Alan F. Vainrib

Left Atrial Appendage Occlusion/Exclusion: Procedural Image Guidance with Transesophageal Echocardiography

&NA; Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. In this article, the authors describe the crucial role of two‐ and three‐dimensional transesophageal echocardiography in the pre‐ and postprocedural assessment and intraprocedural guidance of percutaneous left atrial appendage (LAA) occlusion procedures. Although recent advances have been made in the field of systemic anticoagulation with the novel oral anticoagulants, these medications come with a significant risk for bleeding and are contraindicated in many patients. Because thromboembolism in atrial fibrillation typically arises from thrombi originating in the LAA, surgical and percutaneous LAA exclusion/occlusion techniques have been devised as alternatives to systemic anticoagulation. Currently, surgical LAA exclusion is typically performed as an adjunct to other cardiac surgical procedures, which limits the number of eligible patients. Recently, several percutaneously delivered devices for LAA exclusion from the systemic circulation have been developed, some of which have been shown in clinical trials to reduce the risk for thromboembolism. These devices use an either purely endocardial LAA occlusion approach, such as the Watchman and Amulet procedures, or both an endocardial and a pericardial (epicardial) approach, such as the Lariat procedure. In the Watchman and Amulet procedures, a transseptally delivered structure composed of nitinol is placed in the LAA orifice, thereby excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA. HighlightsThe LAA is the most common site of thrombus formation in nonvalvular atrial fibrillation.In nonvalvular atrial fibrillation, percutaneous LAA occlusion/exclusion is an alternative method of thromboembolism prevention for patients who are either ineligible for or too high risk to receive systemic anticoagulation therapy.2D/3D transesophageal echocardiography has a critical role in all percutaneous LAA occlusion/exclusion procedures, including screening for eligibility, device sizing, intraprocedural guidance, and postprocedural follow up.The most commonly used percutaneous LAA occlusion/exclusion devices worldwide include the Watchman, Amulet, and Lariat.

Enterococcus Faecalis Infective Endocarditis Following Percutaneous Edge-to-Edge Mitral Valve Repair

An 85-year-old woman presented with severe degenerative native mitral regurgitation (MR) in the setting of preserved left ventricular ejection fraction (LVEF) of 65%. Transesophageal echocardiography (TEE) demonstrated a flail P2 scallop and she subsequently underwent percutaneous mitral valve repair with MitraClip®. Four months later, she presented with fatigue, chills, and dyspnea. Blood cultures grew Enterococcus faecalis sensitive to ampicillin. Repeat TEE demonstrated a 1.2 cm × 0.6 cm mobile echodensity associated with the left atrial aspect of the MitraClip® consistent with vegetation with recurrence of severe MR. Given the patient’s advanced age, comorbidities, and poor functional class, surgical mitral valve replacement (MVR) was not deemed appropriate. The patient exhibited rapid clinical decline and expired shortly thereafter. A second case involves a 57-year-old man with severe degenerative native valve MR who underwent percutaneous mitral valve repair with placement of two MitraClips®. Two months later, he presented with acute decompensated heart failure. Blood cultures grew Enteroccus faecalis and a TEE demonstrated a new mobile echodensity on the atrial aspect of the P3 scallop and involving the medial MitraClip® consistent with vegetation. There was new, severe posteriorly directed MR with two jets. The patient was treated with 6 weeks of IV antibiotics. Several months later he had stable NYHA Class II–III symptoms with a repeat transthoracic echocardiogram showing improvement of MR and no evidence of vegetation. The first case of infective endocarditis with MitraClip® was described in 2011. Only a few other cases of this complication have been published since. To our knowledge, these two cases are the first documented cases of Enterococcus faecalis mitral valve endocarditis associated with MitraClip®.

3D transesophageal echocardiography and radiography of mitral valve prostheses and repairs

This paper provides a comprehensive overview of 3D transesophageal echocardiography still images and movies of mechanical mitral valves, mitral bioprostheses, and mitral valve repairs. Alongside these visual descriptions, the historical overview of surgical and percutaneous mitral valve intervention is described with the special emphasis on the incremental value of 3D transesophageal echocardiography (3DTEE). For each mitral valve intervention, 2D echocardiography, chest x‐ray, and fluoroscopy images corresponding to 3DTEE are given. In addition, key references on echocardiographic imaging of individual valves and procedures are enumerated in accompanying figures and tables.

Aortic root thrombus complicated by left main coronary artery occlusion visualized by 3D echocardiography in a patient with continuous‐flow left ventricular assist device

Aortic root thrombus is an uncommon complication of continuous‐flow left ventricular assist devices (LVAD). We present the case of a 71‐year‐old man with ischemic cardiomyopathy who underwent destination therapy HeartMate II LVAD placement. Eighteen months later, he presented with a cerebrovascular accident followed by myocardial infarction. Transesophageal echocardiography revealed an aortic root thrombus spanning the left and noncoronary cusps and obliterating the left main coronary artery. We discuss the incidence, risk factors, and management of aortic root thrombus in LVAD patients. To our knowledge, this is the first report of three‐dimensional echocardiography used to characterize an LVAD‐associated aortic root thrombus.

Functional mitral regurgitation in patients with heart failure and depressed ejection fraction.

Purpose of review Functional mitral regurgitation (FMR) is a common complication of left ventricular dysfunction. It is now recognized as an important clinical entity and an independent predictor of poor prognosis in cardiomyopathy patients. In this review, we provide a comprehensive summary of the pathophysiology, latest imaging modalities, and diagnostic criteria for FMR. Additionally, we discuss the recent literature on the continuously evolving surgical and percutaneous treatment options. Recent findings The criteria for quantification of FMR on echocardiography were updated and are distinct from organic mitral regurgitation in the most recent American College of Cardiology/American Heart Association 2014 valve guidelines. Furthermore, the evolving role of MitraClip for potential treatment of FMR offers exciting prospects to treat high-risk symptomatic patients. Summary Our review serves to consolidate the current diagnostic and treatment modalities for FMR and provide a contemporary resource for clinicians while treating patients. Additionally, we identify the gaps present in our knowledge of FMR to guide further clinical investigation.

Advanced Imaging Techniques for Mitral Regurgitation

Mitral regurgitation (MR) is one of the most commonly encountered valvular lesions in clinical practice. MR can be either primary (degenerative) or secondary (functional) depending on the etiology of MR and the pathology of the mitral valve (MV). Echocardiography is the primary diagnostic tool for MR and is key in determining this etiology as well as MR severity. While clinicians usually turn to 2 Dimensional echocardiography as first-line imaging, 3 Dimensional echocardiography (3DE) has continually shown to be superior in terms of describing MV anatomy and pathology. This review article elaborates on 3DE techniques, modalities, and advances in software. Furthermore, the article demonstrates how 3DE has reformed MR evaluation and has played a vital role in determining patient management.

Outcomes after transcatheter aortic valve replacement in patients with low versus high gradient severe aortic stenosis in the setting of preserved left ventricular ejection fraction

BACKGROUND Transcatheter aortic valve replacement (TAVR) for low gradient (LG) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) remains an area of clinical uncertainty. METHODS Retrospective review identified 422 patients who underwent TAVR between September 4, 2014 and July 1, 2016. Procedural indication other than severe AS (n = 22) or LVEF <50% (n = 98) were excluded. Outcomes were defined by valve academic research consortium two criteria when applicable and compared between LG (peak velocity <4.0 m/s and mean gradient <40 mmHg; n = 73) and high gradient (HG) (n = 229) groups. The LG group was further categorized as low stroke volume index (SVI) (n = 41) or normal SVI (n = 32). Median follow-up was 747 days [interquartile range 220-1013]. RESULTS Baseline thirty-day mortality risk (LG 6.2% [3.8-8.1] vs HG 5.7% [4.1-7.4], P = 0.43) did not differ between groups. Short-term outcomes, including procedural success rate (86.1% vs 88.8%, P = 0.53), peri-procedural complications (intra-procedural heart block: 6.8% vs 7.9%, P = 0.99; permanent pacemaker placement: 11.0% vs 13.6%, P = 0.69; moderate paravalvular regurgitation: 2.7% vs 1.3%, P = 0.60), and all-cause in-hospital mortality (2.7% vs 0.9%, P = 0.25) did not differ between LG and HG groups. On long-term follow-up, all-cause mortality also did not differ between LG and HG groups (6.8% vs 10.0%, plog-rank  = 0.33) or between the LG low SVI (9.8%), LG normal SVI (3.1%), and HG (10.0%) groups (plog-rank  = 0.39). CONCLUSION Patients with preserved LVEF undergoing TAVR for severe AS with LG, including LG with low SVI, have no significant difference in adverse outcomes when compared to patients with HG.

Multimodality imaging of scimitar syndrome in adults: A report of four cases

Partial anomalous pulmonary venous return (PAPVR) comprises a group of congenital cardiovascular anomalies associated with pulmonary venous flow directly or indirectly into the right atrium. Scimitar syndrome is a variant of PAPVR in which the right lung is drained by right pulmonary veins connected anomalously to the inferior vena cava. Surgery is the definitive treatment for scimitar syndrome. However, it is not always necessary as many patients are asymptomatic, have small left‐to‐right shunts, and enjoy a normal life expectancy without surgery. We report multimodality imaging in four adults with scimitar syndrome and the implications for management of this rare syndrome.

Multimodality Imaging of a Rare Case of Bronchogenic Cyst Presenting as New-Onset Atrial Fibrillation in a Young Woman

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Echocardiographic Guidance of the Novel WaveCrest Left Atrial Appendage Occlusion Device

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