Taking the time to get it bright: Use of ultrasound enhancing agent redirects clinical course of an unstable patient.

The use of ultrasound enhancing agents (UEA) during echocardiography helps to optimize visualization in technically difficult studies, with improved left ventricular opacification and endocardial border definition. The use of these agents may often unveil critical data that drastically alter clinical decision making. Despite the potential clinical benefits of UEA and known safety data, clinicians are still sometimes reluctant to take the time to use UEAs in unstable patients. Herein, we demonstrate a challenging case of a patient with late presentation myocardial infarction, complicated with cardiogenic shock and pseudoaneurysm formation that was not observed in non-contrast images, emblematically demonstrating the value of UEA in selected patients. .

Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature.

Patent foramen ovale (PFO) is the most common type of inter-atrial shunt, with prevalence as high as 30%. Detection of PFO has implications in patients with stroke, peripheral embolism, decompression illness, and other conditions. Transesophageal echo (TEE) with saline contrast injection is the current standard for PFO detection, but even with TEE, PFOs are sometimes missed. With advances in percutaneous PFO closure therapies and proven long-term benefit of closure, accurate PFO detection takes on cardinal importance. Various provocative maneuvers to enhance PFO detection are in clinical use and have been studied. The Valsalva maneuver has long-held position as the ideal provocation to unmask PFO, but other maneuvers such as cough, sniff, Müller's, and more have gained relevance. In this article, we will examine various maneuvers and discuss their utility in PFO detection.

Incidental left atrial blood cyst in a patient undergoing transcatheter aortic valve replacement.

Blood cysts of the heart are benign cardiovascular tumors found incidentally in approximately 50% of infants who undergo autopsy at less than 2 months of age. These congenital cysts, frequently present on the atrioventricular valves of infants, are exceedingly rare in adults. Nonetheless, in adults, cardiac blood cysts have been found on the mitral valve, papillary muscles, right atrium, right ventricle, left ventricle, and aortic, pulmonic, and tricuspid valves. Reported complications include left ventricular outflow obstruction, occlusion of the coronary arteries, valvular stenosis or regurgitation, and embolic stroke. In high-risk patients with severe aortic stenosis, transcatheter aortic valve replacement has emerged as an alternative to surgical replacement. Transesophageal echocardiography plays a fundamental role in evaluating the feasibility of intraprocedural transcatheter aortic valve replacement, in measuring aortic annular size, in guiding placement of the prosthetic device, and in looking for possible complications. The embolic risk of rapid pacing and transcatheter aortic valve replacement in a patient with an intracardiac blood cyst is unknown, and such a case has not, to our knowledge, been reported heretofore. We present the case of a 78-year-old woman with severe aortic stenosis, in whom a blood cyst was incidentally found in the left atrium upon transesophageal echocardiography. She underwent successful transcatheter aortic valve replacement without embolic complication.

Imaging in the evaluation of pulmonary artery hemodynamics and right ventricular structure and function.

Among the many approaches for evaluating patients with pulmonary hypertension (PH), imaging plays a crucial role. The primary role of imaging is to identify the severity of PH based on noninvasive hemodynamic assessment and to evaluate right ventricular morphology and function. The major modalities used in current clinical practice for these purposes are echocardiography and cardiac magnetic resonance (CMR) imaging. This review discusses the merits, limitations, and clinical utility of several echocardiographic and CMR techniques used in the evaluation of PH. It also includes a brief discussion of the role of computed tomography and radionuclide imaging.

A case of severe mitral regurgitation due to an unusually long aberrant chorda tendinea straddling the anterior mitral leaflet.

We present a case of a 27-year-old female with severe mitral regurgitation caused by a single long aberrant chorda tendinea. This chorda extended from the base of the right coronary cusp of the aortic valve, through the A2 scallop of the mitral valve, and attached to the dome of the left atrium. Initial transthoracic echocardiogram (TTE) demonstrated a mildly redundant anterior mitral leaflet with thickened leaflet tip and moderate eccentric, posteriorly directed mitral regurgitation. Repeat TTE revealed a chord-like structure attached to the midportion of the anterior mitral leaflet and extending to the left ventricular outflow tract. Transesophageal echocardiography (TEE) suggested two aberrant chordae tendineae tethering the A2 scallop on both the left atrial and left ventricular side. Patient underwent surgical resection of the aberrant chorda. During the excision of the chorda the structural integrity of the A2 scallop was compromised, necessitating mitral valve repair with excellent results.

Acute aortic valve rupture secondary to blunt chest trauma.

Cardiac valve injury after blunt chest trauma is rare. We present a case of blunt chest trauma resulting in an isolated aortic valve rupture treated with aortic valve replacement.

Is heart failure different on the two continents (North America and Europe)?

Heart failure is increasing in both North America and Europe. Although many similarities in the disease are apparent between the two continents, differences do exist. Heart failure with preserved systolic function appears to be increasingly important on both continents, and is associated more frequently with hypertension, aging, and female sex. Treatment guidelines from the two continents show more similarities than differences, though different treatment patterns emerge. Because more patients with heart failure will be older in the future, clinical trials that include greater numbers of these patients are needed to demonstrate that therapies are as effective and safe in this population.