Faculty Bibliography

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.

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.

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.

Background: Patients with severe aortic stenosis in the setting of low gradient and preserved left ventricular ejection fraction (LVEF) remain an area of clinical uncertainty. Methods: Retrospective chart review identified 209 patients who underwent transcatheter aortic valve replacement (TAVR) between September 2014 and September 2015. Of these patients, 3 (1.4%) were excluded due to procedural indication other than severe aortic stenosis and 41 (20%) were excluded due to reduced LVEF (<50%). Of the remaining 165 patients with aortic valve area <1 cm2, 77 (47%) had either a peak velocity <4.0 m2 or mean gradient <40 mmHg (LG group) and 88 (53%) had both peak velocity >4.0 m2 and mean gradient >40 mmHg (HG group) across the AV. Outcomes were defined by the valve academic research consortium 2 criteria when applicable and compared between the LG and HG groups via Fisher's exact test. Median follow-up was 367 days. Continuous data are shown as median [interquartile range] and categorical data are shown as proportions. Results: The 30-day mortality risk as assessed by Society of Thoracic Surgery score was not significantly different between the LG and HG groups (5.9% [3.5-8.1] vs 6.2% [4.4-7.6], p=0.45). There were no significant differences in outcomes (Table). Conclusion: In a high-volume center, patients undergoing TAVR for severe AS with LG preserved LVEF have no significant difference in adverse outcomes, both in-hospital and on 1-year follow-up, when compared to patients with HG preserved LVEF. (Figure Presented)