Detection of LV apical thrombus by three-dimensional transesophageal echocardiography.

INTRODUCTION: Patients with apical myocardial infarction are at higher risk of developing left ventricular (LV) thrombi. Standard transesophageal echocardiography (TEE) is commonly used in assessing cardiac source of embolic cerebrovascular accident (CVA). Contrast-enhanced transthoracic echocardiography (TTE) improves sensitivity for thrombus detection compared with noncontrast TTE, and however for LV apical thrombi, contrast-enhanced magnetic resonance imaging (MRI) and/or contrast-enhanced computed tomography (CT) outperform both TTE and TEE in some studies. CASE: A 67-year-old man with history of prior myocardial infarction (MI), four-vessel coronary artery bypass surgery, congestive heart failure with LV ejection fraction of 30%, and diabetes mellitus presented to our facility with acute right occipital-parietal stroke and recent history of left lower extremity ischemia. Head and neck MRI and MR angiography found multiple posterior circulation infarcts suggestive of cardio-embolic etiology. TTE image quality was suboptimal even after contrast use to evaluate for LV thrombus, and due to renal insufficiency, MRI or CT was precluded and 3DTEE identified large LV apical thrombus with mobile components. CONCLUSION: 3DTEE may increase the detection of LV apical thrombi as well as evaluating its characteristics by live imaging as well as by offline reconstruction. TEE may be a useful diagnostic modality, especially in patients with decreased renal function, where iodinated contrast for cardiac CT or Gadolinium for MRI may be contraindicated. Multimodality imaging studies may further prove the utility of 3D echocardiographic imaging in the detection of LV apical thrombus.

Prevalence and Outcomes of Pericardial Effusion in Kidney Transplant Candidates.

Pericardial disease is a recognized manifestation of cardiovascular disease in the end-stage renal disease (ESRD) population, and can manifest as pericardial effusion, though the prognosis of pericardial disease in ESRD patients is unclear. In the modern era of renal replacement therapy, little is known about the prevalence and the implications of pericardial effusion in ESRD patients, its echocardiographic characteristics, and risk factors. We conducted a retrospective chart review on subjects > than 18 years of age with known ESRD who were undergoing outpatient evaluation for renal transplantation at Mayo Clinic Arizona between January 2001 and December 2015 and had baseline echocardiogram completed within 3 months of their initial evaluation. Patients with moderate sized pericardial effusions or larger were identified. The pericardial effusion cohort was age and gender matched with a cohort of patients with ESRD without pericardial effusion in a 1:2 fashion. 54 patients with moderate or greater sized pericardial effusion out of 2,820 patients that fit our inclusion criteria, corresponding to a prevalence of 1.9%. A total of 41 patients or 75.9%, had a moderate sized effusion. A total of 13 patients, or 24.1% had a large sized effusion, 7 of whom had tamponade physiology on echocardiography. The presence and size of the effusion was not predictive for worse outcomes. Hemodialysis duration was protective, but no other factors were predictive or protective in the development of moderate sized or larger pericardial effusions, including echocardiographic parameters.

A Unique Compensatory Mechanism for Total Pulmonary Vein Occlusion Post Atrial Fibrillation Catheter Ablation Visualized by Multimodality Imaging.

Pulmonary vein (PV) stenosis is a rare and serious complication of radiofrequency catheter ablation (RFCA) for atrial fibrillation. However, it can be asymptomatic or mildly symptomatic depending on the severity of the stenosis and the development of compensatory mechanisms. This study provides a detailed description and visualization of a unique type of venous collaterals that bypass the PV stenosis and drain directly in the left atrium alleviating PV stenosis sequelae. This study reports a case of a 61-year-old male who presented with mild dyspnea and fatigue 3 years post atrial fibrillation RFCA. After a thorough evaluation of the case, a redo-ablation was planned. As a part of the preablation workup, a transesophageal echocardiography (TEE), a ventilation-perfusion (V/Q) scan of the lungs, and a chest computed tomography angiogram (CTA) were performed. The TEE revealed total obstruction of the left superior PV, with no color Doppler flow detected. It also showed evidence of multiple collateral flows at the os of the left superior PV. The V/Q scan showed a large perfusion defect involving the entire left upper lobe consistent with a compromised left upper PV flow. The CTA with 3D volume rendering revealed the total occlusion of the left superior PV at its ostium. Moreover, the scan confirmed the pulmonary venous drainage via small collateral channels that was suggested by the TEE.

Decitabine Induced Delayed Cardiomyopathy in Hematologic Malignancy.

Decitabine is a pyrimidine analogue of nucleoside cytidine, used for the treatment of myelodysplastic syndromes, chronic myelogenous leukemia, and acute myelogenous leukemia. We present a case of cardiomyopathy associated with decitabine used for secondary acute myelogenous leukemia. The patient presented with new heart failure symptoms and an ejection fraction decline.