Ricardo Benenstein

The role of multimodality imaging in percutaneous left atrial appendage suture ligation with the LARIAT device.

Atrial fibrillation (AF), the most common cardiac arrhythmia, is a significant cause of embolic stroke. Although systemic anticoagulation is the primary strategy for preventing the thromboembolic complications of AF, anticoagulants carry major bleeding risks, and many patients have contraindications to their use. Because thromboembolism typically arises from a clot in the left atrial appendage (LAA), local therapeutic alternatives to systemic anticoagulation involving surgical or percutaneous exclusion of the LAA have been developed. Surgical exclusion of the LAA is typically performed only as an adjunct to other cardiac surgeries, thus limiting the number of eligible patients. Furthermore, surgical exclusion of the LAA is frequently incomplete, and thromboembolism may still occur. Percutaneous LAA exclusion includes two approaches: transseptal delivery of an occlusion device to the LAA and epicardial suture ligation of the LAA, the LARIAT procedure. In the LARIAT procedure, a pretied snare is placed around the epicardial surface of the LAA orifice via pericardial access. Proper snare placement is achieved with epicardial and endocardial magnet-tipped guidewires. The endocardial wire is advanced transvenously to the LAA apex after transseptal puncture. The epicardial wire, introduced into the pericardial space, achieves end-to-end union with the endocardial wire at the LAA apex. The snare is then placed over the LAA, tightened, and sutured. On the basis of early clinical experience, the LARIAT procedure has a high success rate of LAA exclusion with low risk for complications. The authors describe the indispensable role of real-time transesophageal echocardiography in the guidance of LAA epicardial suture ligation with the LARIAT device.

Mitral Valve Libman–Sacks Endocarditis Visualized by Real Time Three‐Dimensional Transesophageal Echocardiography

Libman–Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syndrome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets. In this report, mitral valve LSE was visualized by real time 3D transesophageal echocardiography (TEE). 3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allows for an accurate determination of the size, shape, and location of the vegetations. (Echocardiography 2012;29:E100‐E101)

Mitral valve prolapse: role of 3d echocardiography in diagnosis

Purpose of review To review the utility and the latest developments in three-dimensional (3D) echocardiography of mitral valve prolapse. Recent findings Although 3D echocardiography was invented in 1974, it did not gain wide clinical acceptance until the introduction of real-time 3D echocardiography in the first decade of the 21st century. Driven by improvements in probe technology and increases in computing power, 3D echocardiography now provides unprecedented images of mitral valve prolapse and its associated mitral regurgitation with no or minimal requirements for image post processing. Summary 3D echocardiography has become the echocardiographic modality of choice for establishing the diagnosis, describing the precise anatomy, and visualization of mitral regurgitant jets in mitral valve prolapse. 3D echocardiography is becoming indispensable in guiding surgical and percutaneous methods of mitral valve repair and replacement.

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.

The A-Dip of Aortic Regurgitation

Echocardiography has become the diagnostic technique of choice for delineating the intracardiac hemodynamics in a host of pathophysiologic states. Pressures and flows can be estimated or measured with enough accuracy to allow for clinical decision-making. We present a case with an unusual Doppler echocardiographic finding and discuss its derivation.

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.

Ankle‐Brachial Index Testing at the Time of Stress Testing in Patients Without Known Atherosclerosis

Individuals referred for stress testing to identify coronary artery disease may have nonobstructive atherosclerosis, which is not detected by stress tests. Identification of increased risk despite a negative stress test could inform prevention efforts. Abnormal ankle‐brachial index (ABI) is associated with increased cardiovascular risk.

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.