Taking Command of Three-Dimensional Stitching Artifacts: From an Annoyance to an Easy Tool for Navigating Three-Dimensional Transesophageal Echocardiography.

Despite many recent advances in three-dimensional (3D) transesophageal echocardiography (TEE) imagining, the process of orienting 3D TEE images is nonintuitive and uses assumptions based on idealized anatomy. Correlating two-dimensional TEE cross-sectional images to 3D reconstructions remains an additional challenge. In this article, we suggest the repurposing of the stitching artifact generated in 2-beat electrocardiogram-gated 3D TEE as a means of exactly orienting 3D images within a patient's unique anatomy. We demonstrate the application of this strategy to assess a normal mitral valve to localize scallops of mitral valve prolapse and to visualize typical left atrial appendage two-dimensional cuts in a 3D space. By taking command of stitching artifacts, cardiac imagers can successfully navigate the complex structures of the heart for optimal, individualized echocardiographic views.

Native mitral valve staphylococcus endocarditis with a very unusual complication: Ruptured posterior mitral valve leaflet aneurysm.

Infective endocarditis (IE) is a life-threatening disease associated with in-hospital mortality of nearly one in five cases. IE can destroy valvular tissue, which may rarely progress to aneurysm formation, most commonly at the anterior leaflet in instances of mitral valve involvement. We present a remarkable case of a patient with IE and a rare complication of a ruptured aneurysm of the posterior leaflet of the mitral valve. Two- and Three-dimensional transesophageal echocardiography, intra-operative videography, and histopathologic analysis revealed disruption at this unusual location-at the junction of the P2 and P3 scallops, surrounded by an annular abscess.

Two cases of acute endocarditis misdiagnosed as COVID-19 infection.

The COVID-19 pandemic has presented countless new challenges for healthcare providers including the challenge of differentiating COVID-19 infection from other diseases. COVID-19 infection and acute endocarditis may present similarly, both with shortness of breath and vital sign abnormalities, yet they require very different treatments. Here, we present two cases in which life-threatening acute endocarditis was initially misdiagnosed as COVID-19 infection during the height of the pandemic in New York City. The first was a case of Klebsiella pneumoniae mitral valve endocarditis leading to papillary muscle rupture and severe mitral regurgitation, and the second a case of Streptococcus mitis aortic valve endocarditis with heart failure due to severe aortic regurgitation. These cases highlight the importance of careful clinical reasoning and demonstrate how cognitive errors may impact clinical reasoning. They also underscore the limitations of real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 testing and illustrate the ways in which difficulty interpreting results may also influence clinical reasoning. Accurate diagnosis of acute endocarditis is critical given that surgical intervention can be lifesaving in unstable patients.

Unusual Cause of Severe Tricuspid Regurgitation: Tricuspid Leaflet Annular Tear Following Remote Motor Vehicle Accident.

Tricuspid regurgitation (TR) is an uncommon and underdiagnosed complication of blunt chest trauma. Typical mechanisms include torn chordae, papillary muscle rupture, and radial leaflet tear. We describe an unusual case of traumatic TR due to circumferential avulsion of the anterior tricuspid leaflet from the tricuspid annulus and the crucial role of multimodality imaging in its diagnosis and treatment. (Level of Difficulty: Intermediate.).

Photorealistic imaging of left atrial appendage occlusion/exclusion.

Recent improvements in 3D TEE post processing rendering techniques referred to as TrueVue (Philips Medical Systems, Andover, MA, USA). It allows for novel photorealistic imaging of cardiac structures including left atrial appendage (LAA) and its closure devices. Here we present TrueVue images of the LAA prior to and after LAA exclusion/occlusion using various percutaneous and surgical techniques. TrueVue may improve delineation of LAA anatomy prior to occlusion as well as visualization of occluder device position within the LAA.

Klippel-Feil syndrome: A very unusual cause of severe aortic regurgitation visualized by multimodality imaging.

A 51-year-old man with Klippel-Feil syndrome (KFS) and immunodeficiency syndrome, status postintravenous immunoglobulin therapy, presented with shortness of breath. He was found to have severe aortic regurgitation in the setting of a trileaflet aortic valve with thickened leaflets and mild prolapse of the right coronary cusp with left ventricular dilation and borderline left ventricular ejection fraction. Although various cardiac anomalies have been described in KPS, otherwise unexplained severe aortic regurgitation has not been previously reported to the best of our knowledge. The patient underwent an uncomplicated surgical aortic valve replacement with a 25-mm Medtronic Avalus pericardial tissue valve resulting in symptomatic improvement. Intra-operative management and transesophageal echocardiography can be particularly challenging in KFS patients. We describe the first reported case of severe aortic regurgitation in KPS, review the cardiac anomalies associated with the syndrome, and highlight the clinical challenges in intra-operative management of these patients.

Left Atrial Occlusion Device Implantation: the Role of the Echocardiographer.

PURPOSE OF REVIEW: Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. For patients with atrial fibrillation who are unable to tolerate systemic anticoagulation, left atrial appendage (LAA) occlusion has been shown to mitigate stroke risk. In this article, we describe the vital role of the echocardiographer in intraprocedural guidance of percutaneous LAA occlusion procedures as well as in the pre- and post-procedure assessment of these patients. RECENT FINDINGS: A few percutaneously delivered devices for LAA exclusion from the systemic circulation are available in contemporary practice. These devices employ an either exclusive endocardial LAA occlusion approach, such as the Watchman (Boston Scientific, Maple Grove, MN) and Amulet (St. Jude Medical, Minneapolis, MN), or both an endocardial and pericardial (epicardial) approach such as the Lariat procedure (SentreHEART, Palo Alto, CA). Two- and three-dimension transesophageal echocardiography is critical for patient selection, procedure planning, procedural guidance, and ensuring satisfactory immediate as well as long-term LAA occlusion/exclusion efficacy. This review will provide an overview of the role of the echocardiographer in all aspects of LAA occlusion/exclusion procedures for the most commonly used commercially available devices in current practice.