Role of transthoracic and transesophageal echocardiography in right-sided endocarditis: one echocardiographic modality does not fit all.

The added value of transesophageal echocardiography (TEE) over transthoracic echocardiography in the assessment of left-sided infective endocarditis has been extensively validated in the literature. Little research has dealt with the role of echocardiography in right-sided infective endocarditis (RSE), however. In this review, the differences between RSE and left-sided endocarditis and the different types of RSE according to the types of patients who have the disease are described. Both issues have important implications for echocardiographic workup. Moreover, a systematic echocardiographic protocol to avoid missing right-sided vegetations and several specific morphologic aspects of RSE are reviewed. Normal right-sided structures, which may mimic vegetations, particularly when the clinical picture is compatible, are described. Finally, the value of transthoracic echocardiography and TEE in RSE is reviewed according to the publications available. The diagnostic yield of transthoracic echocardiography is comparable with that of TEE in intravenous drug users. On the contrary, TEE is mandatory in patients with cardiac devices. A Bayesian-based diagnostic approach is proposed for a third poorly characterized group of patients with RSE who are not drug addicts, have no cardiac devices, and have no left-sided endocarditis (the "three no's" endocarditis group).

Value of contrast echocardiography for the diagnosis of hepatopulmonary syndrome.

The hepatopulmonary syndrome must be suspected in patients with end-stage liver disease and refractory hypoxemia. We report a case of a 49-year-old woman with hypoxemia and cirrhosis referred to the cardiac ultrasound laboratory in the evaluation of liver transplantation. Contrast-enhanced echocardiography with intravenous injection of agitated saline solution was crucial to obtain the definitive diagnosis. This imaging modality has proven to be a valuable tool in detecting intrapulmonary right-to-left shunt. The present case emphasizes the usefulness of contrast echocardiography in the diagnosis of a noncardiac disease with important prognosis implications.

Clinical and prognostic profile of patients with infective endocarditis who need urgent surgery.

AIMS: Surgery in patients with infective endocarditis (IE) can be elective (upon completion of antibiotic treatment) or urgent (before antibiotic treatment has ended) when the clinical course is unfavourable. However, urgent surgery for left-sided endocarditis is associated with high mortality. The aims of this study were to describe the profile of patients with left-sided endocarditis who underwent urgent surgery and to analyse the factors that predicted mortality. METHODS AND RESULTS: Among 508 consecutive episodes of IE, 391 were left-sided and 89 required urgent surgery. The main reasons for urgent surgery were heart failure that did not respond to medication (72%) and persistent infection despite appropriate antibiotic treatment (31%). Thirty-two patients (36%) died during their hospital stay. Univariate analysis identified renal failure, septic shock, Gram-negative bacteria, persistent infection, and surgery for persistent infection as factors associated with mortality. Multivariate analysis confirmed only persistent infection and renal insufficiency as factors independently associated with a poor prognosis. CONCLUSION: Patients with IE who need urgent surgery have a poor clinical course. Heart failure, the main cause of urgent surgery, was not associated with higher mortality. However, persistent infection and renal failure were factors associated with higher post-surgical mortality.

A case report of a round cystic tumor in the left ventricular outflow tract.

We report a case of a patient who was admitted to our hospital complaining of angina pectoris. On auscultation, a systolic ejection murmur was heard at the right upper sternal border. Transthoracic echocardiography displayed regional wall motion abnormalities and detected a mobile mass in the left ventricular outflow tract, causing mild obstruction during systole. The mass appeared as an unilocular cystic tumor. Coronary angiography showed a significant lesion in the left anterior descending artery. Surgical treatment was indicated for coronary artery disease and for the unpredictable behaviour of the neoplasm. The mass was identified as arising from the top of the anterior papillary muscle. Histopathological examination revealed that the tumor was a cavernous hemangioma. Cardiac hemangiomas are rare, benign vascular tumors of the heart. This is an unusual case of left ventricular hemangioma incidentally discovered, which raised an interesting differential diagnosis.

[Atrial hematoma in cardiac postoperative patients and the diagnostic use of transesophageal echocardiography]. / El hematoma auricular en el paciente postoperado cardíaco y el papel de la ecocardiografía transesofágica en su diagnóstico.

The formation of atrial hematomas with a mass effect in patients who have undergone cardiac surgery originates a clinical and hemodynamic syndrome that is difficult to assess. Hypotension with high right atrial pressure and equalization of pulmonary wedge pressure is not always present due to the irregular distribution of the hematoma in cardiac chambers. Transesophageal echocardiography is a useful diagnostic procedure for atrial hematomas, differentiating them from other similar clinical and hemodynamic situations like left ventricular or prosthetic valve dysfunction. We present five clinical cases of patients who underwent cardiac surgery and presented atrial hematoma, right atrial in four and left atrial in one. All were diagnosed by transesophageal echocardiography. In one case magnetic resonance imaging was used.