. Typical mechanisms include torn chordae, papillary muscle rupture, and radial leaflet tear. We describe an unusual case of traumatic TR due to circumferential avulsion of the anterior tricuspid leaflet from the tricuspid annulus and the crucial role of multimodality imaging in its diagnosis and treatment. (Level of Difficulty: Intermediate.).

OBJECTIVES/OBJECTIVE:To investigate the potential value of adding a tagged three-chamber (3Ch) cine to clinical hypertrophic cardiomyopathy (HCM) magnetic resonance imaging (MRI) protocols, including to help distinguish HCM patients with regionally impaired cardiac function. METHODS:Forty-eight HCM patients, five patients with "septal knuckle" (SK), and 20 healthy volunteers underwent MRI at 1.5T; a tagged 3Ch cine was added to the protocol. Regional strain, myocardial wall thickness, and mitral valve leaflet lengths were measured in the 3Ch view. RESULTS:In HCM, we found a reduced tangential strain with decreased diastolic relaxation in both hypertrophied (p = 0.003) and remote segments (p = 0.035). Strain in the basal septum correlated with the length of the coaptation zone + residual leaflet (r = 0.48, p < 0.001). In the basal free wall, patients with SK had faster relaxation compared to HCM patients with septal hypertrophy. DISCUSSION/CONCLUSIONS:The 3Ch tagged MRI sequence provides useful information for the examination of suspected HCM patients, with minimal additional time cost. Local wall function is closely associated with morphological changes of the mitral apparatus measured in the same plane and may provide insights into mechanisms of obstruction. The additional strain information may be helpful when analyzing local myocardial wall motion patterns in the presence of SK.

In patients with constrictive pericarditis, a characteristic reduction in the regional longitudinal strain seen in the areas of the left ventricular free wall and relative sparing of the septal longitudinal strain values create an easily recognizable bullseye plot pattern that can be described as "hot septum." (Level of Difficulty: Beginner.).

Adults with congenital heart disease (ACHD) are likely at increased risk for complications of COVID-19. ACHD centers should prepare to deliver routine cardiac care and support for patients with COVID-19 safely at home, as the number of COVID-19 infections worldwide continues to increase. This brief report aims to share the strategies we have used in our ACHD program to manage and treat our patients during this global health crisis at one of the initial epicenters of the pandemic in New York City, and offer suggestions for preparation for ACHD clinicians.

Remarkable advances in the care and survival of congenital heart disease (CHD) patients have led to increasing numbers of young women with CHD who carry a pregnancy with significant risk. The profound hemodynamic changes that naturally occur during gestation may unmask CHD or exacerbate an existing condition and place both the woman and fetus in jeopardy. The caring cardiologist should be familiar with the specific lesion and anticipate complications. Pregestational counseling and a multidisciplinary team approach during pregnancy are key for a successful pregnancy and favorable outcomes. In this review we discuss the evaluation of the expecting CHD patient and focus on the commonly encountered lesions.

Background: Atrial switch operations for dextro-transposition of the great arteries (d-TGA) were supplanted by more physiologic arterial switch operations in the late 1980s, but it is important to recognize the complications faced by aging patients who underwent the older procedure. Case: A 35-year-old woman with d-TGA who underwent the Senning atrial switch procedure as an infant has had stable NYHA Class I functional status, with occasional palpitations but no significant exertional symptoms. Stress testing demonstrated mildly reduced exercise capacity and mild oxygen desaturation at peak exercise. CMR and TTE revealed mild enlargement and normal function of the systemic RV, normal size and function of the subpulmonic LV, moderate TR, and a baffle leak. There was also marked systolic anterior motion (SAM) of the mitral valve, leading to both severe left ventricular outflow tract obstruction (LVOTO) and severe MR in the subpulmonic ventricle. Peak systolic LVOT velocity was 4.5 m/s and peak MR velocity was 5 m/s, corresponding to peak gradients of 80 mm Hg and 100 mm Hg, respectively. Decision-making: There is no consensus on optimal treatment for subpulmonic LVOTO. The dynamic nature of our patient's LVOTO suggests that it might be relieved pharmacologically, and she is being trialed on a beta blocker prior to considering surgery. Importantly, the role of ventricular interdependence cannot be overlooked in patients with inverted ventricular morphologies. Literature on patients with congenitally corrected TGA (cc-TGA) who underwent pulmonary banding or have RV-to-pulmonary artery conduits suggests that relief of LVOTO and reduction of LV pressures may paradoxically lead to RV failure and worsened TR. The mechanism is thought to be related to the advantageous role of the interventricular septum being pushed towards the systemic RV by the pressurized subpulmonic LV, reducing RV sphericity and improving tricuspid valve coaptation. Conclusion(s): Characterization of LVOTO is important for prognosis, pharmacologic management and surgical planning in patients with a systemic RV. Treatment decisions must balance the risk that good relief of LVOTO may actually precipitate systemic RV failure.2019 American College of Cardiology Foundation. All rights reserved