Pan-Cardiac Cycle Fixed Mitral Valve Opening in an LVAD Patient Presenting with Hemorrhagic Shock.

We present the case of a patient with a HeartMate II left ventricular assist device (LVAD) who underwent an elective cholecystectomy and abruptly decompensated on postoperative day 9. We highlight the uncommon echocardiogram finding of mitral valve leaflets fixed widely open throughout the cardiac cycle during an LVAD suction event. Bedside echocardiographic confirmation of a suction event enabled the rapid diagnosis and intervention for hemorrhagic shock before blood tests and radiographic results were available. Acoustic image quality can be limited in LVAD patients, and awareness of this uncommon finding may increase specificity for the echocardiographic diagnosis of LVAD suction events.

Strain imaging as a prognostic indicator for complications in COVID-19 patients.

The goal of this study was to determine the potential for right ventricular (RV) and left ventricular (LV) strain to predict cardiopulmonary complications of COVID-19. We identified 276 patients with COVID-19 who underwent transthoracic echocardiography within 30 days of COVID-19 diagnosis at our institution. Patients were excluded if they had a history of any primary outcomes before COVID-19 diagnosis or insufficient imaging. LV global longitudinal strain (GLS) and RV GLS were obtained using 2-dimensional speckle-tracking echocardiography. Primary outcomes were death, pulmonary embolism, congestive heart failure (CHF), cardiomyopathy, pulmonary fibrosis, pulmonary hypertension, acute respiratory distress syndrome (ARDS), and myocardial infarction (MI) occurring after COVID-19 diagnosis. In the final analysis of 163 patients, mean RV GLS and LV GLS were reduced, and 43.6% developed at least one primary outcome. There were significant differences in LV GLS distribution in terms of CHF, cardiomyopathy, and MI in bivariate analysis. However, LV GLS was not significantly associated with CHF after adjusting for LV ejection fraction and RV fractional area change, nor with MI after adjusting for troponin T. RV GLS was significantly associated with ARDS after adjusting for other variables. In the risk stratification of patients with COVID-19, strain imaging can provide incremental prognostic information, as worsened RV GLS is associated with the development of ARDS.

Cardiac Tamponade Secondary to IVC Filter Retrieval.

Cardiac tamponade is a rare but potentially fatal complication of inferior vena cava filter retrieval. We discuss such a case to facilitate prompt recognition and prevention of this complication by medical providers. (Level of Difficulty: Beginner.).

Air Should Not be There: A Case of Pneumomediastinum and Pneumopericardium in COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus identified after widespread pneumonia cases in Wuhan, China at the end of 2019. This virus has been deemed a global pandemic and there remain many unknowns regarding the pathogenesis, management, treatment, and outcomes. This case report highlights a rare condition that possibly developed from the novel virus.  A 68-year-old Hispanic male with hypertension and gastroesophageal reflux disease, presented with two weeks history of fevers, chills, cough, and progressive shortness of breath. He was found to be positive for the novel SARS-CoV-2 upon admission. He rapidly developed severe acute respiratory distress syndrome (ARDS) secondary to his coronavirus disease 2019 (COVID-19) pneumonia requiring intubation and full ventilator support associated with acute anuric renal failure requiring emergent hemodialysis catheter placement and continuous renal replacement therapy (CRRT). Two weeks after being on mechanical ventilation and CRRT, he developed episodes of hypotension and tachycardia. A chest radiograph and computed tomography (CT) scan diagnosed pneumopericardium. In the case presented, the patient's CT of his thorax demonstrated bilateral ground-glass opacities and bilateral reticulations consistent with intraparenchymal injuries, most likely from his ARDS secondary to his initial SARS-CoV-2 infection. To date, there remains an unknown association between COVID-19 and causation of pneumomediastinum and pneumopericardium. There continues to be reports of clinically significant findings of pneumomediastinum and pneumopericardium in COVID-19 patients. It is known that COVID-19 causes dysregulated inflammation leading to diffuse alveolar damage and rupture, as well as myocarditis which may be the precipitant to the development of pneumomediastinum and pneumopericardium. This case highlights the findings of pneumopericardium and pneumomediastinum in the novel SARS-CoV-2 virus. Given the multiple reported cases with similar time frames to the development of spontaneous pneumomediastinum in COVID-19 patients, an association between COVID-19 and spontaneous pneumomediastinum should be further studied.

Safety and feasibility of combined atrial fibrillation ablation and left atrial appendage occlusion after left atrial appendage electrical isolation.

OBJECTIVE: To demonstrate the feasibility of combining left atrial appendage electrical isolation (LAAEI) with left atrial appendage occlusion (LAAO) to increase efficacy of persistent/longstanding atrial fibrillation (PLAF) catheter ablation (CA) while mitigating risk of left atrial appendage (LAA) thrombus. BACKGROUND: CA for atrial fibrillation (AF) plus LAAO is safe and feasible. LAAEI may improve freedom from recurrence in PLAF but may increase LAA thrombus. METHODS: We performed 42 concomitant procedures in patients with PLAF. After standard lesions, LAAEI was performed. LAAO immediately followed ablation. If 3-month transesophageal echocardiogram (TEE) was benign, oral anticoagulation (OAC) was transitioned to dual antiplatelet therapy for 3 more months. RESULTS: Patients were 71.1 ± 8.5 years old, with CHADS2-VASc of 3.3 ± 1.1 and HAS-BLED of 2.5 ± 1.4. Twenty-eight of 42 patients (66.7%) were completely AF free over an average follow-up of 18.6 ± 8.6 months. The AF-free survival estimate was 94.5% at 1 year. There was no thromboembolism (TE) during the follow-up. There were six non-significant leaks acutely and six non-significant leaks at 6 months. There were three device-related thrombi, although 2/3 stopped OAC prematurely. CONCLUSION: A combined procedure is feasible and effective in treating arrhythmia and stroke risk associated with PLAF. The risk of TE despite OAC after LAAEI supports simultaneous LAAO.

Left Atrial Appendage Occlusion Complicated by Appendage Perforation Rescued by Device Deployment.

The Watchman device is a transcatheter left atrial appendage (LAA) occluding device used in patients with nonvalvular atrial fibrillation (NVAF) and a high CHADS2-VA2SC score who are poor long-term anticoagulation candidates. Pericardial effusion related to device deployment and perforation can be a life-threatening complication. While not common in hands of experienced operators, management may require surgical intervention. Here we present a rare case of LAA perforation, which was corrected by successful repositioning of the device foregoing the need for surgical management.

Retained fibrin sleeve: transesophageal echocardiographic observations.

The role of echocardiography for the evaluation of thrombus formation on indwelling intracardiac catheters is well established. Considerably less well described, however, are the echocardiographic characteristics of the so-called retained fibrin sheath, a sleeve of fibrin that surrounds the catheter at the point at which it enters the vein that commonly remains adherent to the vessel wall after catheter removal. The authors report the transesophageal echocardiographic findings of a retained fibrin sheath following catheter removal in a patient with end-stage renal disease and infective endocarditis of the aortic valve.