Hemostasis of left atrial appendage bleed with lariat device

New devices designed for minimally invasive closure of the left atrial appendage (LAA) may be a viable alternative for patients in whom anticoagulation is considered high risk. The Lariat (Sentreheart, Redwood City, CA), which is currently FDA-approved for percutaneous closure of tissue, requires both trans-septal puncture and epicardial access. However it requires no anticoagulation after the procedure. Here we describe a case of effusion and tamponade during a Lariat procedure with successful completion of the case and resolution of the effusion.

Embolic myocardial infarction in a patient with a Fontan circulation

Coronary artery embolism is an uncommon cause of acute myocardial infarction (MI). We present a patient with pulmonary atresia and severe right heart hypoplasia who underwent a lateral tunnel Fontan procedure in childhood and presented with an acute ST-segment elevation MI at 19 years of age. In addition to the known risk of thrombotic complications associated with a Fontan circulation, potential predisposing factors to thromboembolism in this patient included a right ventricle to left anterior descending coronary connection and a Fontan baffle leak. The patient was treated with device closure of the baffle leak and anticoagulation. This is one of the first reports of an embolic MI in a patient with a Fontan circulation. The optimal method of reducing thromboembolic risk in this patient, and those with a Fontan circulation in general, is complicated and no consensus exists.

Intimal sarcoma in the aortic arch partially obstructing the aorta with metastasis to the brain

Primary tumors of the aorta are rare entities. We report the unusual manifestation of an aortic intimal sarcoma that presented as a brain metastasis in a 56-year-old, otherwise healthy woman. After the brain mass had been resected, multiple imaging methods revealed pseudocoarctation and the primary tumor in the aortic arch. To our knowledge, this is the first report of the diagnosis of an aortic intimal sarcoma with use of real-time, 3-dimensional transesophageal echocardiography.

Lone aortic insufficiency and conduction disease: a marker of reactive arthritis

A 48-year-old male with history of chronic arthritis and uveitis presented with 1 year of progressively reduced exercise capacity and nonexertional chest pain. Physical examination was consistent with severe aortic insufficiency. An electrocardiogram demonstrated sinus rhythm with first degree atrioventricular block. Transthoracic and transesophageal echocardiography demonstrated severe lone central aortic insufficiency of a trileaflet valve due to leaflet thickening, retraction of leaflet margins and mild aortic root dilation in the setting of left ventricular dilatation. In addition, computed tomographic angiography revealed a small focal aneurysm of the distal transverse arch. He was found to be positive for the immunogenetic marker HLA-B27. The patient subsequently underwent uncomplicated mechanical aortic valve replacement. The diagnosis of HLA-B27 associated cardiac disease should be entertained in any individual with lone aortic insufficiency, especially if accompanied by conduction disease.

A novel and practical cardiovascular magnetic resonance method to quantify mitral annular excursion and recoil applied to hypertrophic cardiomyopathy

BACKGROUND

We have developed a novel and practical cardiovascular magnetic resonance (CMR) technique to evaluate left ventricular (LV) mitral annular motion by tracking the atrioventricular junction (AVJ). To test AVJ motion analysis as a metric for LV function, we compared AVJ motion variables between patients with hypertrophic cardiomyopathy (HCM), a group with recognized systolic and diastolic dysfunction, and healthy volunteers.

METHODS

We retrospectively evaluated 24 HCM patients with normal ejection fractions (EF) and 14 healthy volunteers. Using the 4-chamber view cine images, we tracked the longitudinal motion of the lateral and septal AVJ at 25 time points during the cardiac cycle. Based on AVJ displacement versus time, we calculated maximum AVJ displacement (MD) and velocity in early diastole (MVED), velocity in diastasis (VDS) and the composite index VDS/MVED.

RESULTS

Patients with HCM showed significantly slower median lateral and septal AVJ recoil velocities during early diastole, but faster velocities in diastasis. We observed a 16-fold difference in VDS/MVED at the lateral AVJ [median 0.141, interquartile range (IQR) 0.073, 0.166 versus 0.009 IQR -0.006, 0.037, P < 0.001]. Patients with HCM also demonstrated significantly less mitral annular excursion at both the septal and lateral AVJ. Performed offline, AVJ motion analysis took approximately 10 minutes per subject.

CONCLUSIONS

Atrioventricular junction motion analysis provides a practical and novel CMR method to assess mitral annular motion. In this proof of concept study we found highly statistically significant differences in mitral annular excursion and recoil between HCM patients and healthy volunteers.

The cholesterol emboli syndrome in atherosclerosis

Cholesterol emboli syndrome is a relatively rare, but potentially devastating, manifestation of atherosclerotic disease. Cholesterol emboli syndrome is characterized by waves of arterio-arterial embolization of cholesterol crystals and atheroma debris from atherosclerotic plaques in the aorta or its large branches to small or medium caliber arteries (100-200 μm in diameter) that frequently occur after invasive arterial procedures. End-organ damage is due to mechanical occlusion and inflammatory response in the destination arteries. Clinical manifestations may include renal failure, blue toe syndrome, global neurologic deficits and a variety of gastrointestinal, ocular and constitutional signs and symptoms. There is no specific therapy for cholesterol emboli syndrome. Supportive measures include modifications of risk factors, use of statins and antiplatelet agents, avoidance of anticoagulation and thrombolytic agents, and utilization of surgical and endovascular techniques to exclude sources of cholesterol emboli.

An unusually accentuated diastolic anterior motion of the mitral valve in aortic insufficiency

A 55-year-old woman was diagnosed with endocarditis involving the aortic valve and resulting in moderate aortic insufficiency. Transesophageal and transthoracic echocardiography demonstrated an unusually accentuated diastolic anterior motion of the anterior mitral valve leaflet toward the interventricular septum. The anterior leaflet remained within a few millimeters of the septum throughout diastole, with a narrow jet of aortic insufficiency separating the anterior leaflet from the septum. We hypothesize that the particularly long anterior mitral leaflet was drawn toward the septum during diastole due to the Venturi effect of the aortic insufficiency jet within a narrow ventricular outflow tract. This accentuated diastolic anterior motion may be a diastolic correlate of systolic anterior motion of the mitral valve.

Catheter-based left atrial appendage occlusion procedure: role of echocardiography

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.

Esophageal perforation, the most feared complication of TEE: early recognition by multimodality imaging

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.