Daniel Minderman

Use of Contrast in Distinguishing Apical Mural Thrombus from Its Echocardiographic Simulators

Transthoracic two-dimensional echocardiography (TTE) has been in wide use for diagnosing left ventricular (LV) mural thrombi for over 25 years. Contrast echocardiography using “Optison” and more recently “Definity” has proven useful over the last few years in clarifying LV pathology; one of these applications is the identification of mural thrombi in cases where there may be room for doubt as to the diagnosis of clot. Herein, we present four patients who all had apical wall-motion abnormality with suspicion of a possible thrombus at this site. The echocardiographic appearances, before and after contrast were of diagnostic interest, ruling out a thrombus in the first two patients, and confirming its presence in the next two patients. Echocardiography using contrast was performed by injecting 2 cc of Optison into an antecubital vein in the first three cases and 1.5 cc of Definity in the last one. Optison, Albumex or “Perflutren protein-type A microspheres” (generic) is manufactured by Mallinckrodt Inc. in St. Louis, MO for Amersham Health Inc., and Definity “Perflutren lipid microsphere” (generic) is manufactured by Bristol-Myers Squibb in N. Billerica, MA.

Cardiac Tamponade With Fibrin Strands Leading to the Diagnosis of Systemic Lupus Erythematosus

A 59-year-old male with an unremarkable past medical history presented with worsening dyspnea and a history of chest tightness for 2 weeks. He had arthritis of multiple hand and foot joints bilaterally. Muffled heart sounds and pulsus paradoxus of 15 mm Hg were noted on examination. Laboratory findings were remarkable for anemia, with a hemoglobin level …

Aortic Sinotubular Ridge Calcification: A Recently Recognized Site of Cardiac Calcification

In an autopsy study, Tveter and Edwards called attention to the frequent occurrence of calcification at the junction of the sinus and tubular segments of the ascending aorta.1 The echocardiographic features of this lesion were described by D’Cruz et al.2 Typically, aortic sinotubular ridge calcification (ASTRIC) manifests on the echocardiogram as a small dense echogenic ridge on the inner aspect of the aortic wall at the junction of the sinus of Valsalva region with the proximal ascending aorta. The former segment is convex and wider, whereas the latter segment is cylindrical. This location of ASTRIC is very constant. The aortic valve cusps are quite separate from the ASTRIC, and are often sclerotic and calcified in patients with ASTRIC.

Sonolucent Space Posterior to Left Atrium: Unusual Echocardiographic Appearance in a Cardiac Transplant Patient

The usual echocardiographic appearances of the atria in heart transplant patients are well known. We report a case of an 81‐year‐old man with a 16‐year‐old cardiac transplant who showed a “new” echocardiographic left atrial abnormality. Two‐dimensional echocardiography showed a large sonolucent space behind the donor left atrium (DLA), which was at first perplexing. This space, the distorted and partly displaced recipient left atrium (RLA), could be shown to communicate with the donor left atrium, by the use of unconventional imaging and by optison opacification.

Mediastinal hematoma causing compression of the right ventricular outflow tract – the role of transthoracic echocardiography in diagnosis

A 57-year-old man presented with acute coronary syndrome for which he was initially treated medically with a regimen that included acetylsalicylic acid, clopidogrel and heparin. Later, he was found to have two-vessel coronary artery disease requiring coronary artery bypass grafting. His postoperative period was complicated by hypotension and excessive bleeding, requiring multiple transfusions of blood products. His continued hemodynamic instability led to the suspicion of a mechanical complication. A transthoracic left parasternal short-axis view at the mitral valve level showed an anterior mediastinal hematoma compressing the right ventricular outflow tract (Figure 1). Figure 1) Transthoracic left parasternal short-axis view showing an anterior mediastinal hematoma (MH) compressing the right ventricular outflow tract. LV Left ventricle; RV Right ventricle The hematoma was also compressing the main pulmonary artery with its bifurcation, as well as the aorta, as shown by the transthoracic high right parasternal short-axis view (Figure 2). Figure 2) Transthoracic high right parasternal short-axis view showing the mediastinal hematoma (MH) compressing the aorta (Ao), as well as the main pulmonary artery with its bifurcation. LMPA Left main pulmonary artery The patient was taken back to the operating room, where the hematoma was evacuated. He did very well after that and left the hospital five days later (1).

Three-dimensional echocardiographic appearances of pericardial effusion with tamponade.

A patient with pericardial effusion and tamponade was studied by routine two‐dimensional as well as three‐dimensional echocardiogram. Chamber “collapses” of the right atrium, left atrium, right ventricle, and inferior vena cava were visualized by both modalities, but were better appreciated on three‐dimensional echo imaging, perhaps because three‐dimensional echo imaging is more suited to depicting three‐dimensional changes in chamber shape.

Quadricuspid aortic valve

A36-year-old man with a history of dyslipidemia underwent transthoracic echocardiography for evaluation of exertional dyspnea, chest heaviness and dizziness. The echocardiography showed a quadricuspid aortic valve with adequate opening of the mildly thickened valve cusps and moderate aortic regurgitation. A short-axis view of the transthoracic, two-dimensional echocardiography revealed a quadricuspid aortic valve in diastole (Figure 1A) and in systole (Figure 1B). Figure 1) A short-axis view of a transthoracic two-dimensional echocardiography revealing a quadricuspid aortic valve in diastole (A) and in systole (B) Isolated quadricuspid aortic valve is a very rare congenital anomaly that may be found unexpectedly during surgery or autopsy, or may be diagnosed preoperatively by echocardiography. The prevalence ranges between 0.013% and 0.043%, according to a recent echocardiography database (1). Two-dimensional transthoracic echocardiography and trans-esophageal echocardiography play an essential role in the diagnosis of an isolated quadricuspid aortic valve. Aortic insufficiency resulting from cusp malcoaptation is the most common hemodynamic abnormality associated with this anomaly. Valve replacement is frequently required after the fourth decade of life (1).

Persistent ductus venosus in an adult associated with hypertrophic cardiomyopathy and pulmonary hypertension

We present a 54-year-old male who was recently diagnosed with small cell carcinoma of the mouth and oral cavity, metastatic to the liver. He denied any cardiac symptoms. A transthoracic 2D echocardiogram performed prior to lung surgery showed normal left ventricular size and wall motion. There was calcification at the base of both mitral leaflets with systolic anterior mitral motion, a hyperdynamic left ventricle and a dynamic left ventricular outflow tract obstruction, with a gradient of about 70 mmHg, as well as septal hypertrophy more prominent than the posterior wall, suggesting hypertrophic cardiomyopathy with obstruction. Peak systolic pulmonary artery pressure was estimated to be 70 mmHg. A large ascites was evident, bisected by the falciform ligament, attached to the abdominal wall anteriorly and to the liver posteriorly. A blood vessel was visualized running in the free edge of this ligament, in which nonpulsatile venous flow carried blood away from the umbilicus (Figs. 1 and 2). This vessel, from the umbilicus to the portal vein, was diagnosed as persistent ductus venosus. The ductus venosus is a normal fetal structure connecting the portal and umbilical veins with the inferior vena cava (IVC), allowing a fraction of the umbilical vein blood to bypass the liver and reach the central circulation. Patent ductus venosus represents the persistence of

Three-Dimensional Echocardiographic Findings in an Acute Anterior Pericardial Bleed Due to Acute Aortic Dissection: Bidirectional To-and-Fro Flow in the Upper Pericardial Sac

Figure 1. Twoand threeechocardiogram. Left Panel: Ascending aorta (AS Ao) showing aortic dissection with an intimal flap (IF) in the dilated aorta. Right Panel: Aortic arch (Ao AR) showing the intimal flap. Right pulmonary artery (RPA), anterior mitral leaflet (MV). later with an initial blood pressure of 194/117 mmHg and a heart rate of 69 beats per minute. A urine drug screen was positive for the presence of cocaine and marijuana. A noncontrast computed tomography scan showed aneurysmal dilatation of the ascending aorta and a pericardial effusion. Transesophageal echocardiography (TEE) was performed, which showed a type-A aortic dissection with an intimal flap seen at the sinotubular junction and the false lumen extending below the diaphragm (Fig. 1).On

46 CAN THE RIGHT SUBCLAVIAN VEIN BE USED AS A SURROGATE OF THE INFERIOR VENA CAVA AS AN INDICATOR OF SYSTEMIC VENOUS CONGESTION?: Table

Background The respiratory variation (RV) in inferior vena cava (IVC) caliber is routinely evaluated on echo for assessment of systemic venous congestion. In obese patients or in those who have recently undergone abdominal or thoracic surgery, IVC visualization can be difficult. We assessed whether RV in the right subclavian vein (RSV) caliber can serve as a surrogate for the RV in the IVC and whether the correlation would be better with the imaging performed in supine position or at a 458 reclining position. Methods In 40 patients, IVC long axis echocardiograms were recorded for 10 beats with patient breathing normally. M-mode recordings were made of the IVC segment 2 to 4 cm inferior to the entry of the IVC into the right atrium, and the minimum (MIN) and maximum (MAX) IVC diameters were obtained. RSV was visualized from the right supraclavicular region. Two-dimensional recordings were made over 10 beats during normal quiet respiration in the supine and in the 458 reclining position; MIN and MAX diameters were obtained and ratio calculated. Correlation between ratio of the MIN to MAX IVC caliber and ratio of RSV MIN to MAX caliber was tested by statistical analysis. Results The mean ratio of respiratory variation of IVC caliber was different from the mean ratio of the respiratory variation in the RSV in the supine position but not from the mean ratio of the respiratory caliber variation in the RSV at 458 position. Using the paired t-test, the IVC respiratory variation correlated better with the RSV respiratory variation in the 458 reclining position. Table Minimum/Maximum Diameter Ratio Conclusions Respiratory variation in RSV caliber at 458 correlates well with the IVC respiratory variation and can be used for noninvasive assessment of systemic venous congestion if the IVC cannot be visualized well due to obesity, recent surgery, or other reasons.