Left atrial appendage occlusion

Left atrial appendage [LAA] occlusion is a treatment strategy to prevent blood clot formation in atrial appendage. Although, LAA occlusion usually was done by catheter-based techniques, especially percutaneous trans-luminal mitral commissurotomy [PTMC], it can be done during closed and open mitral valve commissurotomy [CMVC, OMVC] and mitral valve replacement [MVR] too. Nowadays, PTMC is performed as an optimal management of severe mitral stenosis [MS] and many patients currently are treated by PTMC instead of previous surgical methods. One of the most important contraindications of PTMC is presence of clot in LAA. So, each patient who suffers of severe MS is evaluated by Trans-Esophageal Echocardiogram to rule out thrombus in LAA before PTMC. At open heart surgery, replacement of the mitral valve was performed for 49-year-old woman. Also, left atrial appendage occlusion was done during surgery. Immediately after surgery, echocardiography demonstrates an echo imitated the presence of a thrombus in left atrial appendage area, although there was not any evidence of thrombus in pre-pump TEE. We can conclude from this case report that when we suspect of thrombus of left atrial, we should obtain exact history of previous surgery of mitral valve to avoid misdiagnosis clotted LAA, instead of obliterated LAA. Consequently, it can prevent additional evaluations and treatments such as oral anticoagulation and exclusion or postponing surgeries including PTMC

Timely diagnosis of left ventricular posterior wall rupture by echocardiography: a case report

Left ventricular free wall rupture is responsible for up to 10% of in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction, and its antemortem diagnosis is rarely made. One of the medical complications of myocardial infarction is the rupture of the free wall, which occurs more frequently in the anterolateral wall in hypertensives, women, and those with relatively large transmural myocardial infarction usually 1-4 days after myocardial infarction. We herein present the case of a 66-year-old man suffering inferior wall myocardial infarction with abrupt hemodynamic decompensation 9 days after myocardial infarction. Emergent transthoracic echocardiography revealed massive pericardial effusion with tamponade, containing a large elongated mass measuring 1 x 8cm suggestive of hematoma secondary to cardiac rupture. In urgent cardiac surgery, the posterior wall between the left coronary artery branches was ruptured

Is the peak-to-mean pressure gradient ratio useful for assessment of aortic valve prosthesis obstruction?

The evaluation of prosthetic valves is very difficult with two-dimensional transthoracic echocardiography alone. Doppler and color flow imaging as well as transesophageal echocardiography are more reliable to detect prosthetic valve dysfunction. However, Doppler study sometimes tends to be misleading due to the load-depending characteristics of peak and mean pressure gradients. The peak-to-mean pressure decrease ratio is a load-independent measure, which was previously used for the detecting and grading of aortic valve stenosis. We assessed the usefulness of this method for the evaluation of aortic valve prosthesis obstruction. One hundred fifty-four patients with aortic valve prostheses were included in this study. Transthoracic and transesophageal echocardiographic examinations were performed in all the patients. Peak velocity and velocity time integral of the aortic valve and left ventricular outflow tract, peak and mean aortic valve pressure gradients, peak-to-mean pressure gradient ratio, and time velocity integral [TVI] index were measured. There was a significant relation between the TVI index [p value<0.001] and aortic prosthesis obstruction. A TVI index<0.2 had a sensitivity of 71% and specificity of 100% for the detection of aortic valve prosthesis obstruction. However, no significant relation was found between the peak-to-mean pressure ratio and aortic valve prosthesis obstruction [p value=0.09]. Although the peak-to-mean pressure gradient [PG/MG] ratio is a simple, quick, and load-independent method which may be useful for the grading of aortic valve stenosis, it is poorly associated with aortic valve prosthesis obstruction. The TVI index is a useful measure for the detection of aortic prosthesis obstruction