Morphological Assessment of Left Ventricular Thrombus by Live Three-Dimensional Transthoracic Echocardiography

A comparison of intracardiac echocardiography and transesophageal echocardiography for guiding device closure of ostium secundum atrial septal defect: A 15-year experience

BACKGROUND AND AIM

Our aim was to evaluate the fluoroscopy time (FT), procedure time (PT) safety and efficacy when using intracardiac echocardiography (ICE) in comparison to transesophageal echocardiography (TEE) guidance for transcatheter closure of Ostium Secundum Atrial Septal Defect (OS-ASD).

METHOD

Ninety patients (n = 90) diagnosed with OS-ASD underwent transcatheter closure between March 2006 and October 2021. Fifty-seven patients were treated under ICE guidance, while 33 patients were treated under TEE guidance.

RESULTS

Mean age was 43 ± 15 years and 42 ± 10 years in the ICE and TEE groups, respectively. The majority of patients had a centrally placed defect. Median FT was 8.40 min versus 11.70 min (p < .001) in the ICE group compared to the TEE group, respectively. Median PT was 43 min versus 94 min (p < .001) in the ICE group compared to the TEE group, respectively. Both ICE and TEE provided high quality images. All interventions were completed successfully, except for one patient in the ICE group who experienced a device migration, the development of atrial tachycardia in one patient and atrial fibrillation in two patients in the ICE group which spontaneously cardioverted. There were no other complications.

CONCLUSION

This study on a consistent cohort of patients with OS-ASD undergoing percutaneous closure suggests that use of ICE is safe and efficacious. Compared to TEE, ICE demonstrated significantly shorter FT and PT, decreasing the entire duration of the procedure and x-ray exposure. No relevant differences were observed in terms of success rate and complications.

Utilization of Two- and Three-Dimensional Transesophageal Echocardiography in Successfully Guiding Transcatheter Mitral Valve in Bioprosthetic Mitral Valve/Mitral Ring Implantation without Complications in Patients with Thrombus in Left Atrium/Left Atrial Appendage

BACKGROUND

The aim of this study is to describe, for the first time to our knowledge, the utilization of both two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) in successfully performing transcatheter mitral valve (MV) in bioprosthetic MV/MV annulopasty ring implantation using the apical approach in 12 patients (pts) with co-existing left atrial appendage (LAA) and/or LA (left atrium) body thrombus, which is considered a contraindication for this procedure.

METHODS AND RESULTS

All pts were severely symptomatic with severe bioprosthetic MV stenosis/regurgitation except one with a previous MV annuloplasty ring and severe native MV stenosis. Thrombus in LAA and/or LA body was noted in all by 2D and 3DTEE. All were at high/prohibitive risk for redo operation and all refused surgery. Utilizing both 2D and 3DTEE, especially 3DTEE, guidewires and the prosthesis deployment system could be manipulated under direct vision into the LA avoiding any contact with the thrombus. The procedure was successful in all with amelioration of symptoms and no embolic or other complications over a mean follow-up of 21 months.

CONCLUSION

Our study demonstrates the feasibility of successfully performing this procedure in pts with thrombus in LAA and/or LA body without any complications.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients after Anterior Myocardial Infarction

BACKGROUND

The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior.

METHODS

The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (<40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI.

RESULTS

Transthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively.

CONCLUSIONS

We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Incremental value of live/real-time three-dimensional transthoracic echocardiography over the two-dimensional technique in the assessment of left ventricular endocardial rupture with myocardial dissection and contained apical epicardial rupture following myocardial infarction

We report the incremental value of live/real-time three-dimensional transthoracic echocardiography (3DTTE) over two-dimensional transthoracic echocardiography (2DTTE) in making a definitive diagnosis of left ventricular endocardial rupture with myocardial dissection and contained apical epicardial rupture in an elderly male patient presenting with acute myocardial infarction. To the best of our knowledge, this has not been described previously.

Feasibility and rationale of direct current cardioversion immediately after transcatheter percutaneous edge-to-edge mitral valve repair

AIMS

Atrial fibrillation (AF) is a frequent comorbidity among patients with severe mitral regurgitation (MR). Direct current (DC) cardioversion is one of the strategies for rhythm control. However, the safety and feasibility of immediate DC cardioversion after MitraClip are not elucidated.

METHODS AND RESULTS

In this study, patients with symptomatic severe MR who underwent MitraClip were included. After fixing the MR, synchronized DC cardioversion was attempted for those with AF. A total of consecutive 60 patients, 36 subjects (60%), comorbid with AF. DC cardioversion was performed in 30 patients (mean age of 76.0 ± 9.3 years), and the successful conversion was achieved in 15 patients (50%). There was no any adverse event related to the cardioversion. Subjects with sustained conversion to SR experienced significant improvement in 6MWT (failed: 285 ± 110-308 ± 135 m, P = .278; successful: 269 ± 109 m-328 ± 78, P = .047) and reduction in NT-proBNP level (failed: 4411 ± 7401-3296 ± 4299 ng/mL, P = .217; successful: 4094 ± 2735-2353 ± 2856 ng/mL, P = .026) at 1 month.

CONCLUSIONS

Direct current cardioversion seemed to be safe and feasible immediately after the transcatheter edge-to-edge mitral valve repairs. Subjects who maintain SR experienced better functional improvement.

The Role of Multimodality Cardiovascular Imaging in Peripartum Cardiomyopathy

The burden of pregnancy-related heart disease has dramatically increased over the last decades due to the increasing age at first pregnancy and higher prevalence of cardiovascular risk factors such as diabetes, hypertension, and obesity. Pregnancy is associated with physiological changes in the cardiovascular system, including hemodynamic, metabolic, and hormonal adaptations to meet the increased metabolic demands of the mother and fetus. It has been postulated that pregnancy may act as a cardiovascular stress test to identify women at high risk for heart disease, where the inability to adequately adapt to the physiologic stress of pregnancy may reveal the presence of genetic susceptibility to cardiovascular disease or accelerate the phenotypic expression of both inherited and acquired heart diseases, such as peripartum cardiomyopathy (PPCM). PPCM is a rare and incompletely understood clinical condition. Despite recent advances in the understanding of its pathogenesis, PPCM is not attributable to a well-defined pathological mechanism, and therefore, its diagnosis still relies on the exclusion of overlapping dilated phenotypes. Cardiac imaging plays a key role in any peripartum woman with signs and symptoms of heart failure in establishing the diagnosis, ruling out life-threatening complications, guiding therapy and conveying prognostic information. Echocardiography represents the first-line imaging technique, given its robust diagnostic yield and its favorable cost-effectiveness. Cardiovascular magnetic resonance is a biologically safe high-throughput modality that allows accurate morpho-functional assessment of the cardiovascular system in addition to the unique asset of myocardial tissue characterization as a pivotal piece of information in the pathophysiological puzzle of PPCM. In this review, we will highlight current evidence on the role of multimodality imaging in the differential diagnosis, prognostic assessment, and understanding of the pathophysiological basis of PPCM.

Three-dimensional transthoracic echocardiographic identification of individual cusps of the pulmonary valve: Potential misidentification by the two-dimensional technique

We demonstrate the incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional modality in the identification of all three cusps of the pulmonary valve in patients in whom only two leaflets could be detected by the latter technique. This was because of the ability of 3DTTE to view the cusps enface permitting assessment of relationship to one another and the surrounding cardiac structures. In addition, 3DTTE showed not only the potential errors that can occur in pulmonary valve cusp identification when the two-dimensional modality is used alone but also how some of these errors can be avoided by paying attention to the surrounding structures.

Incremental value of live/real time three-dimensional transthoracic echocardiography over the two-dimensional technique in assessing carcinoid heart disease involving the aortic valve

We present a case of an adult with metastatic carcinoid heart disease, in whom live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional transthoracic echocardiography in assessing involvement of the aortic valve.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic atherosclerotic thrombi and ulcers

We present two cases in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two-dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of primary cardiac malignant fibrous histiocytoma

We describe a case of primary cardiac malignant fibrous histiocytoma where live/real time three-dimensional transesophageal echocardiography added incremental value to the two-dimensional modalities. Specifically, the three-dimensional technique allowed us to delineate the true extent and infiltration of the tumor, to identify characteristics of the tumor mass suggestive of its malignant nature, and to quantitatively assess the total tumor burden.

A pedunculated left ventricular thrombus in a women with peripartum cardiomyopathy: evaluation by three dimensional echocardiography

Peripartum cardiomyopathy is a cardiac condition characterized by development of heart failure during the last month of pregnancy or during the first five months of post partum period without any other identifiable cause of heart failure. The hypercoagulable state in the pregnancy along with left ventricular (LV) systolic dysfunction predisposes the patient to thromboembolic complications like intraventricular thrombi. We report a case of a 30-year-old female with peripartum cardiomyopathy along with a highly mobile mass in the LV cavity on two dimensional echocardiography. Three dimensional transthoracic echocardiography clearly showed the pedicle of the mass attached to the interventricular septum along with internal echolucent areas within the mass. Due to denial of the patient to undergo surgery, she was started on oral anticoagulation, with complete dissolution of the mass within one month.

Transthoracic echocardiographic assessment of spindle cell sarcoma of the pulmonary artery in a child

In this report, we present a case of spindle cell sarcoma of the pulmonary artery diagnosed by transthoracic echocardiography. To the best of our knowledge, this case is the youngest reported case of pulmonary artery sarcoma (PAS) to date. PAS is frequently confused for pulmonary embolism; in this case, echocardiographic findings allowed for differentiation between pulmonary embolism and solid tumor.

Coexisting bicuspid aortic and pulmonary valves with normally related great vessels diagnosed by live/real time three-dimensional transesophageal echocardiography

Coexistence of bicuspid aortic and pulmonary valves in the same patient is a very rare entity identified mainly during surgery and postmortem. To the best of our knowledge, only one case has been diagnosed by two-dimensional echocardiography in a newborn with malposition of the great arteries but no images were presented. Here, we are reporting the first case of bicuspid pulmonary and aortic valves diagnosed by live/real time three-dimensional transesophageal echocardiography in an adult with normally related great arteries.

A silent and late embolization of atrial septal defect occluder device into the right pulmonary artery: a case report

Percutaneous device closure of atrial septal defect (ASD) is an alternative treatment to surgery. The main advantages of the percutaneous approach include avoidance of surgery, short procedure time and hospital length, in addition to comparable rates of complications. However, percutaneous device closure is associated with infrequent early and late complications including device embolization, air embolism, cardiac tamponade and thrombotic complications. We report a rare complication of silent and late device embolization of the ASD occluder device into the right pulmonary artery, three months after implantation.

Incremental value of live/real time three-dimensional echocardiography in the diagnosis and evaluation of pericardial cyst

Pericardial cysts are rare anomalies of the pericardium that are usually asymptomatic and followed by two-dimensional (2D) echocardiography. Here we report a large pericardial cyst that could not be measured accurately by 2D echocardiography but three-dimensional (3D) echocardiography enabled measurements of the cyst that correlated well with computed tomography measurements. In addition, 3D echocardiography demonstrated the mono-trabeculated nature of the cyst further suggesting the incremental value of 3D echocardiography in the evaluation of pericardial cysts. The cyst was subsequently resected surgically.

Real time three-dimensional echocardiography evaluation of intracardiac masses

The evaluation of cardiac masses is often a challenge for cardiac imaging techniques. The traditional standby has been two-dimensional echocardiography (2DE). Real time three-dimensional echocardiography (RT3DE) offers incremental value for the evaluation of intracardiac masses by providing more accurate assessment of the size and shape of the mass as well as in some cases, composition of the mass. RT3DE aids with the relationship between the mass and adjacent structures. Therefore, here we discuss the subject of RT3DE evaluation of cardiac masses is reviewed and discussed in detail.

Incremental role of three-dimensional over two-dimensional ultrasound in the assessment of traumatic peripheral arteriovenous fistula

We present a patient with an accidental self-inflicted stab wound to his right thigh in whom three-dimensional (3D) ultrasound was able to find two communications between the right femoral artery and the femoral vein, in contrast to two-dimensional (2D) peripheral ultrasound which could find only one communication between them, thereby showing an incremental value of 3D over 2D ultrasound.

Live/Real time three-dimensional transthoracic echocardiographic assessment of inferior vena cava and hepatic vein thrombosis in sickle cell disease

We describe the value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over two-dimensional transthoracic echocardiography (2DTTE) in the assessment of inferior vena cava (IVC) and hepatic vein (HV) obstruction in a patient with sickle cell disease. 3DTTE provided additional information when compared to 2DTTE by (1) identifying the obstructing lesion as a likely thrombus, (2) by providing assessment of anatomical severity of IVC lumen obstruction since the thrombus could be visualized en face also, and (3) identifying an area of increased mobility of a portion of the thrombus suggesting greater risk of embolization. (Echocardiography 2010;27:594-596).

Usefulness of live/real time three-dimensional transthoracic echocardiography in the assessment of descending thoracic aorta graft dehiscence

We report the usefulness of live/real time three-dimensional transthoracic echocardiography to identify endovascular graft showing leakage not visualized using two-dimensional transthoracic echocardiography.

Live Three-Dimensional Transthoracic Echocardiographic Assessment of Left Ventricular Hydatid Cyst

We report an adult patient in whom live three-dimensional transthoracic echocardiography (3DTTE) complemented two-dimensional transthoracic echocardiography (2DTTE) in making a definitive diagnosis of a hydatid cyst located in the left ventricular cavity. The parent hydatid cyst, as well as the daughter cysts, contained within it could be delineated by both 2DTTE and live 3DTTE. However, the tertiary or granddaughter cysts originating from the daughter cysts as well as great-granddaughter cysts budding from tertiary cysts could be visualized only when the live 3DTTE data sets were cropped and sectioned sequentially using multiple cutting planes. In addition, apparent intrinsic mobility of some of the tertiary cysts implying viability was detected only by 3DTTE.

Incremental value of live/real time three-dimensional transthoracic echocardiography in the assessment of right ventricular masses

This case series demonstrates the incremental value of three-dimensional transthoracic echocardiography (3D TTE) over two-dimensional transthoracic echocardiography (2D TTE) in the assessment of 11 patients with right ventricular (RV) masses or mass-like lesions (three cases of RV thrombus, one myxoma, one fibroma, one lipoma, one chordoma, and one sarcoma and three cases of RV noncompaction, which are considered to be mass-like in nature). 3D TTE was of incremental value in the assessment of these masses in that 3D TTE has the capacity to section the mass and view it from multiple angles, giving the examiner a more comprehensive assessment of the mass. This was particularly helpful in the cases of thrombi, as the presence of echolucencies indicated clot lysis. In addition, certainty in the number of thrombi present was an advantage of 3D TTE. Also, sectioning of cardiac tumors allowed more confidence in narrowing the differential diagnosis of the etiology of the mass. In addition, 3D TTE allowed us to identify precise location of the attachments of the masses as well as to determine whether there were mobile components to the mass. Another noteworthy advantage of 3D TTE was that the volumes of the masses could be calculated. Additionally, the findings by 3D TTE correlated well with pathologic examination of RV tumors, and some of the masses measured larger by 3D TTE than by 2D TTE, which was also validated in one case by surgery. As in the case of RV fibroma, another advantage was that 3D TTE actually identified more masses than 2D TTE. RV noncompaction was also well studied, and the assessment with 3D TTE helped to give a more definitive diagnosis in these patients.

Usefulness of live/real time three-dimensional transthoracic echocardiography in diagnosing acquired left ventricular-right atrial communication misdiagnosed as severe pulmonary hypertension by two-dimensional transthoracic echocardiography

We describe an adult patient with an acquired left ventricular-right atrial communication that was misdiagnosed as severe pulmonary hypertension (PH) by two-dimensional (2D) transthoracic echocardiography, but accurately detected on three-dimensional (3D) transthoracic echocardiography. Open heart surgery confirmed the defect.

Demonstration of Left Ventricular Thrombi with Real-time 3-Dimensional Echocardiography in a Patient with Cardiomyopathy

Two-dimensional echocardiography is a conventional tool to evaluate left ventricular thrombus but the use of real-time 3-dimensional echocardiography is not widespread. We report a 35-year-old man with unsuspected cardiomyopathy and a long history of both amphetamine and alcohol abuse. He presented with abdominal pain and right lower leg numbness and pain. Computed tomography revealed infarctions of the spleen and both kidneys, along with occlusion of the right femoral artery. Echocardiography demonstrated left ventricular systolic dysfunction and multiple large thrombi in the left ventricle. The thrombi had a specific dynamic pattern on real-time 3-dimensional echocardiography. The patient underwent surgical embolectomy of the right femoral artery and was anticoagulated. Two months later, the cardiac thrombi had totally disappeared.

Thrombotic "ghosts": echocardiographic appearance of thrombi with hollow cores and implications regarding mechanism of spontaneous clot lysis

We present a case of a patient whose transesophageal echocardiogram revealed multiple thrombi in different stages of central lysis. This produced the appearance of undulating thin outer shells and lucent central cores resembling "ghosts." Although most thrombi appear to resolve by a lytic process that produces reduction in size from the exterior surface inward, the thrombi illustrated in this case appear to lyse from the interior outward. In this report we discuss the mechanisms of intracardiac clot lysis and speculate that a newly described protein factor, thrombin-mediated inhibition of fibrinolysis, may play a role in formation of hollow thrombi.