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Vascular, congenital, and other interventional complications

A Dual-Snare Percutaneous Retrieval of Venous Stent Embolization to the Right Side of the Heart Ajay K. Sharma, MD Sarju Ganatra, MD James Hansen, MD Neil Yager, DO Thomas Piemonte, MD Gautam Gadey, MD Michael S. Levy, MPH, MD A 57-year-old man with a medical history of asthma was transferred from an outside hospital for evaluation of cardiac mass where he was treated for extensive right lower extremity iliofemoral deep venous thrombosis with…

Vascular, congenital, and other anatomy and pathophysiology

Hemodynamic Findings of Effusive-Constrictive Pericarditis Anand D. Shah, MD Daniel L. Molloy, MD John E.A. Blair, MD A 64-year-old man with rheumatoid arthritis presented with progressive abdominal and leg swelling, anorexia, and dyspnea for several years. Physical examination was notable for a pericardial knock, pulsatile hepatomegaly, and lower extremity edema. The jugular vein was distended past the angle of the jaw and did not decrease with inspiration (Kussmaul sign).…

Structural heart disease: Complications and techniques

Acute Artery Occlusion During Transcatheter Aortic Valve Replacement in a Patient With an Anomalous Origin of the Left Circumflex Coronary Artery Juan Gabriel Acosta-Vélez, MD Bruno García del Blanco, MD Josep Guindo, MD Jose Montiel Serrano, MD Hug Cuellar Calabria, MD Gerard Martí Aguasca, MD Teresa Gonzalez-Alujas, MD Ignasi Durán, MD Pilar Tornos, MD, PhD The images presented are of an 86-year-old woman with severe aortic stenosis in whom a transcatheter aortic valve replacement (TAVR)…

Coronary interventional techniques

A Giant Coronary Artery Aneurysm Treated With Multiple Overlapping Covered Stents Alberto F. Cereda, MD Gianluca Tiberti, MD Isidoro G. Pera, MD Edoardo Cantù, MD Luca A. Ferri, MD Stefano Savonitto, MD Luigi Piatti, MD A 62-year-old man with known coronary artery ectasias was referred to our center in 2001 for ischemic symptoms and mild inferior hypokinesis on echocardiography. Coronary angiography showed diffused coronary artery ectasias with an aneurysmatic appearance of the proximal…

Complications of coronary intervention

Acute Stent Thrombosis: Technical Complication or Inadequate Antithrombotic Therapy? An Optical Coherence Tomography Study Sammy Elmariah, MD, MPH Ik-Kyung Jang, MD, PhD A 68-year-old woman was admitted to the hospital with non–ST-segment elevation myocardial infarction. Coronary angiography showed a 95% mid stenosis in the left anterior descending artery ( Fig. 2.1 A). The lesion was treated with a 2.50 × 18 mm Xience drug-eluting stent (Abbott Vascular, Santa…

Coronary anatomy and pathophysiology

A Rare Case of Anomalous Original Left Circumflex Artery Stenosis After Artificial Mitral Valve Replacement Qing Dai, MD Jie Song, MD Jian He, MD Biao Xu, MD A 72-year-old woman was admitted because of progressive 9-year chest tightness. Nine years ago, she underwent mitral valve replacement using a Hancock II porcine mitral valve bioprosthesis (size 27) (Medtronic, Minneapolis, Minnesota) for posterior mitral valve prolapse. Preoperative coronary angiogram showed anomalous origin…

Transcatheter closure devices

Atrial septum CASE 14-1 Anatomy and imaging of atrial septum See Case 7-1 in Chapter 7 , Adult Congenital Heart Disease. CASE 14-2 PFO device closure for recurrent transient neurological events About 3 years ago this 44-year-old female had an episode of transient dysarthria with a CT scan revealing evidence of a small cerebral infarct at that time. About 6 months ago, she had several brief…

Transcatheter valve therapies

Transcatheter aortic valve replacement Since the first transcatheter bioprosthetic aortic valve was implanted, changes have included smaller and more flexible delivery systems for use in smaller vessels; lower frame height in order to minimize interference with coronary blood flow, mitral valve function, and atrioventricular heart block; a basal skirt to minimize paravalvular regurgitation; and greater variety of valve sizes to accommodate different annular dimensions. Figs 13.8…

Mechanical circulatory support

In addition to standard cardiopulmonary bypass during cardiac surgery, there now are several options for longer-term mechanical circulatory support ranging from a simple intraaortic balloon pump to a total artificial heart. Some of these devices are used in the hospital setting because of the external components of the device and need for continuous monitoring, including the intraaortic balloon pump (IABP), percutaneous assist devices, and use of…

Masses

Normal variants CASE 11-1 Left atrial appendage TEE is often requested before electrical cardioversion or catheter ablation for atrial fibrillation to evaluate the left atrial appendage for the presence of thrombus. Adequate visualization of the atrial appendage requires at least two orthogonal views, using a high-frequency (5 MHz or higher) transducer and with the image zoomed to show the appendage anatomy. This case shows normal views…

Diseases of the great vessels

Pseudoaneurysms CASE 10-1 Aortic pseudoaneurysm after avr with anterior extension This 41-year-old man with Reiter’s syndrome underwent mechanical aortic valve replacement 9 years ago for aortic regurgitation. Four months ago he developed prosthetic valve endocarditis. He was treated with antibiotics and repeat aortic valve replacement with that procedure complicated by a paravalvular abscess requiring placement of a pericardial patch in the periannular region. Postoperatively, he had…

Pericardial disease

CASE 9-1 Pericardial effusion Examples of pericardial effusions seen on intraoperative TEE in several different patients are shown. Comments A pericardial effusion is diagnosed based on the echocardiographic finding of an echo-lucent area around the heart. Pericardial effusions are usually circumferential, with fluid filling the entire pericardial space around the right and left ventricles, although pericardial effusions may also be asymmetric due to adhesions resulting in…

Hypertrophic cardiomyopathy

CASE 8-1 Transplant for hypertrophic cardiomyopathy This 26-year-old woman with hypertrophic cardiomyopathy and prolonged QT syndrome was referred for heart transplantation for low-output heart failure with clinical symptoms of fatigue and marked exercise intolerance with New York Heart Association (NYHA) class III symptoms despite maximal medical therapy. Right heart catheterization documented a pulmonary artery pressure of 24/9 mm Hg with a pulmonary wedge pressure of 10…

Adult congenital heart disease

Atrial septal defects CASE 7-1 Anatomy and imaging of the atrial septum The atrial septum is close to the TEE transducer position and is well visualized, as the normal orientation is perpendicular to the ultrasound beam. From a single high TEE probe position, the entire atrial septum can be examined by starting in a four-chamber view and then incrementally rotating the image plane to the bicaval…

Right-sided valve disease

TABLE 6-1 Best Views for Assessing Tricuspid Valve ME four-chamber view With probe anteflexed, septal leaflet will be seen adjacent to interventricular septum, and anterior leaflet adjacent to right ventricular free wall. Retroflexion will allow visualization of posterior leaflet adjacent to free wall. ME RV inflow–outflow view With transducer angle rotated to about 50–80 degrees, anterior leaflet and posterior leaflet are seen. TG views Transgastric short-axis…

Surgical prosthetic valves

Prosthetic valves Normal valves CASE 5-1 Bioprosthetic aortic valve Comments The two major categories of prosthetic valves are tissue valves and mechanical valves. Bioprosthetic (or tissue) valve leaflets are fashioned from bovine pericardium or a porcine aortic valve. The leaflets are supported by a rigid ring around the annulus with metal or polymer stents that support the commissures of the valve leaflets or by the cylindrical…

Endocarditis

Native valve endocarditis CASE 4-1 Aortic valve endocarditis This 39-year-old female with a history of intravenous drug use, uncontrolled diabetes, and chronic pancreatitis had recently undergone a 21-day course of antibiotics for a soft tissue infection of her hand. In the 2 days before admission she had become severely fatigued and more short of breath on exertion. Auscultation of a murmur prompted a transthoracic echocardiogram that…

Aortic valve disease

Aortic valve anatomy CASE 3-1a Normal trileaflet aortic valve CASE 3-1b Bicuspid aortic valve This 47-year-old male presented to the OR for mitral valve repair. Incidentally, a bicuspid aortic valve was detected; however, the systolic opening was normal with a normal antegrade flow velocity, and only mild aortic regurgitation was present. CASE 3-1c Unicuspid aortic valve This 22-year-old male with a known unicuspid valve had mild…

Mitral valve disease

TABLE 2-1 The Systematic Mitral Valve Examination Name of View Description of View See Case 2-1 , Normal Mitral Valve Anatomy ME four-chamber view (0 degrees) AML is on left side, adjacent to aortic valve. PML is on right side. Area of PML and AML that are visible are mostly P2 and A2. ME commissural view (60 degrees) Two apparent coaptation points. From left to right,…

Coronary artery disease

Visualization of the coronary arteries and regional wall motion CASE 1-1 Normal coronary arteries Comments As shown in these examples, the proximal coronary arteries can often be visualized on TEE. The left main coronary artery arises from the left coronary sinus of Valsalva, is easily visualized in over 85% of patients and has a normal diameter of 4.2 ± 0.7 mm, with a slightly smaller average…