It's Crowded Here - A Case of Cor Triatriatum Sinister.

The image presented is a still frame taken from a transesophageal echocardiogram of a 76-year-old male who was referred for evaluation of mitral valve disease. He was found to have a non-flow limiting membrane, dividing the left atrium into two sections, consistent with the diagnosis of cor triatriatum sinister.

Recurrent Admissions for Respiratory Distress Caused by Large Renal AVF.

Renal arteriovenous fistulas (AVFs) are an uncommon complication of nephrectomy. In this report, we present the case of a 66-year-old female presenting with progressive dyspnea on exertion and exercise intolerance. She was diagnosed and treated for adult onset reactive airway disease. The patient underwent nephrectomy at age 18 secondary to recurrent pyelonephritis from vesicoureteral reflux. She underwent a surveillance computed tomography (CT) scan to evaluate a small ascending aneurysm that was initially detected on cardiac echocardiogram. A large left renal AVF was detected incidentally on the CT scan. The fistula was successfully treated by ligation of the renal artery with resolution of pulmonary symptoms.

Targeted Transthoracic Acoustic Activation of Systemically Administered Nanodroplets to Detect Myocardial Perfusion Abnormalities.

BACKGROUND: Liquid core nanodroplets containing condensed gaseous fluorocarbons can be vaporized at clinically relevant acoustic energies and have been hypothesized as an alternative ultrasound contrast agent instead of gas-core agents. The potential for targeted activation and imaging of these agents was tested with droplets formulated from liquid octafluoropropane (C3) and 1:1 mixtures of C3 with liquid decafluorobutane (C3C4). METHODS AND RESULTS: In 8 pigs with recent myocardial infarction and variable degrees of reperfusion, transthoracic acoustic activation was attempted using 1.3 to 1.7 MHz low (0.2 mechanical index [MI]) or high MI (1.2 MI) imaging in real time (32-64 Hertz) or triggered 1:1 at end systole during a 20% C3 or C3C4 droplet infusion. Any perfusion defects observed were measured and correlated with delayed enhancement magnetic resonance imaging and postmortem staining. No myocardial contrast was produced with any imaging setting when using C3C4 droplets or C3 droplets during low MI real-time imaging. However, myocardial contrast was observed in all 8 pigs with C3 droplets when using triggered high MI imaging and in 5 of 6 pigs that had 1.7 MHz real time-high MI imaging. Although quantitative myocardial contrast was lower with real-time high MI imaging than 1:1 triggering, the correlation between real-time resting defect size and infarct size was good (r=0.97; P<0.001), as was the correlation with number of transmural infarcted segments by delayed enhancement imaging. CONCLUSIONS: Targeted transthoracic acoustic activation of infused intravenous C3 nanodroplets is effective, resulting in echogenic and persistent microbubbles which provide real-time high MI visualization of perfusion defects.

Utilization of modified diagnostic ultrasound and microbubbles to reduce myocardial infarct size.

OBJECTIVE: We sought to determine whether guided high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion could augment low-dose fibrinolytic therapy in treating acute myocardial infarction (ST segment elevation myocardial infarction, STEMI). METHODS: Acute thrombotic occlusions of the left anterior descending were created in 32 atherosclerotic pigs. Fourteen historical control pigs received half dose of tissue plasminogen activator alone (half tPA), while the subsequent 18 were randomised to (a) 1.0 mg/kg tPA (full-dose tPA); (b) low-dose tPA (0.5 mg/kg) and an intravenous microbubble infusion where guided transthoracic high MI impulses were applied intermittently to the risk area (guided high MI/half tPA) or (c) guided high MI impulses and microbubbles alone (guided high MI alone). Angiographic recanalisation, ST segment resolution and wall thickening (WT) at 60 min were compared between all pigs, while indexed infarct size at 48 h was compared in the 18 randomised pigs. RESULTS: Recanalisation rates improved from 36% for half dose tPA alone to 83% with the addition of guided high MI impulses, while it was 50% for full-dose tPA and guided high MI alone. WT recovery within the risk area following treatment was highest for guided high MI/half tPA (p=0.007 compared with full-dose tPA; ANOVA), and indexed infarct size was lowest (p<0.05 compared to full-dose tPA). CONCLUSIONS: Guided high MI-induced microbubble cavitation from a diagnostic transducer added to low-dose tPA can immediately improve regional function and reduce infarct size in acute STEMI. TRIAL REGISTRATION NUMBER: Clinical Trials.gov NCT02170103.

Bioprosthetic mitral valve thrombosis complicating antiphospholipid antibody syndrome, successfully treated with thrombolysis.

The incidence of bioprosthetic valve thrombosis and related embolic complications is extremely rare, obviating the need for long-term anticoagulation. As a result, experience in the diagnosis and treatment of bioprosthetic valve thrombosis is fairly limited. We report the first case of antiphospholipid antibody syndrome presenting as bioprosthetic mitral valve thrombosis, 15 months after valve replacement, and successfully treated with thrombolytic therapy.

Clinical assessment and rest and stress echocardiography for prediction of long-term prognosis in African Americans with known or suspected coronary artery disease.

BACKGROUND: There is limited information on noninvasive risk stratification of African Americans, a high-risk group for cardiovascular events. We investigated the value of clinical assessment and echocardiography for the prediction of a long-term prognosis in African Americans. METHODS: Dobutamine echocardiography was performed in 324 African Americans. Two-dimensional measurements were performed at rest, and rest and stress wall motion was assessed. A retrospective follow-up was conducted for cardiac events: myocardial infarction (MI) or cardiac death (CD). RESULTS: The mean age was 59 +/- 12 years, and 83% of patients had hypertension. The follow-up was obtained in 318 (98%) patients for a mean of 5.3 years. The events occurred in 107 (33%) subjects. The independent predictors of events were history of MI (P = 0.001, risk ratio [RR] 2.04), ischemia (P = 0.007, RR 1.97), fractional shortening (P = 0.033, RR 0.08), and left atrial (LA) dimension (P = 0.034, RR 1.39). An LA size of 3.6 cm and a fractional shortening of 0.30 were the best cutoff values for the prediction of events. Prior MI, ischemia, LA size >3.6 cm, and fractional shortening <0.30 were each considered independent risk predictors for events. The event rates were 13%, 21%, 38%, 59%, and 57% in patients with 0, 1, 2, 3, and 4 risk predictors, respectively. Event-free survival progressively worsened with an increasing number of predictors: 0 or 1 versus 2 predictors, P < 0.001; 2 versus 3 or 4 predictors, P = 0.003. CONCLUSION: The long-term prognosis of African Americans can be accurately predicted by clinical assessment combined with rest and stress echocardiography.

Use of multidetector computed tomography for evaluation of global and regional left ventricular function.

Left ventricular (LV) function was shown to play a paramount role in the evaluation, management, and prognosis of patients with cardiac pathology. With the advent of multidetector computed tomography (MDCT), a novel tool for cardiac function assessment became available. This comes at no additional cost to the patient undergoing coronary CT angiography in terms of radiation exposure or contrast material delivery. The accuracy of LV function assessment by retrospective electrocardiographic gating intimately depends on the level of spatial and temporal resolution achievable during scanning. With the aid of today's fast-advancing technology, MDCT is now capable of acquiring data with isotropic submillimeter voxels that allow true 3-dimensional threshold-based chamber segmentation for accurate volumetric analysis. The challenge, however, continues to involve optimizing temporal resolution through various reconstruction techniques and technologic innovations. MDCT-determined global LV function variables were shown to strongly correlate with those of standard imaging methods. Regional function assessment has now become feasible with today's latest scanners. Its accuracy, however, still awaits a major breakthrough in temporal resolution to approach or possibly surpass that of echocardiography or magnetic resonance imaging.