Esophageal dissection complicating transesophageal echocardiogram--the lesson to be learned: do not force the issue

Spontaneous circumferential intramural esophageal dissection complicated with esophageal perforation and esophageal-pleural fistula: a case report and literature review

Spontaneous intramural esophageal dissection (IED) is a rare disease entity. There are few reports of spontaneous IED requiring surgical treatment. Hereby, we report a 37-year-old gentleman who was diagnosed to have spontaneous extensive circumferential IED complicated with esophageal perforation, empyema, and esophageal-pleural fistula. Esophageal stenting and drainage of empyema were unsuccessful. Computed tomography and gastrografin contrast swallow demonstrated a leak to the pleural cavity, suggestive of esophageal-pleural fistula. Subsequently, a two-stage operation was performed: cervical esophagogastrostomy to bypass the perforated esophagus, followed by esophagectomy and decortication of the right lung. The patient recovered and was discharged home after a 3-week hospitalization. The management principles and recent published literature related to IED were reviewed.

Transthoracic two-dimensional xPlane and three-dimensional echocardiographic analysis of the site of mitral valve prolapse

This study sought to assess the value of two-dimensional (2D) transthoracic echocardiography (TTE), 2D xPlane imaging and three-dimensional (3D) TTE for the definition of the site and the extent of mitral valve (MV) prolapse. Fifty patients underwent transthoracic 2D, 2D xPlane and 3D echocardiography. With 2D xPlane a segmental analysis of the MV was performed, by making a lateral sweep across the MV coaptation line as seen in the parasternal short-axis view. Inter-observer agreement for specific scallop prolapse was for 2D xPlane excellent (97 %, kappa = 0.94) and for 3D TTE moderate (85 %, kappa = 0.67). The respective sensitivities of standard 2D TTE, 2D xPlane, and 3D TTE for the identification of the precise posterior scallop prolapse were for P1 92, 85, and 92 %, for P2 96, 96, and 82 %, and for P3 86, 81, and 71 %. In total, 5 (8 %) prolapsing MV scallops were missed by 2D TTE, 7 (12 %) by 2D xPlane, and 12 (20 %) by 3D TTE. The sensitivity of 3D TTE was significantly lower than standard 2D imaging (80 % versus 93 %, P < 0.05). The extent of P2 prolapse was under or overestimated in 5 patients with 2D xPlane and in 9 patients with 3D TTE. 2D xPlane imaging is an accurate, easy to use (compared to 3D TTE) and easy to interpret (compared to 2D and 3D TTE) imaging modality to study the site and the extent of MV prolapse.

Cardiovascular computed tomography and MRI in clinical practice: aortopathy

The aorta serves as a lifeline for arterial supply throughout the body, the site of potentially fatal mechanical complications, and a mechanistic partner in hypertension and numerous cardiovascular diseases, thus meriting our careful attention. The following clinical vignette illustrates a case of aortic disease, paying homage to the aorta as we begin a series on cardiovascular imaging in the Journal of Cardiovascular Medicine. This series seeks to present contemporary approaches to diagnosis and management in cardiovascular medicine that include state-of-the-art imaging techniques guided by bedside clinical assessment. Incorporating volumetric multidetector computed tomography and dynamic MRI at various stages of this patient's care afforded the timely detection and management of her aortopathy.