Left Atrial Compression by an Intramural Hematoma: A Rare Case of Obstructive Shock.

A 3.5 cm diameter descending aorta focal aneurysm was incidentally found when a computed tomography (CT) was conducted due to persistent pyrexia in an 85-year-old woman hospitalized for a non-obstructive urinary tract infection. Ten days later, whilst fever subsided and inflammation markers decreased, she became hypoxic. CT revealed an aortic intramural hematoma (Stanford type B) increasing the diameter of the thoracic aorta aneurysm to 6.5 cm. A thoracic endovascular aortic repair (TEVAR) surgery was performed. Seven days after the operation she developed respiratory and hemodynamic compromise. CT depicted further enlargement of the aortic intramural hematoma, increasing the aortic diameter to 8 cm. Transthoracic echocardiography provided valuable information showing extrinsic compression of the left atrium and left ventricle inflow obstruction provoking obstructive shock.

Interatrial Septum Assessment by Transthoracic Echocardiography Part 1: Secundum ASD.

This 10-minute video aims at improving skills for the structural assessment of the interatrial septum using 2-dimensional transthoracic echocardiography (TTE) to increase the ability to diagnose-or rule out-the different types of interatrial communications. Of the five types of lesions, this video focuses on ostium secundum atrial septal defect. This is the first video in our MicroLearning Video Series, designed to help a target audience of sonographers, general cardiologists, general practitioners who want to gain knowledge on fundamental cardiology, and technicians. View the video at https://vimeo.com/989145537/4898c3c590.

Advancements in Interventional Pulmonology: Harnessing Ultrasound Techniques for Precision Diagnosis and Treatment.

Medical ultrasound has emerged as an indispensable tool within interventional pulmonology, revolutionizing diagnostic and procedural practices through its non-invasive nature and real-time visualization capabilities. By harnessing the principles of sound waves and employing a variety of transducer types, ultrasound facilitates enhanced accuracy and safety in procedures such as transthoracic needle aspiration and pleural effusion drainage, consequently leading to improved patient outcomes. Understanding the fundamentals of ultrasound physics is paramount for clinicians, as it forms the basis for interpreting imaging results and optimizing interventions. Thoracic ultrasound plays a pivotal role in diagnosing conditions like pleural effusions and pneumothorax, while also optimizing procedures such as thoracentesis and biopsy by providing precise guidance. Advanced ultrasound techniques, including endobronchial ultrasound, has transformed the evaluation and biopsy of lymph nodes, bolstered by innovative features like elastography, which contribute to increased procedural efficacy and patient safety. Peripheral ultrasound techniques, notably radial endobronchial ultrasound (rEBUS), have become essential for assessing pulmonary nodules and evaluating airway structures, offering clinicians valuable insights into disease localization and severity. Neck ultrasound serves as a crucial tool in guiding supraclavicular lymph node biopsy and percutaneous dilatational tracheostomy procedures, ensuring safe placement and minimizing associated complications. Ultrasound technology is suited for further advancement through the integration of artificial intelligence, miniaturization, and the development of portable devices. These advancements hold the promise of not only improving diagnostic accuracy but also enhancing the accessibility of ultrasound imaging in diverse healthcare settings, ultimately expanding its utility and impact on patient care. Additionally, the integration of enhanced techniques such as contrast-enhanced ultrasound and 3D imaging is anticipated to revolutionize personalized medicine by providing clinicians with a more comprehensive understanding of anatomical structures and pathological processes. The transformative potential of medical ultrasound in interventional pulmonology extends beyond mere technological advancements; it represents a paradigm shift in healthcare delivery, empowering clinicians with unprecedented capabilities to diagnose and treat pulmonary conditions with precision and efficacy. By leveraging the latest innovations in ultrasound technology, clinicians can navigate complex anatomical structures with confidence, leading to more informed decision-making and ultimately improving patient outcomes. Moreover, the portability and versatility of modern ultrasound devices enable their deployment in various clinical settings, from traditional hospital environments to remote or resource-limited areas, thereby bridging gaps in healthcare access and equity.

Global hypokinesis in resting transthoracic echocardiography diagnosis of heart failure and coronary artery disease.

Objectives: Although coronary artery disease (CAD) and heart failure (HF) are separate entities, HF is a common complication of CAD, and both CAD and HF are known causes of wall motion abnormalities (WMA) of transthoracic echocardiography (TTE). Specifically, global hypokinesis on TTE could logically be due to multivessel CAD or non-ischemic cardiomyopathy. The purpose of this study was to investigate the relationship between CAD, HF, and WMA on TTE. Methods: A single-center retrospective chart review was conducted of adults who had a resting TTE and cardiac catheterization within 30 days. We analysed the association between global hypokinesis, triple-vessel CAD, and HF diagnosis. Results: Across 754 included patients, there was a positive association between global hypokinesis on TTE and HF diagnosis (P < .001). There was no association between global hypokinesis on TTE and triple-vessel CAD (P = .341), possibly an inverse correlation. The sensitivity of regional (R) WMAs on TTE for diagnosing CAD was generally lower in patients without heart failure (44%), while specificity was higher in these same patients (89%). Conclusions: There was a positive association between global hypokinesis and HF, and a possible inverse correlation between global hypokinesis and triple-vessel CAD. This could be explained by heart failure diagnosis and other diagnoses having a stronger effect on global hypokinesis than any potential effect from triple-vessel CAD. These sensitivity and specificity results for RWMA on CAD, stratified by HF diagnosis and/or global hypokinesis, can be used to inform clinical decision-making in an acute coronary syndrome case with borderline electrocardiography and/or troponin findings.

A Rare Case of Bivalvular Infective Endocarditis With Left Atrial Mural Endocarditis.

Infective endocarditis (IE) is a life-threatening cardiac infection usually associated with cardiac valves. Left atrial (LA) mural endocarditis is rarely seen and occurs in isolation or in conjunction with mitral valve endocarditis. We present a case of a 61-year-old male with no prior cardiac history who presented with melena and fevers. Blood cultures were positive for Enterococcus faecalis. Transesophageal echocardiogram (TEE) demonstrated aortic and mitral valve vegetations with several small echo densities present on the left atrial wall. These findings were further assessed with a computed tomography angiogram of the heart and cardiac magnetic resonance imaging Ti600 sequence. The patient was treated with intravenous antibiotics and underwent aortic and mitral valve replacement with resection of numerous small fungating masses on the left atrium. There are currently no formal guidelines in place for managing mural endocarditis. However, conducting a multidisciplinary evaluation by an endocarditis team could aid in achieving earlier and more precise diagnoses of the underlying condition and its complications. This approach could also ensure consistent antibiotic therapy and appropriate timing for surgical intervention.

Unmasking a Silent Threat: Office-Based Diagnosis of an Ascending Aortic Dissection With Transthoracic Echocardiography.

Type A aortic dissection (TAAD) is a potentially life-threatening diagnosis that can present with elusive symptomatology. A high degree of clinical suspicion is necessary for prompt diagnosis and management. We describe a case of a transthoracic echo (TTE) in a non-suspicious clinic patient diagnosed with TAAD. A 66-year-old Caucasian male presented for a routine clinic visit with one episode of acute severe chest pain. An echocardiogram was ordered for further workup of hypertension and chest discomfort. The echocardiogram demonstrated an ejection fraction of 60% without significant valvular abnormalities. There was suspicion of aortic pathology, which required multiple attending to review the images. The final interpretation was TAAD with a thrombus present in the false lumen. The patient then presented to the Emergency Department. A computed tomographic angiography was performed, which subsequently confirmed the TAAD. The patient was admitted to the cardiovascular ICU and ultimately underwent a successful repair of the dissection. The patient had an unremarkable post-operative course and was ultimately discharged home. Our case demonstrated a diagnosis of TAAD by office-based TTE as the original imaging modality. While this was unconventional, a TAAD should remain on the differential diagnosis when being ordered for the patient's with uncontrolled hypertension with chest pain as a presenting symptom.

Pediatric Central Retinal Artery Occlusion Attributed to a Patent Ductus Arteriosus.

This report presents a rare case of a central retinal artery occlusion in an eight-year-old girl attributed to an undiagnosed patent ductus arteriosus (PDA). Despite intensive treatment, the patient's eyesight failed to improve. Cases of central retinal artery occlusion may occur in patients with undiagnosed, small PDA, with only symptomatic treatment being available.

An Unusual Case of Bicuspid Aortic Valve With Prolapse Masquerading as Cusp Perforation.

We present a unique clinical scenario of a 58-year-old male with a past medical history of hypertension who initially presented with chest pain and was ruled in for non-ST elevation myocardial infarction (NSTEMI) but rapidly developed respiratory failure secondary to aortic insufficiency complicated by cardiogenic shock (CS), attributed to aortic valve prolapse. Intriguingly, the patient had a normal ECG on presentation, underscoring the dynamic nature of valvular pathology. The development of CS highlights the importance of early recognition, prompt diagnosis, and interdisciplinary management in such complex cases.

Atrial Myxoma: Presenting as a Large Splenic Infarction.

Cardiac myxomas are the most common benign primary heart tumors, with the majority occurring in the left atrium. Clinical manifestations are a result of constitutional, obstructive, and/or embolic events. Complications include myocardial infarction and stroke, as well as renal and limb ischemia. Our unusual case is a middle-aged female who presented with a one-week history of progressively worsening abdominal pain and was found to have a large splenic infarction on a CT scan. There was no personal or family history of autoimmune diseases or hypercoagulable states. The evaluation revealed a large left atrial myxoma confirmed on biopsy after surgical resection. Our patient's clinical presentation was relatively benign compared to the size of her mass. Although her myxoma was very large, morphologically solid, and attached to the interatrial septum, she did not have any evidence of congestive heart failure. The tumor's irregular surface and mobility likely led to splenic embolization. Hence, the differential diagnosis of splenic infarction should include left atrial myxoma.

Cardiac Tamponade in Down's Syndrome Associated With Hypothyroidism: An Uncommon Presentation.

Down syndrome often coincides with hypothyroidism, a condition that may lead to pericardial effusion (PE), though cardiac tamponade remains an infrequent complication. Cardiac tamponade is an emergency that requires immediate diagnosis and treatment. Here, we present a case of a patient who presented to the emergency department (ED) with Down syndrome associated with hypothyroidism and underwent immediate pericardiocentesis and pericardial window placement. A 52-year-old male, with a history of Down's syndrome and hypothyroidism, presented to the ED complaining of shortness of breath and chest pain. He had previously been diagnosed with PE. On examination, he exhibited average heart rate, low blood pressure, decreased heart sounds, and jugular venous distention, with no murmur or frictional rub. Initial investigations revealed normal sinus rhythm on EKG but an enlarged cardiac silhouette on chest X-ray. Laboratory tests showed elevated C-reactive protein and sedimentation rate, suggestive of inflammation, while arterial blood gas showed compensated respiratory alkalosis. Thyroid-stimulating hormone (TSH) was elevated. Despite supplemental oxygen, the patient's condition worsened, prompting a bedside ultrasound revealing cardiac tamponade. A cardiology consultation recommended immediate transfer for treatment. At a different hospital, pericardiocentesis was performed, followed by the placement of a pericardial window to prevent recurrence. Follow-up imaging showed improvement in pleural effusion and resolution of cardiac tamponade. The patient's symptoms improved, and he was discharged with regular follow-up. Down's syndrome is a chromosomal disorder characterized by the trisomy of chromosome 21. It is associated with various cardiac complications. Such patients have an elevated risk of PE due to a variety of reasons, such as viral infections, hypothyroidism, or autoimmune diseases. Although PE has been found, the incidence of cardiac tamponade has rarely been reported. The pathogenesis of PE in hypothyroidism is due to the leakage of fluids from the capillaries and the build-up of fluid in the pericardial space. The treatment of PE is treating hypothyroidism with thyroxine. In rare cases like ours, when the patient develops cardiac tamponade, the patient often needs pericardiocentesis. Our patient had to undergo pericardial window placement, as well to prevent recurrent symptoms. In conclusion, this case report sheds light on the occurrence of cardiac tamponade in a patient with Down's syndrome and hypothyroidism, a relatively rare complication that necessitates prompt recognition and intervention. Through this report, we emphasize the importance of considering cardiac tamponade in the differential diagnosis of patients with Down's syndrome presenting with symptoms suggestive of cardiovascular compromise.

Presentation of Complex Congenital Cardiac Anomalies in a Newborn Pediatric Patient: A Case Report.

Tricuspid atresia, a critical congenital heart defect (CHD), accounts for approximately 1% of all cases of CHDs. When tricuspid atresia is coupled with numerous other unexpected congenital cardiac anomalies, a patient's condition becomes more serious and more complex. We present a case that demonstrates the stepwise approach to the holistic treatment of congenital tricuspid atresia in the presence of normally related great vessels, a large ventricular septal defect (VSD), atrial septal defect (ASD), and trivial patent ductus arteriosus (PDA). While expanding upon the implementation of chest X-ray imaging, serial transthoracic echocardiogram (TTE) imaging, and the balloon atrial septostomy (BAS) procedure, we also provide insight into the multidisciplinary team-based approach utilized for this patient's case. This case illustrates a rare critical CHD coupled with other, more common congenital anomalies, and suggests that with multidisciplinary management and treatment, it is possible the mortality rates associated with this diagnosis could decline.

A case report of a young woman with pulmonary emboli and a right coronary artery-to-coronary sinus fistula.

Background: Coronary artery fistulae are rare cardiovascular anomalies that can present with atypical symptomatology and therefore pose diagnostic challenges, especially in young patients. Case summary: A 34-year-old woman presented with left-sided pleuritic chest pain, haemoptysis, and flu-like symptoms. Initial evaluation revealed multiple left-sided pulmonary emboli, and her transthoracic echocardiography showed turbulent flow in a dilated coronary sinus. A right coronary artery (RCA) to coronary sinus fistula was confirmed by computed tomography coronary angiogram. The patient was treated with lifelong anticoagulation, and a subsequent stress cardiac magnetic resonance imaging did not show inducible myocardial ischaemia. As such, the patient was managed conservatively. Discussion: Utilization of multi-modality imaging is of utmost importance for diagnostic and therapeutic purposes in coronary artery fistulae. In this case report, our patient presented with unprovoked pulmonary emboli, which could be caused by the turbulent flow and stasis, due to the RCA-to-coronary sinus fistula.

Quantifying cardiac dysfunction and valvular heart disease associated with subretinal drusenoid deposits in age-related macular degeneration.

BACKGROUND/AIMS: Demonstrate through objective multidisciplinary imaging that subretinal drusenoid deposits (SDDs) in age-related macular degeneration (AMD) are linked to both coexistent valvular heart disease (VHD) and reduced systemic perfusion via cardiac index (CI). METHODS: Post-hoc analysis of cross-sectional study. 200 intermediate AMD (iAMD) subjects were assigned by masked readers to two groups: SDD (with or without drusen) and drusen (only) based on multimodal ophthalmic imaging. 65 transthoracic echocardiograms (TTEs) reports were available for cardiologist evaluation of VHD severity of the four cardiac valves and the presences of precursor lesions of aortic sclerosis (ASc) and mitral annular calcification (MAC). Necessary parameters to calculate CI were also obtained. Univariate testing was performed using Fisher's Exact test and t-test. RESULTS: 82.6% (19/23) of the iAMD subjects with at least one moderate/severe VHD had concurrent SDDs (p = 0.0040). All cases of aortic regurgitation (6/6, p = 0.0370) and mitral regurgitation (13/13, p = 0.0004) were found with coexisting SDDs. Stenotic VHD was not significantly associated with SDDs, however 70.7% of subjects with ASc (29/41, p = 0.0108) and 76.0% of subjects with MAC (19/25, 0.0377) had coexisting SDDs. CI was available in 48 subjects and was significantly below normal levels in the SDD cohort (mean CI SDD 1.95 ± 0.60 L/min/m2, non-SDD 2.71 ± 0.73 L/min/m2, p = 0.0004). CONCLUSIONS: Several specific VHDs have been found associated with the SDD form of AMD. Decreased systemic perfusion as measured by CI was also associated with SDDs, which supports a perfusion hypothesis of SDD pathogenesis. Further research is warranted to understand the relationship between cardiovascular disease and SDDs.

Tako-Tsubo Syndrome Triggered by a Fibroscopy: Case Report.

Tako-Tsubo cardiomyopathy, also called stress cardiopathy, is a rare syndrome characterized by transient regional systolic dysfunction. It can mimic myocardial infarction but the absence of coronary obstruction allows to redress the diagnosis. Its pathogenesis is not well understood. However, the role of physical or emotional stress has often been associated with this pathology. Here we report, a rare case of a 63-year-old female, with no cardiac risk factors, who presented Tako-Tsubo syndrome after a fibroscopy. This case aims to show that Tako-Tsubo syndrome should be suspected in patients, especially women, with no cardiac risk factors, who present acute chest pain in the context of physical or emotional stress, after excluding differential diagnoses.

Giant Right Coronary Artery Aneurysm Incidentally Found During Stroke Evaluation Through Echocardiography.

Giant coronary artery aneurysms (CAAs) are rare forms of coronary artery disease. An 82-year-old man presented to the hospital with generalized weakness, arm numbness, and dizziness and was found to have a multi-infarct stroke. A transthoracic echocardiogram was obtained to determine a possible cardiovascular etiology of his stroke. However, it did not reveal thrombi or vegetation; instead, it showed a ring-like structure adjacent to the tricuspid valve that appeared to be a large right atrial cyst. A transesophageal echocardiogram was performed localizing the ring-like mass near the tricuspid annulus. Cardiac catheterization revealed aneurysms of the coronary arteries with complete distal occlusion of the left anterior descending artery (LAD), an aneurysmal left circumflex, and a right coronary artery with a very large aneurysm without signs of thrombus or flow-limiting lesion. CAAs are usually found through cardiac catheterization. Echocardiography may be a novel way of identifying CAAs.

Hepatic artery branch perforation with hemoperitomeum: A rare complication of pericardiocentesis.

A 58-year-old male patient presented with anterior myocardial infarction after 36 hours of symptom onset.

Echocardiography and Electrocardiography in Detecting Atrial Cardiomyopathy: A Promising Path to Predicting Cardioembolic Strokes and Atrial Fibrillation.

(1) Background: Atrial cardiomyopathy constitutes an intrinsically prothrombotic atrial substrate that may promote atrial fibrillation and thromboembolic events, especially stroke, independently of the arrhythmia. Atrial reservoir strain is the echocardiography marker with the most robust evidence supporting its prognostic utility. The main aim of this study is to identify atrial cardiomyopathy by investigating the association between left atrial dysfunction in echocardiography and P-wave abnormalities in the surface electrocardiogram. (2) Methods: This is a community-based, multicenter, prospective cohort study. A randomized sample of 100 patients at a high risk of developing atrial fibrillation were evaluated using diverse echocardiography imaging techniques, and a standard electrocardiogram. (3) Results: Significant left atrial dysfunction, expressed by a left atrial reservoir strain < 26%, showed a relationship with the dilation of the left atrium (p < 0.001), the left atrial ejection fraction < 50% (p < 0.001), the presence of advanced interatrial block (p = 0.032), P-wave voltage in lead I < 0.1 mV (p = 0.008), and MVP ECG score (p = 0.036). (4) Conclusions: A significant relationship was observed between left atrial dysfunction and the presence of left atrial enlargement and other electrocardiography markers; all of them are non-invasive biomarkers of atrial cardiomyopathy.