Cardiac mass causing pulmonary hypertension: Dilemma resolved with multimodality imaging.

Myxoma, the most common cardiac tumor is known to cause mitral valve obstruction and right heart failure with pulmonary hypertension. Patients with this condition often present with dyspnea, peripheral edema, and other signs of right heart failure. Pulmonary hypertension secondary to mitral valve obstruction presents unique difficulties in diagnosis as opposed other secondary causes such as thromboembolic pulmonary hypertension. Multimodality imaging with MRI, CT, and echocardiography can help resolve this dilemma. This case report serves to elucidate the important role of multimodality imaging in the management of patients with such a presentation. We also demonstrate in our case report how surgical removal can be curative by relieving mitral valve obstruction and thereby reversing pulmonary hypertension.

Enigma of pulmonary hypertension; echocardiography in the crossroads.

Pulmonary hypertension (PH) with its myriad presentations provides a challenge in its diagnosis and management. Recent WHO classification of pulmonary hypertension as defined at the 5th World Symposium held in Nice, France in 2013 tries to highlight different forms of pulmonary hypertension based on different pathophysiology, clinical presentation and therapeutic strategies [1]. These are classified in 5 groups as follows (1): PAH, (2) PH due to left heart disease, (3) PH due to chronic lung disease and/or hypoxia, (4) chronic thromboembolic PH (CTEPH), and (5) PH due to unclear or multifactorial mechanism. In clinical practice we encounter patients with pulmonary hypertension which is often very difficult to diagnose accurately and therefore presents with therapeutic challenge. Echocardiography plays a vital role in diagnosis and management of this enigmatic disease entity. Due to the complex nature of the disease, there can be some overlaps in various groups of pulmonary hypertension. This is particularly true about the two groups according to WHO classification-pulmonary arterial hypertension (WHO group 1) and chronic thromboembolic pulmonary hypertension (WHO group 3). As clinicians we are often faced with the dilemma of making the correct diagnosis and echocardiography plays a pivotal role in this crossroad. We want to present two cases of pulmonary hypertension with different etiologies as stated above and review literature to elucidate the role of echocardiogram in these cases.

Evaluation of the electrocardiographic criteria for left ventricular hypertrophy with use of three-dimensional echocardiography.

BACKGROUND: Left ventricular hypertrophy (LVH) is a common condition that carries an increased risk of cardiovascular events. Use of ECG in detection of LVH is limited because of the reported low sensitivity. Conventional echocardiographic techniques used as the standard for estimating left ventricular (LV) mass have limitations related to the position of the image plane and shape of the ventricle. Three-dimensional echocardiography is free of these limitations and therefore is more accurate. We hypothesized that accuracy of ECG criteria for LVH would improve when LV mass was assessed by three-dimensional echocardiography. RESULTS: For most of the criteria, sensitivity, specificity and accuracy improved when LV mass was assessed by three-dimensional echocardiography. Two-dimensional echocardiography significantly overestimated LV mass as compared with the three-dimensional method. CONCLUSIONS: Sensitivity, specificity, and accuracy of the ECG criteria improved when LV mass was estimated by three-dimensional echocardiography. This improvement may be attributed at least in part to superior accuracy of three-dimensional measurements.

Methemoglobinemia following transesophageal echocardiography: a case report and review.

Benzocaine (ethyl aminobenzoate) is a topical anesthetic widely used for oropharyngeal anesthesia prior to transesophageal echocardiography (TEE). Topical anesthetics have been reported to cause methemoglobinemia, but this adverse event is extremely rare and has not been listed as one of the possible complications of TEE. However, recently the number of published case reports of TEE-associated methemoglobinemia has increased. Since its first description in 1950, 65 cases of methemoglobinemia have been reported including a recent report of five cases from a single center. Physicians who are not familiar with the association of TEE with benzocaine-induced methemoglobinemia may not recognize the idiosyncratic and often nonspecific characteristic of this condition. Recognition is critical, however, since left untreated methemoglobinemia can lead to cardiopulmonary compromise, neurological sequelae, and even death. The current report documents an additional case of TEE-associated methemoglobinemia from a high-volume (8000 cases /year including 400-450 TEE/year) echo lab. A review of the literature suggests that this complication may be more prevalent, than generally appreciated. This case report emphasizes the importance of appropriate dose, recognition, and the treatment of this entity to cardiologists performing TEE.

Culture-negative suppurative endocarditis causing severe mitral valve obstruction: complementary use of transesophageal and transthoracic echocardiography.

Infective endocarditis causes a myriad number of serious complications. Mitral valve obstruction is a rare complication. We report a 48-year-old Asian female who presented with two-week duration of fever and rapidly developed acute pulmonary edema and cardiogenic shock. Sequential transthoracic and transesophageal echocardiography revealed a rapidly growing vegetation on the anterior mitral leaflet with severe stenosis of the valve. All the blood cultures were negative. The patient underwent a successful mitral valve replacement. A review of 21 previously reported cases of mitral valve obstruction from endocarditis demonstrates the poor prognosis of this entity and supports early surgery.