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INTRODUCTION Transesophageal echocardiography (TEE) is frequently used in children with and without congenital heart disease when transthoracic echocardiography is inadequate for visualizing cardiac structures. Recent guidelines state relative contraindications of TEE include post-gastrostomy tube (GT) or Nissen fundoplication surgery. No data exist documenting the incidence of complications in this population after a TEE. Aim of this study was to document the incidence of abdominal complications after TEE in pediatric patients who previously had a GT or Nissen fundoplication. METHODS Single institution retrospective study was performed evaluating patients from 2013 through 2020. Patients were included if they had previously undergone a GT or Nissen procedure and subsequently underwent a TEE procedure. Baseline demographics were obtained. Major (esophageal/gastric perforation, oropharyngeal dysphagia, GT displacement, and Nissen breakdown) and minor (abdominal pain, feeding intolerance, and GT leakage) complications were recorded. RESULTS Total of 34 patients underwent 48 TEE procedures. Age was 6.2 ± 6.6 years (median 3.0 years, .4 - 23.0 years) and weight was 18.5 ± 14.8 kgs (median 12.4 kgs, 4.2 - 57.5 kg) at time of TEE. Twenty-nine patients had congenital heart disease. Five patients had a Nissen fundoplication, 14 patients had a GT, and 15 patients had both procedures prior to the TEE. No patient had a major abdominal complication after the TEE. One patient had abdominal pain (2.1%), one patient had feeding intolerance and leakage around the GT site (2.1%), and two patients had leakage around the GT site (4.2%) after the TEE. Patients that experienced complications were significantly younger (1.7 ± 1.1 years vs. 6.6 ± 6.7 years, P

We present a case of a 70-year-old woman with exertional shortness of breath. A transthoracic echocardiogram showed a large mass on the ventricular side of the pulmonary valve. The anatomy of the mass was additionally investigated with a transesophageal echocardiogram, which delineated the anatomical details of the structure. The mass was surgically excised, and histopathology confirmed a cardiac papillary fibroelastoma.

We report the case of a 74-year-old male, with a medical history of cor triatriatum, admitted with a 10-day history of intermittent fever. Three sets of blood cultures were positive for Providencia rettgeri. Transthoracic and transesophageal echocardiogram excluded infective endocarditis, but revealed a congenital accessory tissue adhering to the mitral valve, causing supravalvular mitral stenosis. Cor triatriatum sinistrum is a rare congenital cardiac anomaly, even more uncommon in adults, and quite exceptional when associated with mitral valve disease. Because the patient had no symptoms related to the heart valve disease, no surgical indication was given and he was managed conservatively.

The accurate identification of thrombus in the left atrial appendage with transesophageal echocardiogram (TEE) in patients with atrial fibrillation (AF) before cardioversion is essential. Most of these patients have some grade of spontaneous echo contrast (SEC). Severe SEC is often called "sludge," and its prognosis and treatment are still controversial. Current guidelines suggest the use of ultrasound enhancing agents (UEAs) when significant SEC is present. However, little is known about the utility of the UEAs in the differentiation between sludge and less severe SEC.

A 43-years-old patient with hepatitis C and HIV co-infection was referred to debridement of a left sternoclavicular septic arthritis. Due to suspicion of endocarditis, the patient underwent transthoracic echocardiogram which revealed an mass posterior to left atrium and descending aorta. A thoracic computed tomography revealed esophageal varices. Transesophageal echocardiogram was not performed. The patient has progressed favorably.

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.

Aims Mitral valve aneurysms (MVA) are most frequently associated with endocarditis. Echocardiography is the method of choice for diagnosis, and color flow imaging is an important, easy method to detect MVA ruptures. We aimed to study the clinical and echocardiographic findings and their relation to the mechanism of aneurysm formation. Methods and Results We reviewed clinical and echocardiographic records of 18 patients during a 17-year period, corresponding to 0.02% of the total studies performed at our institution. All patients underwent transthoracic echocardiogram (TTE), and all except two underwent transesophageal echocardiogram (TEE). The aneurysm was located either on the anterior leaflet (16 cases) or on the posterior leaflet (two cases). In seven cases, the probable aneurysm formation mechanism was an aortic regurgitant jet striking the anterior mitral leaflet. Perforation was present in 17 (94.4%) patients, and 10 (55.5%) cases presented more than one aneurysm. No patients underwent surgery exclusively because of the echocardiography finding. Conclusion Different etiologies and formation mechanisms can occur in MVA. Echocardiography plays a fundamental role, providing meticulous examination of the mitral valve anatomy and flow. Unlike standard recommendations, clinical management is possible, and diagnosis does not imply immediate surgical correction.

A sinus of Valsalva aneurysm is a rare cardiac anomaly, and it is usually clinically silent. However, it may lead to symptoms when it compresses adjacent cardiac structures. Herein, we would like to report a 45-year-old lady with exertional dyspnea who was first diagnosed with having a cystic cardiac mass on transthoracic echocardiogram. Then, transesophageal echocardiogram and cardiac computed tomography revealed an unruptured aneurysm of noncoronary sinus of Valsalva.

Background In patients with atrial fibrillation or flutter, a left atrial appendage ejection velocity measured via transesophageal echocardiography equal to or less than 40 cm/sec has been shown to correlate with an increased risk of developing left atrial appendage thrombus while velocities greater than 40 cm/sec are at lower risk. The CHADS2 and CHA2DS2-VASc scores calculated from clinical variables have been developed to risk stratify patients with atrial fibrillation/flutter in regard to the need for anticoagulation. This study was designed to assess whether a relationship exists between left atrial appendage ejection velocities and the respective CHADS2 and CHA2DS2-VASc scores, and whether this relationship is affected by the presence of atrial fibrillation or atrial flutter. Methods A retrospective chart review was performed on patients in the last 5 years who had undergone a transesophageal echocardiogram in which LAA velocity was measured. Once these patients were identified, relevant clinical information allowing for the calculation of the CHADS2 and CHA2DS2-VASc scores was also extracted from the medical record. Results Data from a total of 151 patients were included in the study. A statistically significant correlation between LAA velocity and CHADS2 score (P = 0.942) or between LAA velocity and CHA2DS2-VASc scores (P = 0.723) was not found. Conclusions We could not identify a relationship between either the CHADS2 or CHA2DS2-VASc scores and LAA velocities. This was true regardless of whether patients were in sinus rhythm or AF at the time of the TEE. While reduced LAA velocities increase the risk of LAA thrombus, the development of stroke in patients with AF is secondary to a complex interplay of multiple clinical variables.

The WATCHMAN left atrial (LA) appendage closure system is an alternative therapy for stroke prevention in patients with atrial fibrillation who are intolerant to chronic oral anticoagulation with warfarin. Infrequently, LA device-related thrombus (DRT) has been suspected. Optimal treatment of DRT is not known, and the efficacy of novel oral anticoagulants (NOAC) in this setting has not been previously described. A 69-year-old woman with permanent atrial fibrillation underwent WATCHMAN device placement. A transesophageal echocardiogram (TEE) performed 45 days following implant revealed a well-seated device. A 1-year follow-up TEE revealed a 1.2 × 0.8 cm sized DRT on the LA aspect of the WATCHMAN device. She was prescribed dabigatran 150 mg po BID for 3 months and she remained on aspirin 325 mg per day. She returned approximately 4 months later (and several weeks after completing her 3-month course of dabigatran) for a repeat TEE, which revealed complete resolution of the DRT. A TEE was performed approximately 8 months later and revealed a new DRT measuring 1 cm in diameter on the LA aspect of the device. This is the first report of successful WATCHMAN DRT treatment with a NOAC, and the first report of late DRT recurrence following treatment to resolution with an anticoagulant. This case report demonstrates that (1) WATCHMAN DRT may form late following implantation, (2) DRT resolution is possible with NOACs, specifically dabigatran, and (3) late recurrence of DRT is possible, even after treatment to initial resolution with systemic anticoagulation.

We present a case of a 68-year-old man with calciphylaxis, who was found to have a floating thrombus in the descending aorta on a transesophageal echocardiogram. The use of 3D echocardiography demonstrated nicely the free motion of the thrombus, emerging from an atherosclerotic plaque in the descending aorta. Anticoagulation was started for thromboembolism prevention.

This case describes an unusual intraoperative transesophageal echocardiogram (TEE) finding of an unknown sinus of Valsalva mass in a patient undergoing an off-pump coronary artery bypass procedure. The intraoperative TEE finding not only revealed a protruding right coronary ostial stent but also changed the surgical procedure to include an aortotomy that allowed successful removal of the stent. As interventional cardiologists begin exploring more techniques to manage difficult ostial lesions, this finding may be seen more commonly in the future. This case highlights how the use of routine TEE even in off-pump coronary artery bypass procedures may be very beneficial.

Rupture of aneurysm of sinus of Valsalva into the right atrium mimicking tricuspid valve endocarditis is a rare presentation. We review a case of spontaneous rupture of aneurysm of sinus of Valsalva into the right atrium presenting as a murmur. Transthoracic echocardiogram showed a mobile mass that appeared to be attached to the tricuspid valve leaflet with moderate tricuspid regurgitation suggestive of tricuspid valve endocarditis. The diagnosis was confirmed as spontaneous rupture of noncoronary sinus in to the right atrium by transesophageal echocardiogram. Patient recovered completely after surgical repair.

Background Transesophageal echocardiogram (TEE) is a gold standard test for diagnosis of left atrial (LA) thrombus, but it has limited sensitivity for identification of small thrombi within side lobes. Thus, the absence of visualizing a left atrial appendage (LAA) thrombus does not equate with the absence of a LAA thrombus. Aim To assess the predictive value of mitral annular systolic velocity (Sa) and D-dimer for the detection of LA thrombus and spontaneous echocardiographic contrast (SEC) in mitral stenosis (MS) patients with sinus rhythm (SR). Methods Transthoracic echocardiogram, TEE, and D-dimer analysis were performed in 104 severe MS patients and divided them into three groups: Group I:no LA thrombus or SEC; Group II:LA SEC only; and Group III:LA thrombus. Results Group III had more severe New York Heart Association (NYHA) class (III-IV) dyspnea and lower Sa (6.9 ± 0.7 vs.10.0 ± 1.2 cm/sec), lower LAA late emptying velocity (17.7 ± 2.1 vs. 24.4 ± 4.2 cm/sec), larger LA transverse dimension, and LAA area (LAAA) than group I+II. Mean D-dimer levels were higher in groups III and II than in group I. In multivariate analysis Sa, D-dimer levels, LAAA, and NYHA class were independent predictors of LA thrombus. ROC curve analysis revealed that higher Sa >8 cm/sec and lower D-dimer levels 510 μg/L predict the presence of LA thrombus. Conclusion Measurement of Sa and D-dimer levels is necessary for better assessment of LA thrombus and SEC, for identification of patients who are at high risk for LA thrombus formation and for initiation of prophylactic anticoagulation.

Congenital absence of left atrial appendage (LAA) is an extremely rare condition and its physiological consequences are unknown. We present two cases of incidental finding of a congenitally absent LAA in a 79-year-old male who presented for routine transesophageal echocardiogram (TEE) to rule out intracardiac thrombus prior to placement of biventricular implantable cardioverter-defibrillator and a 54-year old female who presented for TEE prior to radiofrequency ablation of atrial fibrillation. Characterization of patients with such an absence is important because congenitally absent LAA may be confused with flush thrombotic occlusion of the appendage. There are very few published reports of congenital absence of LAA. To our knowledge, our report is the first to demonstrate the congenital absence of LAA by 3D transesophageal echocardiography.

A 71-year-old male presented after sudden onset of confusion and expressive aphasia. MRI head revealed multiple ischemic lesions consistent with cardio-embolic pathophysiology. A computed tomography angiography of lung showed peripheral pulmonary emboli. He underwent a transesophageal echocardiogram as a part of the stroke workup and was found to have vegetations on both aortic and tricuspid valves. The blood cultures did not show any growth, and the patient remained afebrile during the course of hospitalization. A diagnosis of nonbacterial thrombotic embolism was made, and he was discharged on anticoagulation therapy with subcutaneous low molecular heparin.

Isolated congenital left ventricular diverticulum (LV) is reportedly a rare finding. It is frequently associated with other congenital defects involving heart, pericardium, sternum, diaphragm, and abdominal wall. It is an outpouching from the ventricle and has all three layers of left ventricular free walls. We present the case of a 53-year-old woman who was discovered to have an outpouching of the LV apex on a nongated chest CT scan raising possibility of a pseudoaneurysm. A transesophageal echocardiogram (TEE) showed systolic diminution of this outpouching with unique Doppler flow-patterns suggesting a diagnosis of a muscular type of LV diverticulum instead of a postinfarct LV pseudoaneurysm. The patient was reassured and treated conservatively.

The left atrial appendage (LAA) is a small muscular extension that grows from the anterolateral wall of the left atrium, in the proximity of the left pulmonary veins. The presence of a membrane in the LAA is a rare clinical entity whose origin is not known. Its clinical implication in the genesis of atrial arrhythmias and thromboembolic risk remains unknown. We report a case of an obstructive membrane located at the base of the LAA, found incidentally in a young patient who was initially undergoing a transesophageal echocardiogram prior to an invasive treatment for atrial fibrillation.

This report describes a 42-year-old man with a history of lymphoma who is admitted with symptoms of chest pain, ST elevation changes, and elevated troponins. Immediate bedside echocardiographic evaluation led to an aborted urgent coronary angiography and a diagnosis of presumed endocarditis. Transesophageal echocardiography (TTE) subsequently revealed an aortic noncoronary cusp aneurysm masking as vegetation. The rapid assessment by TTE and transesophageal echocardiogram prevented an alternate course for this patient's management. We reviewed the necessity of heart catheterization in patients with significantly elevated troponins, pericarditis symptoms, and the rare sighting of aortic valve cusp aneurysms.

Purpose To investigate whether plasma B-type Natriuretic peptide (BNP), a surrogate of left ventricular filling pressure (LVFP), is predictive of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (AF) independent of known clinical risk predictors. Methods We conducted a retrospective cohort study of 297 consecutive subjects with AF who underwent a clinically indicated transesophageal echocardiogram (TEE) to evaluate for LAAT and spontaneous echo contrast (SEC). Among those, 136 had a clinically indicated BNP level. Using multivariate logistic regression analysis models, we determined factors independently predictive of the primary endpoint of LAAT and the secondary endpoint of either LAAT or SEC. Results Nineteen subjects (6.4%) had LAAT and they were found to have a higher mean CHADS2 score (2.53 vs 1.76, P = 0.01) and mean BNP level [1949 vs. 819 pg/mL, P = 0.001] than those without LAAT. None of the patients with a BNP level ≤500 pg/mL had LAAT. Multivariate logistic regression analysis demonstrated that BNP was predictive of LAAT and the composite of LAAT/SEC independent of the CHADS2 score and warfarin therapy [OR = 1.23 and 1.6 per 500 pg/mL increment in BNP, P-values = 0.03 and 0.001; respectively]. Moreover, adding BNP to the predictive model negated the influence of the CHADS2 score. Conclusion These data indicate that BNP is an independent predictor of LAAT in AF and may complement the role of the CHADS2 score in predicting stroke risk.

Invagination of an appendage into the left atrium is a rare complication. It occurs spontaneously or after open-heart surgery. In our case, a postoperative transesophageal echocardiogram, after closure of a ventricular septal defect in a 5-month-old infant, revealed a large mass in the left atrium. A diagnosis of a left appendage inversion was confirmed after external examination of the heart. Herein, we provide echocardiographic images before, during, and after manual reversion of the left appendage. Misdiagnosis of this complication could have led to an additional unnecessary surgical procedure that could have impacted on the patient's morbidity.

This case illustrates an unusual and fatal complication after endovascular treatment of type B aortic dissection and highlights the role of echocardiography in the early diagnosis of complications. In this case, a patient with previous diagnosis of chronic type B aortic dissection and moderate aortic regurgitation underwent endovascular repair of the proximal descending aorta and conservative surgical correction of the aortic valve. On early postoperative, a transesophageal echocardiogram and aortic angiotomography demonstrated proximal endoleak by contrast extravasation around the proximal graft attachment site, causing compression of the stent in its middle portion, resulting in narrowing with reduced cross-sectional area.

Atheromatous disease of the aorta is a known marker of vascular disease and is associated with ischemic stroke, peripheral embolization, and coronary events. Transesophageal echocardiogram is routinely used to assess aortic atheromas. Discrepancies exist in the grading of aortic atheromas. Atheromas with >4 mm thickness or with plaque rupture and mobile fragments are more likely to be associated with peripheral embolic events. Antiplatelet agents, oral anticoagulants, and statins have been suggested in the management of atheromas but sufficiently powered, randomized, controlled trials are not available to guide medical management of atheromas. (Echocardiography 2011;28:1157-1163)

Modern diagnostic imaging modalities for ascending aortic dissection include transesophageal echocardiography (TEE), computed tomography angiography (CTA), and magnetic imaging resonance (MRI). All have extremely high sensitivity and specificity for detection of an intimal flap to diagnose ascending aortic dissection. We present a case of fatal cardiac tamponade caused by a limited aortic dissection not detected by multiple imaging modalities. This may represent a class of aortic dissection variant that cannot be detected by conventional testing. A high index of suspicion should be maintained in the appropriate clinical setting and should prompt serial imaging and even consideration for preemptive surgical exploration.

BACKGROUND Patent foramen ovale (PFO) is a well-recognized risk factor for ischemic strokes. The true prevalence of PFO among stroke patients is still under debate. Transesophageal echocardiography (TEE) is the "gold standard" in diagnosing PFO but the physiology requires right-to-left atrial shunting. In this report, we evaluate the prevalence of PFO in a diverse group of ischemic stroke patients studied by TEE. METHODS TEE of 1,663 ischemic stroke patients were reviewed for cardiac source of embolism, including PFO and atrial septal aneurysm (ASA). Agitated saline bubble injection was performed to look for right to left atrial shunting. Success of maneuvers to elevate right atrial pressure (RAP) was noted by looking at the atrial septal bulge. RESULTS Among 1,435 ischemic stroke patients analyzed, the presence or absence of PFO could not be determined in 32.1% because bulging of the septum could not be demonstrated in patients with negative contrast study despite aggressive maneuvers to elevate RAP. Of the remaining 974 patients, 294 patients (30.2%) had a PFO. The mean age was 61.5 years in both groups, with a bimodal distribution of PFO and the highest prevalence occurring in < or =30-year-old group. Prevalence of PFO was similar in men (32.4%) and women (28.15%, P = 0.15); and in Caucasian (32.1%) and African American (27.7%; P = 0.15). ASA was present in 2.02% and hypermobile septum in 2.49% of the 1,435 patients. PFO was seen in 79.3% of the patients with ASA. CONCLUSION Successful elevation of RAP cannot be achieved in a significant number of patients undergoing TEE and determination of PFO may be difficult. In our series, the true prevalence of PFO among ischemic stroke patients was 30.2% taking into account only those patients who showed no shunting despite bulging of the atrium septum into the left atrium (PFO absent group) during the contrast study. There was no gender or racial difference in the prevalence of PFO, but there was a bimodal distribution in prevalence with age.

Lambl's excrescences are thin, mobile, filiform structures, often referred to as valvular strands in the echocardiography literature. These valvular strands may occur as a single strand, in rows, or clusters. The differential diagnosis for these excrescences includes fibroelastoma, myxoma, thrombi, vegetations, and cardiac neoplasms and metastases. Most difficult is the distinction between Lambl's excrescences and fibroelastomas. Studies regarding the clinical importance of these valvular strands are contradictory. Surgical intervention versus conservative observation should be determined on a case-by-case basis. The transesophageal views of Lambl's excrescences in this case report are meant to serve as a classic example of this commonly misinterpreted lesion.

Cardiac tamponade is usually a consequence of increased pericardial pressure with accumulation of pericardial effusion. Pericardial effusion may be caused by acute pericarditis, tumor, uremia, hypothyroidism, trauma, cardiac surgery, or other inflammatory/noninflammatory conditions. In this article we describe four scenarios illustrated by case reports where a small or apparently small pericardial effusion may produce cardiac tamponade. The first scenario illustrates how a small pericardial effusion can cause clinically significant cardiac tamponade when it accumulates rapidly. The second scenario exhibits how an apparently small pericardial effusion on transthoracic echocardiogram (TTE) turned out to be a small amount of unclotted blood and an echogenic hematoma. The third scenario details how an apparently small pericardial effusion on TTE was actually a large loculated effusion in an unusual location seen only by transesophageal echocardiogram (TEE). The fourth scenario demonstrates how the combination of a large pleural effusion and a small pericardial effusion can result in cardiac tamponade. The role of echocardiography in the diagnosis and management of these scenarios is discussed here. Although many clinicians depend on the amount of pericardial effusion to suspect cardiac tamponade, it is important to suspect cardiac tamponade when patients have hemodynamic compromise regardless of the amount of pericardial effusion.

The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow-up studies have reported an association between aortic atheromas and stroke in the high-risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE-based studies in the low-risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future.

A quadricuspid aortic valve (QAV) is a rare congenital heart defect, previously described as an incidental finding at the time of surgery or postmortem, which is now being increasingly detected by 2D transthoracic or transesophageal echocardiogram. With advances in echocardiography, secondary cardiac anomalies are also being described in association with QAV. Herein we describe a patient with QAV with a secundum atrial septal defect.

A 49-year-old woman developed a chronic obstruction of the superior vena cava (SVC) as a complication of mediastinal tuberculosis. Echocardiography findings are presented along with the cavography. Symptoms disappeared after stenting the fibrosed SVC. Transesophageal echocardiogram findings led to the condition's final resolution.

Background Cor triatriatum is rarely found in adults and its diagnosis is mostly dependent on transesophageal echocardiogram. We present a case of an adult male with cor triatriatum and discuss our approach to diagnosis with a review of literature. Case A 49-year-old male presented with progressive exertional dyspnea for the past two-and-half years. A transthoracic echocardiogram revealed a thin linear echo-dense structure traversing the left atrium (LA). A transesophageal echocardiogram demonstrated a thin immobile membrane in the LA attached medially to the interatrial septum. No fenestration of the membrane was seen. A swirling spontaneous contrast was noted in the posterior chamber. Color Doppler did not reveal any flow across the membrane. A CT scan of the chest was unhelpful to differentiate extracardiac versus intracardiac origin. Contrast echocardiogram with Optison was performed, which showed a differential opacification of the two atrial chambers and delayed emptying of contrast into true LA establishing communication between the chambers. Left and right heart catheterization were performed with simultaneous pulmonary capillary wedge and left ventricular end diastolic pressure measurement, revealing a mean gradient of 17 mmHg. Surgical correction of the membrane was recommended. Intraoperatively, an orifice of 0.7 cm was identified in an eccentric position with mosaic pattern of continuous turbulent flow across the membrane by color Doppler. Discussion Our case demonstrates the impact of contrast echocardiography in a situation where the transesophageal approaches were limited even with the aid of color Doppler.

Background: The incidence of coronary arteries lesion in Takayasu's arteritis varies from 9% to 10% and is usually discovered at autopsy. Recent studies have demonstrated the value of echocardiography in noninvasive detection of significant coronary stenosis. Aim: The aim of our study was to evaluate coronary reserve in 15 patients with Takayasu's arteritis using contrast transesophageal echocardiography (Optison). Methods: Transesophageal echocardiogram under basal conditions and in the hyperemic phase with dipyridamole challenge, myocardial perfusion studies and coronary angiography were performed on all patients. Seventy-three percent of them had histories of systemic hypertension, and the most frequent cardiovascular symptoms were shortness of breath (80%), headache (46%), angina (40%), and dizziness (33%). Results: The transthoracic echocardiogram showed left ventricular systolic dysfunction in 6% and diastolic dysfunction in 53%. Aortic regurgitation was found in 67% of the patients, and 60% had mitral and/or tricuspid regurgitation. Coronary reserve was diminished in 3 patients with significant coronary lesions and in 2 patients with coronary dilation (33%). In the 3 patients with obstructive lesions and diminished coronary reserve, reversible perfusion defects were found with thallium-201 single-photon emission computed tomography. One patient with coronary dilation had normal perfusion, while the other demonstrated reversible and irreversible perfusion defects. One patient without coronary lesions and with normal coronary reserve had an irreversible fibrotic changes and the other reversible defects due to abnormal microcirculation. Conclusions: Transesophageal echocardiography is a feasible and promising technique for assessing coronary reserve in patients with Takayasu's arteritis.

Aneurysms of the coronary arteries are rare and are usually associated with atherosclerosis in adults. Mycotic coronary artery aneurysms are exceedingly uncommon and are typically associated with systemic bacteremia, endocarditis, or septic emboli. Literature and data describing the management of mycotic coronary artery aneurysms are limited. This case describes the successful diagnosis of a large right coronary artery aneurysm by transesophageal echocardiogram as well as the successful management of the aneurysm.

Cardiac papillary fibroelastoma is an uncommon nonmalignant tumor. It is usually found in adults, arising from endocardium within the left side of the heart. We present a case of an asymptomatic pediatric patient with sickle cell disease, in whom a relatively rapidly growing papillary fibroelastoma emanating from the aortic valve was detected on routine echocardiogram (Philips iE33, Philips Ultrasound, Bothell, WA, USA). The tumor was surgically removed without compromising the aortic valve. A mechanism is suggested for the development of this tumor in a patient with sickle cell disease. A 15-year old female with sickle cell disease (homozygous SS) and splenectomy was seen in cardiology clinic. As part of our protocol for following patients with SS-disease, we obtained an echocardiogram to assess left ventricular size and function. The study demonstrated a (9.1 mm 9 8.4 mm) mobile, echo dense mass, attached by a thin stalk to the aortic surface of the right coronary cusp of the aortic valve, close to the commissure between the right and left coronary cusps (Fig. 1). There was no aortic outflow obstruction or aortic valve insufficiency. An echocardiogram performed 17 months earlier showed no mass within the heart (Fig. 2). The patient had no recent fever, infection, headache, or neurologic deficit. A transesophageal echocardiogram (TEE) (Philips iE33), performed just prior to surgery, confirmed our preoperative findings (Fig. 3). There were no additional intracardiac masses seen. The operation was conducted under conditions of normothermia with the hemoglobin S level maintained