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Papillary fibroelastoma of aortic valve is a rare benign tumor that can present with symptoms of obstruction or embolization and can be asymptomatic. The main stay of diagnosis is echocardiography. The size of the tumor affects the sensitivity of transthoracic echocardiography which can miss small size tumors. The treatment is surgical resection. Here, we report a case of papillary fibroelastoma of aortic valve that was detected intraoperatively by transesophageal echocardiography and was missed by transthoracic echocardiography in a patient undergoing coronary artery surgery. The tumor was resected successfully with preservation of aortic valve with no complication. This case highlights importance of intraoperative transesophageal echocardiography in making the diagnosis. [ABSTRACT FROM AUTHOR]

Background Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders. Objectives We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs). Methods A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis. Results A total of 5 articles met inclusion criteria, representing 1709 patients in the STE cohort and 1716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days. Our meta-analysis found no differences in all surgical outcomes except for explantation risk. STE use was associated with increased odds of explantation by over 50% compared to TTE use (odds ratio = 1.53; 95% CI = 1.15 to 2.02; P =.003). Conclusions Overall, STEs and TTEs had similar complication profiles. However, STEs had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single case of BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Mitral valve surgery (MVS), with repair preferred to replacement, is a common procedure for the treatment of severe primary mitral regurgitation related to leaflet prolapse. Structural complications after MVS include left ventricular outflow obstruction, paravalvular leak and atrial septal defect. Intraoperative transoesophageal echocardiography and predischarge transthoracic echocardiography (TTE) specifically screen for these complications. Ventricular septal defect (VSD), a known complication after aortic valve surgery, is rarely reported after MVS. Recently, unsuccessful valvuloplasty prior to replacement was suggested as a risk factor. We present such a case and explore mechanisms with advanced cardiac imaging. In this case, the patient was found to have an elongated membranous septum that likely predisposed her to septal injury. Finally, we provide guidance on specific transoesophageal/transthoracic echocardiography views to avoid a missed diagnosis. [ABSTRACT FROM AUTHOR]

The article presents the discussion on case study of 61-year-old woman with a mechanical mitral valve replacement who was found to have a mobile echo-dense image resembling a mass on echocardiography. Topics include the identification and differentiation of microcavitation from other echo-dense lesions, the significance of this finding to avoid unnecessary interventions; and techniques for improving echocardiographic image interpretation.

This article, published in the European Heart Journal Case Reports, presents a case study of a 79-year-old woman with severe aortic stenosis (AS) who underwent transcatheter aortic valve replacement (TAVR). The study used transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) to assess cardiac-coronary interactions before and after the procedure. The findings showed that the patient had systolic flow reversal in the left anterior descending coronary artery (LAD) before TAVR, which changed to forward flow after the procedure. Additionally, the patient's endocardial global longitudinal strain (GLS) increased after TAVR. The study suggests that these findings contribute to a better understanding of cardiac-coronary interactions in AS and can be used in clinical practice. [Extracted from the article]

Background: Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation.Objectives: The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction.Methods: The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated.Results: A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction.Conclusions: STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.Level Of Evidence:4: [ABSTRACT FROM AUTHOR]

This article, published in the European Heart Journal, discusses a case study of a 6-month-old female patient who developed a left ventricular pseudoaneurysm (LVPA) after surgical repair of a ventricular septal defect (VSD). The LVPA was not detected preoperatively and was poorly visualized with transoesophageal echocardiography. Due to the risks associated with redo surgery and radiation exposure in infants, the LVPA was percutaneously closed under transthoracic echocardiography (TTE) guidance. The procedure was successful, and follow-up imaging showed the disappearance of the LVPA and normalization of left ventricular function. The authors note that this is the first reported case of percutaneous closure of an LVPA exclusively under TTE guidance. [Extracted from the article]

A 30-year-old male presented to an outside facility with acute pancreatitis and triglycerides of 1594. He was transferred to our facility after becoming febrile, hypoxic and in acute renal failure with triglycerides of 4243. CT scan performed showed wall-off pancreatic necrosis. He underwent continuous renal replacement therapy and his acute renal failure resolved. He was treated with broad spectrum antibiotics and discharged. He developed a fever to 101 a week later and was found to have a large infected pancreatic pseudocyst. This was managed with an IR placed drain. This was continued for 6 weeks. He came to the emergency department several weeks later with shortness of breath and 3+ edema to bilateral lower extremities and lower abdomen. TTE performed showed an EF of 15%. He was diuresed 25 L during that stay. His heart failure was medically managed. We present this case of dilated cardiomyopathy secondary to acute pancreatitis. [ABSTRACT FROM AUTHOR]

In the current era of expanding catheter-based and complex repair procedures to treat aortic valve (AV) diseases, growing consideration is being given to understanding the functional anatomy of the AV complex. Echocardiography is the primary imaging modality to assess and follow-up AV diseases, and the recent three-dimensional (3D) capabilities allow clinicians to appreciate the functional complexity of the aortic root in the beating heart. Despite being subject to several limitations, 3D echocardiography (3DE) holds promise as a more suitable imaging backup for aortic interventions of mounting complexity and for circumventing some of their current complications. In this review, we discuss the key principles of 3DE for assessing the AV pathology and the incremental clinical benefits in comparison with conventional 2DE and Doppler echocardiography, justifying its implementation in the diagnostic workup of aortic diseases. In view of an effective clinical use, a brief section is dedicated to the acquisition modalities, display, and interpretation of various abnormalities by 3DE. [ABSTRACT FROM AUTHOR]

The article offers information on the usefulness of three-dimensional (3D) echocardiographic (3DE) imaging, representing a major innovation in cardiovascular ultrasound. It discusses the evaluation of cardiac chamber volumes and mass as well as the assessment of regional left ventricular (LV) wall motion and quantification of systolic dyssynchrony. It also discusses the transthoracic 3DE examination protocol.

Abstract: Objective: Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. Methods: A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. Results: Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213ml (range 100–400ml) for the TH group and 216ml (range 80–500ml) for the TT group. The median operating times for both approaches were similar (398min TH vs 382min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80mmHg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥10mmHg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p =0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p =0.01. Conclusion: This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient''s pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact. [Copyright &y& Elsevier]

The effect of cardiopulmonary bypass (CPB) on pulmonary function was investigated in 32 adult patients, including 23 patients undergoing coronary artery bypass grafting and nine patients undergoing heart-valve replacement. Clinical indicators for pulmonary insufficiency, such as chest X-ray, gas exchange and lung function tests were measured. Transthoracic electrical impedances were measured, and the mean specific thoracic impedance (RHO) was calculated. (RHO is an accurate indicator for the intrathoracic fluid content; low RHO values correspond with high intrathoracic fluid content.) Significant postoperative decreases in RHO were paralleled by a significant impairment of gas exchange. Chest X-rays demonstrated accumulation of intrathoracic fluid. Lung function tests showed significant postoperative decreases in lung volumes and vital capacity. These findings are consistent with the concept that CPB provokes an inflammatory reaction in the lung. The non-invasive RHO meaurement proved to be simple and in good agreement with clinical indicators. This method may be a real asset in the prevention and treatment of pulmonary dysfunction after CPB. The possibility of calibrating RHO with respect to absolute values of intrathoracic fluid content should. [ABSTRACT FROM PUBLISHER]

Background Infective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus. Methods She was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added. Results Patient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth. Conclusion This case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Metastatic tumours are the commonest cardiac tumours being found in 1–3% of patients dying of cancer while primary tumours are unusual and have an incidence of 0.02–0.5%. The majority (80%) of all primary cardiac tumours are benign with myxomas accounting for 50%. Myxomas arising from the right atrium are uncommon. [ABSTRACT FROM PUBLISHER]

Chronic constrictive pericarditis (CCP) is the most common pericardial pathology. CCP complicating with intracardiac thrombus is a rare entity, the detection of thrombus preoperatively is life-saving in avoiding the risk of pulmonary thromboembolism during anterior pericardiectomy. Transesophageal echocardiography has been shown to have better sensitivity in detecting atrial thrombus than transthoracic echocardiography. Surgical removal of right atrial thrombus under cardiopulmonary bypass should be considered. [ABSTRACT FROM AUTHOR]

Background The emergence of carbapenem-resistant Klebsiella pneumoniae (CR-Kp) presents significant clinical challenges with our limited antibiotic armamentarium. Infective endocarditis caused by CR-Kp is rare, with few cases reported in the literature. The use of the novel β-lactam/β-lactamase inhibitor combination ceftazidime–avibactam (CAZ-AVI) in this setting has only been described in one 2018 case in Italy. Guidance in how these novel antibiotics should be used becomes more prudent as the prevalence of complicated CR-Kp infections increases. Methods A 51-year-old male with a past medical history of a gunshot wound to the neck, type 2 diabetes, and osteomyelitis status post right below-the-knee and left toe amputations presented to the emergency department with altered mental status and right upper extremity weakness. The patient's hospital course was complicated by hemorrhagic stroke, left above-the-knee amputation, and intraoperative cardiac arrest. Subsequently, blood cultures on hospital days 41 and 43 grew CR-Kp and a transthoracic echocardiogram (TTE) showed moderate to severe aortic regurgitation. Results Antimicrobial therapy was changed from imipenem-cilastatin and colistin to CAZ-AVI and amikacin. The organism was found to be susceptible to CAZ-AVI and amikacin, intermediate to colistin, and resistant to all carbapenems. A transesophageal echocardiogram (TEE) confirmed the presence of a small mobile vegetation on the aortic valve with perforation and severe regurgitation. CAZ-AVI and amikacin were continued for two weeks, and then switched to CAZ-AVI and ertapenem for an additional four weeks. Follow-up blood cultures on and after day 44 were negative for CR-Kp. A TTE performed after therapy completion no longer demonstrated aortic regurgitation; however, the valves were poorly visualized. The patient then suffered anoxic brain injury after a second cardiac arrest, thought to be unrelated to endocarditis. The patient's family then decided on hospice care and the patient expired. Conclusion We report the successful treatment of CR-Kp endocarditis with CAZ-AVI and amikacin for two weeks followed by CAZ-AVI and ertapenem for four weeks. This regimen can be a viable option for patients that present with this rare multidrug-resistant infection. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Pulmonic valve (PV) infective endocarditis (IE) is a rare entity, accounting for ~1.5–2% of all cases of IE. As a result, published literature describing the diagnosis and management of patients with PVIE is limited. Methods A retrospective review of patients ≥18 years old admitted to Wake Forest Baptist Medical Center from 2012 to 2017 with a diagnosis of PVIE based on the modified Duke criteria was performed. Results Ten patients were identified as having PVIE, 9 of whom had isolated PV involvement and 1 of whom had concurrent aortic valve involvement. The diagnosis of IE was definite per the modified Duke criteria in 8 patients. The median age was 41 years and 30% were female. Two patients had pacemakers, 1 had a prosthetic PV, and 1 had congenital heart disease. Six patients were identified as persons who inject drugs (PWID). On admission, 5 patients manifested fever and 5 had a documented murmur. Seven patients had septic pulmonary emboli with 4 of 7 patients manifesting pulmonary hypertension. Transthoracic echocardiography (TTE) revealed vegetations in 4 of 10 patients whereas PV vegetations were demonstrated in all 8 patients undergoing transesophageal echocardiography (TEE). S. aureus was the most common causative organism, accounting for 5 of the cases of PVIE with four of the five isolates being methicillin-resistant. Bacteremia persisted for a median of 3 days. One patient underwent PV replacement. The planned median duration of antimicrobial therapy was 6 weeks. The median length of stay was 18 days. Three patients died during the index hospitalization, 1 of whom was a PWID. No episodes of repeat PVIE occurred within 1 year. Conclusion PVIE is a rare disease. Only 40% of our patients had vegetations on TTE in contrast to a reported diagnostic yield of >90% in the literature. As such, PVIE may be underdiagnosed. S aureus was the most common organism isolated, which is in keeping with prior reports. PWID appear to be at high risk for PVIE. In view of the worsening opioid epidemic, more research on PVIE is warranted. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Management commonly includes six-weeks of antibiotics and surgical intervention, if the patient has complications. Current guidelines recommend obtaining an echocardiogram. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram (TTE). We wanted to evaluate the role of a TEE in changing management of MRSA IE. Methods A retrospective cohort of patients with MRSA IE was analyzed between January 2013 and July 2017 at a tertiary care facility in East Tennessee. Patients with prosthetic valves or cardiac devices were excluded. Demographic, echocardiographic, antibiotic, blood culture, mortality, and intravenous drug use data were collected (Figure 1). Results Seventy-eight patients met the inclusion criteria. TTE was performed on 73 patients while five patients proceeded directly to TEE. Of the 73 patients that had a TTE, 33 (45.2%) detected the presence of vegetation and 40 (54.8%) did not. Of the 33 patients with a positive TTE, 15 subsequently underwent TEE, confirming IE. Out of the 40 patients with a negative TTE, 34 underwent TEE, of which 22 (64.7%) showed a vegetation. (Figure 2). A total of ten patients (12.8%) from the study underwent surgery. Of these ten, three (30%) had a positive TTE only, with no subsequent TEE. Five (50%) had both a positive TTE and TEE, and two (20%) had a negative TTE but positive TEE. Conclusion Transthoracic echocardiogram was adequate to visualize vegetations in 45.2% of patients. Completing a TEE increased the sensitivity of visualizing a vegetation, but management was most often not altered. Only two patients (5%) with a negative TTE, but positive TEE proceeded to surgery because of the findings. This causes us to question whether a subsequent TEE needs to be pursued when a TTE is negative in the setting of definite or possible IE by the modified Duke criteria. Even if a vegetation is seen on TEE the patient would most likely receive the same treatment, 6 weeks of intravenous antibiotics, as if no vegetation was seen. Forgoing a TEE reduces risk to the patient of undergoing a procedure, and reduces costs to the healthcare system. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

A 49-year-old diabetic male was admitted to a hospital in 2018 following a 3-week history of worsening dyspnoea and pedal oedema. Early review and investigations indicated acute heart failure. Transthoracic echocardiogram (TTE) revealed mitral regurgitation (MR), aneurysmal change of the ventricles, a ventricular septal defect (VSD) and systolic dysfunction. Coronary angiogram demonstrated a significant left anterior descending and right coronary artery disease. He was diagnosed with a late presenting myocardial infarction (MI) with secondary mechanical complications. Mechanical complications of MI frequently require surgical intervention. The patient underwent a repair of VSD, mitral valve repair, excision of aneurysmal segment and coronary artery bypass grafting. Post-operative recovery was complicated by a sternal wound infection managed in conjunction with the plastic surgeons. A post-operative TTE showed a repaired ventricular septum and no residual MR. Early recognition and appropriate medical optimisation are required to achieve good patient outcomes. [ABSTRACT FROM AUTHOR]

This case presentation involves a 57-year-old-male who suffered multiple adverse sequels from the delayed diagnosis of a large presacral mass. He initially presented with lower extremity deep vein thrombosis (DVT). Several months later, he had developed a pulmonary embolus. Imaging demonstrated a 13 × 14 cm presacral pelvic mass that occluded the right-sided venous return from the leg and caused the DVT and pulmonary embolism. An inferior vena cava filter was placed and eventually clotted. He then was referred to our institution for surgical consultation. The patient received lytic therapy and unfortunately developed hematemesis and a significant hemoglobin drop. An esophagogastroduodenoscopy (EGD) showed a black esophagus. A transthoracic echocardiogram showed a patent foramen ovale. The patient eventually stabilized and a repeat EGD a week later showed resolution of the ischemic esophagus. The patient later underwent a resection of the pelvic mass. The surgical approach and the surgical decision-making will be discussed. [ABSTRACT FROM AUTHOR]