Apical hypertrophic cardiomyopathy: elegant use of contrast-enhanced echocardiography in the diagnostic work-up.

A 69-year-old woman was evaluated for chest pain complaints. The ECG demonstrated sinus rhythm with deep negative T waves from V2 to V6, in l, aVL and the inferior leads.Transthoracic echocardiography (TTE) showed suboptimal image quality and was nondiagnostic. A repeat TTE study after administration of an echo contrast agent showed normal contractile function with apical hypertrophy. This report contains two messages. First, contrast-enhanced echocardiography is an elegant bedside tool to assess left ventricular apical segments. Secondly, in patients with ECG repolarisation abnormalities without an obvious ischaemic cause, routine echocardiography without contrast may not exclude apical HCM. Definitive exclusion of this important diagnosis requires further imaging such as CMR or contrast echocardiography.

Late infective endocarditis of an atrial septal occluder device presenting as a cystic mass.

We report an atypical echocardiographic presentation of a vegetation in a patient with late infective endocarditis of an atrial septal defect (ASD) occluder device. Transesophageal echocardiography demonstrated a penduculated mass attached to the left atrial side of the occluder device. This mass presented as an oscillating echo free area surrounded by a membrane attached to the device by a thin stalk. At time of surgical excision, the lesion did not present as a spherical cyst. It was assumed that the content of the echo free mass had already emptied into the left atrium. Histopathology diagnosed the mass as a vegetation. The contribution of contrast echocardiography to the evaluation of intracardiac masses is briefly discussed.

Staphylococcus aureus infective endocarditis mimicking a hydatid cyst.

We report an atypical echocardiographic presentation of Staphylococcus aureus infective endocarditis (IE) of the mitral valve in an octogenarian female. Echocardiography revealed perforation of the anterior mitral valve leaflet (AMVL), with a large cystic mass seemingly attached to the AMVL and surrounded by a thin membranous structure. These images were strongly reminiscent of a hydatid cyst. The significant comorbidity of the patient did not justify an urgent surgical approach, and the patient subsequently expired of cardiogenic and septic shock. Autopsy revealed a large vegetation attached to the interatrial septum in the immediate proximity of the AMVL, without signs of the membranous structure and without pathological evidence for septic embolism. This atypical presentation of IE prompted us to discuss a brief review of intracardiac cystic masses.

Atrial myxomas grow faster than we think.

The finding of a cardiac myxoma usually implies immediate consequent surgical excision to prevent embolic events. Reports with documented growth rate are therefore very rare, and the actual growth rate remains a controversial issue. We report the growth of a left atrial myxoma in an asymptomatic 65-year-old patient with several years of follow up for aortic valve disease. A MEDLINE search with the terms "cardiac myxoma and tumor growth" was performed. The calculated growth rate showed an average growth rate of 0.49 cm/month. These reports suggest that the growth rate of myxomas may be faster than is usually thought.

Persistent left superior vena cava diagnosed by bedside echocardiography.

BACKGROUND: Persistent left superior vena cava (PLSVC) is a congenital anomaly with an estimated incidence of 0.3-0.5% in the normal population. Its usual discovery is often made by an abnormally positioned catheter inserted in the left subclavian or left jugular vein. In this situation, an easy bedside approach to confirm an anatomic variation in the central venous system is helpful. In the majority of cases, the PLSVC drains to the coronary sinus. OBJECTIVE: To describe the contribution of bedside echocardiography in diagnosing the unstable patient in whom there is suspicion of a PLSVC. CASE REPORT: A 29-year-old man underwent an emergent laparotomy for multiple intra-abdominal abscesses. Postoperatively, after insertion of a central line catheter through the left subclavian vein, a chest X-ray study showed the tip of the catheter in a left paramediastinal position instead of crossing the midline to the superior vena cava. A PLSVC was suspected. The patient was hemodynamically unstable; therefore, a bedside non-invasive confirmation of the diagnosis of PLSVC was preferred. A transthoracic echocardiography study was performed after injection of agitated saline (creating air-filled microbubbles by shaking saline solution in a syringe), which showed that the coronary sinus was opacified, confirming the diagnosis of a PLSVC. CONCLUSION: In this brief report, we describe the contribution of echocardiography to the diagnosis of a PLSVC. Echocardiography is a reliable and easy diagnostic tool that allows a bedside approach in a patient in whom there is suspicion of a PLSVC, without administration of radiographic contrast.

Right atrial inflow obstruction of the inferior vena cava due to atrial septal aneurysm and an elongated Eustachian valve.

We describe a patient with oedema of the legs and ascites due to right atrial (RA) inflow obstruction, caused by atrial septal aneurysm (ASA) and an elongated Eustachian valve (EV). Both structural abnormalities created a narrow inflow channel to the free RA cavity. RA inflow obstruction is usually related to constrictive pericardial disease and pericardial tamponade. Other cardiac causes of RA inflow obstruction are rare and include lipomatous hypertrophy of interatrial septum, tumour or thrombus in the right atrium (RA). Reports, describing inflow obstruction in the RA as a consequence of an elongated EV or an ASA, are extremely rare.

A patient with cardiac fibroma and a subvalvular aortic stenosis caused by a subvalvular membrane.

In this report, we describe a patient with two uncommon cardiac abnormalities: a subvalvular membrane in the left ventricular outflow tract and a cardiac fibroma (CF) in the left atrium. This 56-year-old patient presented with a known subaortic stenosis caused by a subvalvular membrane, a large mass attached to the interatrial septum in the immediate proximity of mitral valve, and a cardiac history of infective endocarditis. Initially, the mass was thought to be an old vegetation. However, the histology of this lesion diagnosed a CF. Primary cardiac tumors are rare. Myxoma and papillary fibroelastoma are the most frequently encountered primary cardiac tumors. CF is usually diagnosed during childhood. In this case, the presentation of the CF was atypical for 3 reasons: the tumor was diagnosed in an adult, the fibroma was pedunculated, and not located within the myocardium but originated from the interatrial septum.

Left atrial compression by dissecting aneurysm of the ascending aorta.

We report a case of a 39-year-old man with extensive left atrial compression by a dissecting aneurysm of the ascending aorta. Presumably this compression caused hypotension. A dissecting aneurysm of the ascending aorta, limiting left ventricular inflow by left atrial compression, has not been described in English-language medical literature before.

Rapid hemodynamic deterioration because of acute rupture of an aneurysm of the sinus of Valsalva: the importance of echocardiography in early diagnosis.

We report a patient with an acute rupture of an aneurysm of the right sinus of Valsalva of a bicuspid aortic valve into the right atrium. This congenital disorder is a result of a weak point in the aortic wall resulting from a localized interruption of the media. Because of rapid hemodynamic deterioration, early diagnosis is mandatory and often lifesaving. Echocardiography is the most reliable method to confirm the diagnosis.