Three-Dimensional Cardiac Imaging: A Necessity to the Diagnosis and Treatment of Swiss-Cheese Atrial Septal Defect.

Swiss-cheese atrial septal defect (ASD) is a malformation characterized by multi-fenestrated interatrial defects. Here, we describe a vignette of a 23-year-old man with Swiss-Cheese ASD characterized by two defects with areas of 0.74 cm2 and 0.44 cm2, complicated with an atrial septal aneurysm successfully repaired with a cribriform amplatzer septal occluder (ASO) via the percutaneous transcatheter approach. This case emphasizes the importance of attaining a clear view of three-dimensional structures for proper device selection and deployment in repair as additional structural defects such as concomitant aneurysms impose significant challenges.

A rare variant of a ruptured sinus of valsalva aneurysm forming an aorto-atrial fistula: a case report and review of literature.

Background: Sinus of valsalva aneurysms (SOVAs) are infrequent findings and generally diagnosed incidentally. A SOVA may be at risk for rupture, which would lead to an aorto-cardiac shunt. These patients present similarly to decompensated heart failure. Case Presentation: We present a case of a 44-year-old female with a ruptured non-coronary SOVA diagnosed by echocardiogram during evaluation for exertional dyspnoea. A trans-oesophageal echocardiogram (TEE) revealed a 2.1 cm non-coronary SOVA with windsock communication to the right atrium. The patient refused surgery, and two years later, presented with florid right heart failure with preserved left ventricular function. The right ventricle was severely dilated and hypokinetic with right atrial enlargement. After finally agreeing to surgery, a pre-operative catheterization revealed non-obstructive coronaries and a significant left to right shunt with elevated pulmonary pressure. The patient had suboptimal response to diuretic therapy and was sent for successful repair of the aneurysm with the closure of the aorto-atrial fistula via bovine pericardial patch and resolution of the left to right shunt as demonstrated by intra-operative TEE. Her right-sided heart failure symptoms subsequently resolved. Discussion: SOVA is a rare finding but should still be considered in the differential in young and middle-aged patients with symptoms of acute heart failure, hemodynamic compromise, and a new continuous heart murmur. Early surgical repair is highly recommended to prevent acute and long-term complications.

A cluster of grapes: Right atrial masses of uncertain origin.

Implanted ports have provided clinicians with long term venous accessibility, while maintaining comfort and convenience for their patients. One of the most commonly used implanted ports for oncological access is a Mediport (Norfork Medical, Skokie, IL). Guidelines (INS2021) strongly recommend placing central catheter tips at the cavo-atrial junction. In fact, too deep atrium position may be associated with micro-traumatism, possibly leading to a catheter associated right atrial thrombosis (CRAT). No significant literature discusses the possibility of such port masses being seeded by a bacteria, as in the case for endocarditis, which was seen in our patient. In the following case report, we will explore the case of a 41-year-old female with metastatic urothelial carcinoma who developed multiple right atrial masses possibly associated with a deeply seated totally implanted vascular access device (TIVAD) tip within the right atrial wall. These right atrial masses were of unknown origin, and in the setting of MRSA bacteremia, multiple possible etiologies would be discussed. We will also explore ways in which similar complications can be easily prevented in the future.

Heart Disease Self-management for African American Older Adults: Outcomes of an Adapted Evidence-Based Intervention.

Background and Objectives: To assess the impact of an evidence-based self-management intervention adapted through a community-engaged process for African American midlife and older adults with heart disease and/or cardiovascular risk factors. Research Design and Methods: Adults 50 years and over, living in or near Detroit, MI, with diagnosed heart disease or greater or equal to two major risk factors for heart disease, were randomized to a 7-week group-format program called Take Heart, or a usual-care control group. Take Heart included education about heart disease and support for behavioral lifestyle change, using a goal-setting process based on self-regulation theory. Outcome data were collected via telephone surveys at baseline and 1 year from baseline. Primary outcomes were self-reported emergency department visits and hospitalizations in the last year. Secondary outcomes were health-related quality of life (PROMIS-29 Adult Profile) and cardiac symptom burden. Results: A total of 453 participants enrolled (74% female, 84% African American, mean age 65.4 years; 55% with diagnosed heart disease and 45% with risk factors only); 362 provided baseline and follow-up data. Using generalized linear and binomial regression models, at 12-month follow-up, there were no significant differences between intervention and control groups in ED visits or hospitalizations. Intervention versus control participants had greater improvements in PROMIS fatigue (p = .003) and sleep (p = .04) subscales as well as cardiac symptom burden (p = .04). Discussion and Implications: The Take Heart intervention was associated with modest improvements in sleep, fatigue, and cardiac symptom burden. Take Heart was well received and has potential for dissemination by agencies serving older adults.Clinical Trial Registration Number: https://www.clinicaltrials.gov/ct2/show/NCT02950818.

A Case of Quadricuspid Aortic Valve Regurgitation: The Cardiac Clover.

A quadricuspid aortic valve is a very rare congenital heart condition that can present as aortic regurgitation in the 5th and 6th decade of life. The following case report will describe a patient who presented with symptoms of severe aortic regurgitation and was found to have a quadricuspid aortic valve on echocardiography. The case will describe the clinical manifestations in which the patient presented and the subsequent diagnosis of the quadricuspid aortic valve. The rationale for the surgical approach will also be discussed, along with the patient's clinical response.

Takotsubo cardiomyopathy caused by infusion reaction to paclitaxel.

Takotsubo cardiomyopathy (TCM) secondary to an infusion reaction is extremely rare in the literature. Here, we present an unusual case of TCM in a patient with cervical squamous cell carcinoma who presented with acute hypoxic respiratory failure following the initiation of the first-cycle paclitaxel infusion therapy.

Description and Clinical Implications of Myocardial Clefts Using Echocardiography.

Background Myocardial clefts (MCs) are rare anomalies with debatable clinical significance. Increased use of cardiac magnetic resonance (CMR) has led to the appreciation of subtle left ventricular (LV) wall structural defects, and studies showed varying clinical significance, ranging from asymptomatic incidental findings to being considered a novel imaging marker of hypertrophic cardiomyopathy. Sparse data are available about the utility of two-dimensional echocardiography (2DE) to visualize these anomalies. We describe our institutional experience categorizing MCs using 2DE. Methods The echocardiography database was retrospectively queried for diagnosing MCs using Synapse® Cardiovascular Picture Archiving and Communication System (PACS) (Fujifilm, Tokyo, Japan). Identified patients were admitted to Detroit Medical Center (DMC) between January 2012 and May 2019. MCs were defined as recesses filled with luminal blood, obliterate during systole, and have U, wedge, and tunnel shapes. Images were interpreted by a cardiologist blinded to the data. Baseline demographics and clinical characteristics were documented. The study was descriptive; no intervention was done. Results Sixteen patients with a mean age of 62.43 were included; 68.75% were women, and 81.25% were African American. The prevalence of cardiac comorbidities was primary hypertension 12 (75%), coronary artery disease 5 (31.25%), heart failure with reduced ejection fraction (HFrEF) 4 (25.0%), valvular heart disease 4 (25.0%), arrhythmia/heart block 4 (25.0%), and heart failure with preserved ejection fraction (HFpEF) 2 (12.5%). The indications for 2DE evaluation were heart failure/cardiogenic shock 2 (12.5%), acute coronary syndrome 2 (12.5%), syncope/presyncope 2 (12.5%), atypical chest pain 2 (12.5%), and others 8 (50.0%). Twenty-one MCs were visualized in eight segments of LV walls and septum as follows: basal inferior 7, mid inferoseptal 6, mid inferior 3, mid anteroseptal 2, mid inferolateral 1, mid anterolateral 1, basal inferoseptal 1, apical inferoseptal 1, and apical septal 1. Morphology was classified as tunnel in 66.66%, wedge in 23.8%, and U in 9.5%. Conclusion In various LV and septal walls, MCs detected on 2DE were benign and incidental findings without significant implications for preclinical hypertrophic cardiomyopathy (HCM).

Recurrent Stroke Due to Pulmonary Vein Thrombosis in a Patient with Metastatic Lung Adenocarcinoma.

BACKGROUND Pulmonary vein thrombosis (PVT) is a rare clinical entity. Etiologies include malignancy, hyper-viscosity syndromes, and other etiologies. Patients may present with dyspnea, cough, or hemoptysis. CASE REPORT We present a case of a 64-year-old man with a history of metastatic lung cancer diagnosed with PVT through transesophageal echocardiography (TEE) and complicated by 2 cerebrovascular accidents. The patient had a complicated hospital course and died later due to his malignancy burden and overall condition, despite anticoagulation therapy. CONCLUSIONS Patients with PVT are often asymptomatic or may have a nonspecific clinical presentation. Anticoagulation should be considered in patients with PVT given the life-threatening complications such as peripheral embolization. More research is needed to address this potentially catastrophic finding.

Massive right atrial tamponade early after coronary artery bypass grafting.

If unrecognized, tamponade after coronary artery bypass grafting can be fatal. We describe a 63-year-old man who developed unexplained hypotension and tachycardia and was found to have severe compression of the right atrial cavity by a large hematoma in the pericardial sac.

A Doppler Echocardiographic Pulmonary Flow Marker of Massive or Submassive Acute Pulmonary Embolus.

BACKGROUND: To date, echocardiography has not gained acceptance as an alternative imaging modality for the detection of massive pulmonary embolism (MPE) or submassive pulmonary embolism (SMPE). The objective of this study was to explore the clinical utility of early systolic notching (ESN) of the right ventricular outflow tract (RVOT) pulsed-wave Doppler envelope in the detection of MPE or SMPE. METHODS: Two hundred seventy-seven patients (mean age, 56 ± 16 years; 52% women), without known pulmonary hypertension, who underwent contrast computed tomographic angiography for suspected pulmonary embolism (PE) and underwent echocardiography were retrospectively studied. Extent of PE was categorized using standard criteria. ESN identified from pulsed-wave spectral Doppler interrogation of the RVOT was analyzed, as were other echocardiography parameters such as McConnell's sign, the "60/60" sign, and acceleration and deceleration times of the RVOT Doppler signal. Analysis was conducted using probability statistics and receiver operating characteristic curve analysis. RESULTS: Of the 277 patients studied, 100 (44%) had MPE or SMPE, 87 (38%) had subsegmental PE, and 90 (39%) did not have PE. ESN was observed in 92% of patients with MPE or SMPE, 2% with subsegmental PE, and in no patients without PE. Interobserver assessment of early systolic notching demonstrated 97% agreement (κ = 0.93, P < .001). Compared with more widely recognized echocardiographic parameters, the area under the receiver operating characteristic curve (AUC) of 0.96 (95% CI, 0.92-0.98) for ESN was superior to that for McConnell's sign (AUC, 0.75; 95% CI, 0.68-0.80), the 60/60 sign (AUC, 0.74; 95% CI, 0.68-0.79), and RVOT acceleration time ≤ 87 msec (AUC, 0.84; 95% CI, 0.79-0.88), as well as other study Doppler variables, in patients with computed tomography-confirmed MPE or SMPE. CONCLUSIONS: The pulmonary Doppler flow pattern of ESN appears to be a promising noninvasive sign observed frequently in patients with MPE or SMPE. Future prospective study to ascertain diagnostic utility in a broader population is warranted.

Use of direct oral anticoagulants in the treatment of left ventricular thrombi: A tertiary center experience and review of the literature.

Direct oral anticoagulants can potentially provide a more convenient oral alternative for the management of left ventricular thrombi than Warfarin. These medications do not require frequent monitoring and have less drug-drug interactions. Randomized controlled trials are needed to further demonstrate their efficacy and safety in this setting.

Fibrin sheath-associated endovascular infection of the heart: the Trojan horse of indwelling central venous catheters.

Chronic indwelling central venous catheters can result in formation of fibrin sheaths increasing risk of occlusion, thrombosis and infection. Endovascular infection of right-sided heart structures induced by such sheaths is very rare. A 48-year-old woman with end-stage renal disease initially treated for diabetic ketoacidosis developed persistent Staphylococcus epidermidis bacteraemia without an identifiable source. Although transthoracic echocardiography was unremarkable, transoesophageal echocardiography revealed a fibrin sheath and vegetations in superior vena cava-right atrium junction, which was the site of the tip of a central catheter that had been removed 2 months prior, consistent with fibrin sheath-associated endovascular infection. The bacteraemia cleared and clinical improvement was seen with prolonged intravenous vancomycin. In patients with unexplained bacteraemia and history of a central catheter, rare causes of endovascular infections of right-sided heart structures like fibrin sheaths should be considered. These can persist months after catheter removal. Transoesophageal echocardiogram should be used for earlier detection.

Atrial septal defect repair gone wrong.

Isolated atrial septal defect (ASD) accounts for 13% of congenital heart disorders. The anatomic location, size, and coexistence of other cardiac anomalies determine outcomes of repair. Surgical closure was the first-choice treatment until the 1990s and remains the only treatment for large defects. We describe a case of a 64-year-old woman who underwent surgical repair for an ASD as a child in 1959. She presented with dyspnea to the hospital almost 53 years after the surgery. Diagnostic cardiac imaging revealed interesting anatomy of the repair surgery. Transthoracic echocardiography showed areas of flow signal across the patch consistent with surgical perforation of the patch to reduce symptoms of superior vena cava (SVC) syndrome. Despite intervention, severe dilation of the SVC along with a thrombus is seen. CT angiography of the heart showed the ASD patch occluding the ostium of the SVC instead of patching the ASD. Transesophageal echocardiography showed malpositioned patch allowing the sinus venosus ASD to remain patent.

Incremental Value of Two Dimensional Speckle Tracking Echocardiography in the Functional Assessment and Characterization of Subclinical Left Ventricular Dysfunction.

Subclinical left ventricular (LV) dysfunction refers to subtle abnormalities in LV function which typically precede a reduction in the left ventricular ejection fraction (LVEF). The assessment of myocardial function using LVEF, a radial metric of systolic function, is subject to load dependence, intra-observer and inter-observer variability. Reductions in LVEF typically manifest late in the disease process thus compromising the ability to intervene before irreversible impairment of systolic performance sets in. 2-Dimensional speckle tracking echocardiography (2D-STE), a novel strain imaging modality has shown promise as a sensitive indicator of myocardial contractility. It arms the clinician with a powerful and practical tool to rapidly quantify cardiac mechanics, circumventing several inherent limitations of conventional echocardiography. This article highlights the incremental utility of 2D-STE in the detection of subclinical LV dysfunction.

Ultrasound Assisted Catheter Directed Thrombolysis in the Management of a Right Atrial Thrombus: A New Weapon in the Armamentarium?

Catheter related thrombosis (CRT) is a commonly encountered entity fraught with substantial risk for mortality secondary to various complications including pulmonary embolism (PE), tricuspid regurgitation, endocarditis, right sided heart failure, and cardiogenic and septic shock. CRT carries a mortality rate of 18% in hemodialysis patients and more than 40% in nonhemodialysis patients. Management strategies include systemic anticoagulation, systemic thrombolysis, surgical evacuation, and percutaneous retrieval with no established guidelines. Ultrasound assisted catheter directed thrombolysis emerges as promising modality with a relatively lower risk of hemorrhage compared to systemic thrombolysis. We report a case of a 75-year-old man with dialysis catheter related thrombosis without PE for which ultrasound assisted catheter directed thrombolysis was used successfully as an alternative therapy.

Guide Wire Induced Cardiac Tamponade: The Soft J Tip Is Not So Benign.

Central venous catheter (CVC) insertion rarely causes cardiac tamponade due to perforation. Although it is a rare complication, it can be lethal if not identified early. We report a case of cardiac tamponade caused by internal jugular (IJ) central venous catheter (CVC) insertion using a soft J-tipped guide wire which is considered safe and rarely implicated with cardiac tamponade. A bedside transthoracic echocardiogram (TTE) revealed a pericardial effusion with tamponade. An emergent bedside pericardiocentesis was done revealing bloody fluid and resulted in clinical stabilization.

Comparison of Left Ventricular Contractile Abnormalities in Stress-Induced Cardiomyopathy versus Obstructive Coronary Artery Disease Using Two-Dimensional Strain Imaging.

BACKGROUND: Data on left ventricular (LV) strain profiles in patients with takotsubo cardiomyopathy (TC) in comparison with obstructive coronary artery disease (CAD) are limited. We sought to investigate regional and global LV longitudinal strain in a cohort of patients with known TC using two-dimensional strain imaging (2DS) in comparison with patients with acute cardiomyopathy (ACM) due to severe obstructive left anterior descending arterial disease or triple-vessel disease and healthy controls. METHODS: Transthoracic echocardiography was performed in 34 patients with established TC, 24 patients with ACM, and 30 healthy subjects. We measured the segmental longitudinal strain in apical views by the use of EchoInsight Epsilon software. Left ventricular global longitudinal strain (GLS) was calculated by averaging segmental wall strains. RESULTS: The TC and ACM groups were comparable for age and demographic characteristics. Systolic and diastolic function were significantly impaired in both groups compared to controls. LV global and segmental systolic strain was also significantly attenuated in patients with TC and ACM compared to controls (P < 0.001). Moreover, LV basal segmental longitudinal strain was higher in the patients with TC compared to ACM (P = 0.02). Global and apical segmental strain appear to be higher in patients with mid-ventricular variant compared to those with apical variant of TC with apical strain cutoff value of -7.85%, offering the best discriminatory value for differentiating these two patterns (P = 0.001). CONCLUSIONS: The results of this hypothesis-generating study indicate that longitudinal LV strain parameters are similarly impaired in patients with TC and ACM due to severe obstructive left anterior descending arterial disease or triple-vessel disease. Assessment of two-dimensional LV strain parameters could help differentiate between different TC patterns.