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Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) is an appealing alternative to surgical intervention on failed aortic prosthesis with comparable safety and efficacy. ViV TAVR has proven to be a technical challenge in stentless bioprosthetic aortic valves like free style aortic valve prosthesis. In this case series of two patients we report the utility of transesophageal echocardiogram guidance to help visualize surgical annulus and TAVR deployment.

The quadricuspid aortic valve (QAV) is a rare congenital anomaly that typically is unrelated to other cardiac anomalies. It usually is discovered incidentally through imaging modalities such as echocardiogram or computed tomography angiogram, during surgery, or autopsy. Some patients with QAV develop aortic regurgitation and, rarely, other cardiovascular complications like aortic aneurysm. Due to its rarity, it is difficult to characterize these patients or standardize management. However, review of case reports can be very useful in rare medical conditions such as QAV. In this manuscript, in addition to presenting two cases of QAV, the authors reviewed 149 cases of QAV from 2010 to 2020 from published case studies and series in order to gain a better insight into the characteristics of the patient population with QAV and its management.

Background Repair of complete atrioventricular septal defect with absent or diminutive primum defect is challenging because of atrial septal malposition and abnormal anatomy of the left atrioventricular valve. We sought to define the incidence, anatomy, and surgical outcomes of this entity. Methods We identified all patients in our institutional database presenting for complete atrioventricular septal defect repair from 2006 to 2018. Operative reports and echocardiograms were reviewed to determine the presence and size of the primum defect, atrioventricular valve anatomy, degree of atrioventricular valve regurgitation, repair method, and complications, including reoperation for atrioventricular valve regurgitation. Functionally univentricular patients and those receiving repair at an outside institution were excluded. Results Of 183 patients with complete atrioventricular septal defect, absent/diminutive primum defect occurred in 16 patients (8.7%; 10 absent, 6 diminutive). Six patients (38%) had leftward malposition of the atrium septum on the common atrioventricular valve. The rate of reoperation for left atrioventricular valve regurgitation was 31% (3 early, 2 late), for which preoperative predictors included leftward malposition of the atrial septum onto the common atrioventricular valve (4/6 patients with malposition required reoperation, P = .036, Fisher exact test). One patient exhibiting this risk factor died. The overall rate of moderate or greater left atrioventricular valve regurgitation on the most recent postoperative echocardiogram was 13% (2/16 patients; median follow-up, 141 days; range, 3-2236 days). Conclusions Complete atrioventricular septal defect with absent or diminutive primum defect is a unique variant of complete atrioventricular septal defect for which the risk of reoperation for left atrioventricular valve regurgitation after complete repair is high and risk factors include leftward malposition of the atrial septum on the common atrioventricular valve.

Objectives The aim of this study was to evaluate the efficacy of radiofrequency (RF) energy applications targeting the atrial side of a significant residual leak in patients with acute and chronic evidence of incomplete percutaneous left atrial appendage (LAA) occlusion. Background RF applications have been proved to prevent recanalization of intracranial aneurysms after coil embolization, thereby favoring complete sealing. From a mechanistic standpoint, in vitro and in vivo experiments have demonstrated that RF promotes collagen deposition and tissue retraction. Methods Forty-three patients (mean age 75 ± 7 years mean CHA2DS2-VASc score 4.6 ± 1.4, mean HAS-BLED score 4.0 ± 1.1) with residual leaks ≥4 mm after Watchman implantation were enrolled. Procedural success was defined as complete LAA occlusion or presence of a mild or minimal (1- to 2-mm) peridevice leak on follow-up transesophageal echocardiography (TEE), which was performed approximately 45 days after the procedure. Results RF-based leak closure was performed acutely after Watchman implantation in 19 patients (44.2%) or scheduled after evidence of significant leaks on follow-up TEE in 24 others (55.8%). The median leak size was 5 mm (range: 4-7 mm). On average, 18 ± 7 RF applications per patient (mean maximum contact force 16 ± 3 g, mean power 44 ± 2 W, mean RF time 5.1 ± 2.5 minutes) were performed targeting the atrial edge of the leak. Post-RF median leak size was 0 mm (range: 0-1 mm). A very low rate (2.3% [n = 1]) of major periprocedural complications was observed. Follow-up TEE revealed complete LAA sealing in 23 patients (53.5%) and negligible residual leaks in 15 (34.9%). Conclusions RF applications targeting the atrial edge of a significant peri-Watchman leak may promote LAA sealing via tissue remodeling, without increasing complications. (RF Applications for Residual LAA Leaks [REACT]; NCT04726943 )

Implantable cardiac devices are widely used devices that serve several purposes. Complications from devices are not uncommon and include localized or systemic infections, device-related endocarditis, and device malfunction leading to serious outcomes, including death. Another possible complication that has been reported in the literature is thrombus formation on the device leads. We present a rare case of large thrombi forming on the leads of an implantable cardioverter defibrillator leading to lead fracture and device malfunction. After the device alerted for malfunction, the patient underwent a transesophageal echocardiogram which demonstrated masses on the right atrium and ventricle. He subsequently had a right atrial exploration and lead extraction which revealed large thrombi on the leads which histologically were identified as sterile vegetations.

Background Persons with atrial fibrillation (AF) are at risk for stroke. Atrial fibrillation-related strokes most often result for emboli arising from the left atrial appendage (LAA). Stroke prevention includes the use of anticoagulants and/or antiplatelets. These medications can result in bleeding complications. An alternative to anticoagulants is the WATCHMAN device, which is delivered in the left atria resulting in closure of LAA. Objective The aim of this study was to describe patient, procedural, and follow-up characteristics in patients who have undergone WATCHMAN implantation. Methods This study used a retrospective design to review data previously collected and entered into the National Cardiovascular Data Registry database. Results During a 2-year period, 41 patients underwent the WATCHMAN procedure at our facility. The most common indication for the procedure in this population of patients with nonvalvular AF on oral anticoagulants was bleeding in the gastrointestinal or genitourinary systems. (Gastrointestinal/genitourinary bleed does not limit candidacy for surgical closure of the LAA.) There was only 1 postprocedure adverse event that included a groin hematoma. A transesophageal echocardiogram at 45 days indicated that the LAA seal showed no leak or flow around the device or a leak less than 5 mm. At 1 year, 95% (n = 36) of patients were only taking a single antiplatelet drug with aspirin. Eight patients were on a single antiplatelet medication at the time of follow-up 2 years after the procedure. Discussion A skilled team including a designated AF clinical nurse specialist contributed to program success measured by efficient placement of the WATCHMAN device and discontinuation of anticoagulation.

Prosthetic valve endocarditis after transcatheter aortic valve replacement (PVE after TAVR) is a feared complication most often observed during the early postprocedural period. We report a case of severe, multivalvular PVE after TAVR with complete heart block caused by an uncommon organism. A 78-year-old female with prior Streptococcus agalactiae mitral valve endocarditis treated with antibiotics presented one year later with severe, symptomatic aortic insufficiency. She subsequently underwent TAVR given high surgical risk. Six weeks post-TAVR, she presented with syncope, fever, and complete heart block. Transthoracic echocardiogram was not demonstrative of vegetation. Blood cultures were positive for Staphylococcus lugdunensis. Transesophageal echocardiogram (TEE) demonstrated vegetations of the aortic, mitral, and tricuspid valves and aorto-mitral continuity. While awaiting surgery, the patient developed cardiac arrest; she was resuscitated and taken to surgery emergently. The patient underwent TAVR explantation, bovine pericardial tissue aortic and porcine bioprosthetic mitral valve replacements, and tricuspid valve repair. Additionally, left main coronary artery endarterectomy was performed due to presence of infectious vegetative material. Staphylococcus lugdunensis is an unusual but virulent organism that may damage both native and prosthetic valves. Early surgery is recommended for PVE after TAVR, especially in cases with perivalvular disease causing conduction abnormalities. Learning Objectives. TAVR has revolutionized the management of severe aortic stenosis and has even been successfully utilized in select cases of aortic regurgitation. Unfortunately, there are a number of associated complications that can be difficult to diagnose, such as prosthetic valve endocarditis (PVE). We emphasize maintaining a high clinical suspicion for PVE after TAVR in patients presenting with conduction abnormalities and highlight the importance of early surgical management in cases complicated by heart block, abscesses, or destructive penetrating lesions.

Aortic root abscess and endocarditis should be suspected in patients with bradycardia and sepsis. We present a case of a 76 year old male who presented with urinary tract infection and sepsis and developed bradycardia and ventricular stand still during hospital admission. Transthoracic echocardiogram was unrevealing; transesophageal echocardiogram showed prosthetic valve dehiscence and aortic root abscess, intracardiac fistula, and tricuspid valve endocarditis. This case highlights the importance of suspecting endocarditis in patients with sepsis and known source of infection, especially if blood cultures do not clear or conduction abnormalities develop.

Purpose To compare effectiveness of different treatments for atrial fibrillation (AF) patients who were scheduled for cardioversion (CV) or ablation (CA) presenting with left atrium appendage (LAA) thrombus despite chronic oral anticoagulation therapy (OAC). Methods This was a retrospective cohort study. We analyzed 2014–2019 medical records of patients scheduled for CV or CA of AF who were diagnosed with LAA thrombus despite optimal OAC and had a follow-up transesophageal echocardiogram (TOE). Changes in treatment were divided into the following groups: switch to a drug with different mechanism of action, switch to a drug with similar mechanism of action, initiation of combination therapy, or deliberate no change in treatment. Patients with contraindications to non-vitamin K antagonists were excluded from the analysis. Results We analyzed data of 129 patients comprising 181 cycles of treatment. The overall effectiveness of LAA thrombus dissolution was 51.9% regardless of the number of cycles and 42.6% for the first cycle of treatment. Any change of treatment was more effective than deliberate no change—OR 2.97 [95% CI: 1.07–8.25], P = 0.031, but no particular strategy seemed to be more effective than the other. Left atrium area (OR 0.908 [95% CI: 0.842–0.979]) and number of treatment cycles (OR 0.457 [95% CI: 0.239–0.872]) were both adversely related to thrombus resolution. There was one ischemic and three bleeding adverse events during the treatment. Conclusion LAA thrombus resolution in patients already on OAC may require a change of previous OAC treatment but the overall effectiveness of dissolution seems to be about 50%.

BACKGROUND: Aortic root evaluation is conventionally based on two-dimensional measurements at a single phase of the cardiac cycle. This work presents an image analysis method for assessing dynamic three-dimensional changes in the aortic root of minimally calcified bicuspid aortic valves (BAVs) with and without moderate to severe aortic regurgitation. METHODS: The aortic root was segmented over the full cardiac cycle in three-dimensional transesophageal echocardiographic images acquired from 19 patients with minimally calcified BAVs and from 16 patients with physiologically normal tricuspid aortic valves (TAVs). The size and dynamics of the aortic root were assessed using the following image-derived measurements: absolute mean root volume and mean area at the level of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction, as well as normalized root volume change and normalized area change of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction over the cardiac cycle. RESULTS: Normalized volume change over the cardiac cycle was significantly greater in BAV roots with moderate to severe regurgitation than in normal TAV roots and in BAV roots with no or mild regurgitation. Aortic root dynamics were most significantly different at the mid-level of the sinuses of Valsalva in BAVs with moderate to severe regurgitation than in competent TAVs and BAVs. CONCLUSIONS: Echocardiographic reconstruction of the aortic root demonstrates significant differences in dynamics of BAV roots with moderate to severe regurgitation relative to physiologically normal TAVs and competent BAVs. This finding may have implications for risk of future dilatation, dissection, or rupture, which warrant further investigation.

Background: The promotion of clinical abilities could represent a significant factor leading the clinicians to in making the correct diagnosis in a timely matter. Case: Our patient is a 42-year-old African male with a history of Hypertension, ESRD on hemodialysis via right-sided Permcath (PC), Mastoidectomy & Right ear surgery due to trauma in childhood, AV Fistula (Needed intervention 4 times) in left upper extremity, admitted due to witnessed seizures in the setting of hypertensive emergency. The patient denied family history and toxic habits. While the patient was at the emergency room, CT head revealed stable curvilinear hyper-attenuation thought to be a thrombosed developmental vein more likely than small subarachnoid hemorrhage. He was loaded with levetiracetam, received Ativan 1mg IV and HD done as per Nephrology. The patient was transferred to the floor he was not in acute distress and was asymptomatic, the cardiovascular (CV) examination showed regular pulse, normal S1, S2, S4+ appreciated with 2/4 diastolic murmur at second right intercostal space (ICS); 2/6 pansystolic murmur at third right intercostal space left parasternal border (LPSB) radiated to the right parasternal border (RPSB) and right mid-clavicular line (MCL); 3/6 systolic murmur at 5LICS MCL radiated to the posterior axillar line (PAL). Point of maximal impulse (PMI) displaced to mid axillar line (MAL). Parasternal heave present; the neurological exam was preserved. Endocarditis was suspected and echocardiogram was expedited, it showed severe aortic regurgitation, 1.60cm x 1.68cm mass in the tip of the catheter in the right atrium, possible vegetation in the tricuspid valve with mild regurgitation, moderate mitral valve regurgitation. Later, staphylococcus epidermidis was identified in blood cultures twice, as well as the culture from the PC. The transesophageal echocardiogram found 2.41 X 0.62 cm mass appears to be a fibrin sheath, possibly remnant of a prior catheter, small perforation in the non-coronary cusp likely in the setting of healed endocarditis. Infectious disease onboard for antibiotic management. Conclusion: The art of the clinician goes beyond the available technology; it could prevent the loss of critical time as well as unnecessary studies, guiding a better assessment and treatment of our patients and potentially improving their outcomes.

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

Background: Right heart thrombi and thrombi in transit across a patent foramen ovale (PFO) are uncommonly seen in patients with pulmonary embolism (PE) and are associated with high risk of adverse outcomes. We present a case of bi-atrial thrombi and thrombus in transit in a patient with acute submassive PE. Methods/Case Description/Results: A 31-year-old male with no significant past medical history presented with 8 days of dyspnea on exertion and pleuritic chest pain. Computed tomography angiography showed large volume of bilateral PE with right ventricular (RV) strain and right atrial (RA) thrombus. He was hemodynamically stable. Cardiac biomarkers were elevated. COVID testing was negative. Pulmonary embolism response team (PERT) was activated. Transthoracic echocardiogram revealed severely dilated RV with severely reduced function. A mobile mass was seen in the RA, possibly anchored to the interatrial septum. An emergent transesophageal echocardiogram showed mobile thrombus within both atria and thrombus in transit through a PFO. After multidisciplinary PERT discussion, involving the patient and his family, decision was made to proceed with a surgical approach, including pulmonary artery and bi-atrial embolectomy, and PFO closure. Post-surgical recovery was uneventful, and he was discharged on aspirin and apixaban on postoperative day 6. Follow up TTE 4 weeks after discharge showed recovered RV size and function. The patient is back to normal functional status. Conclusion: Combined biatrial thrombi and thrombi in transit are rare in patients with PE. Multidisciplinary approach to such patients, taking into account risks and benefits of each treatment approach, and patient preferences, is of paramount importance to achieve optimal patient outcome..

We report the case of an octogenarian with severe aortic valve stenosis, chronic kidney disease (CKD) and heart failure. Due to advanced CKD, we used a 3-dimensional transesophageal echocardiogram for sizing the device before transcatheter aortic valve replacement (TAVR). Noncontrast computed tomography found complex aortic dissection involving the arch, descending thoracic aorta, and abdominal aorta. TAVR was approached via the right carotid artery using a CoreValve. There was no cerebral vascular event. Renal function was well preserved. Transcarotid TAVR can be performed safely with complex type B aortic dissection. Three-dimensional transesophageal echocardiogram provides an alternative sizing solution in advanced CKD. Résumé: Nous décrivons ici le cas d'un octogénaire présentant une sténose sévère de la valve aortique, une néphropathie chronique et une insuffisance cardiaque. En raison de sa néphropathie chronique de stade avancé, nous avons eu recours à l’échocardiographie tridimensionnelle par voie transœsophagienne pour déterminer la taille du dispositif devant être utilisé avant le remplacement valvulaire aortique par cathéter (RVAC). Une tomodensitométrie sans contraste a révélé une dissection aortique complexe touchant l'arc aortique, l'aorte thoracique descendante et l'aorte abdominale. Le RVAC a été effectué par l'artère carotide droite à l'aide du système CoreValve. Il n'y a pas eu d'accident vasculaire cérébral. La fonction rénale a été bien préservée. Le RVAC par voie transcarotidienne peut être réalisé sans danger dans le cas d'une dissection aortique de type B complexe. L’échocardiographie tridimensionnelle par voie transœsophagienne constitue une solution de rechange pour déterminer la taille du dispositif chez les patients atteints de néphropathie chronique à un stade avancé.

Background. Libman-Sacks endocarditis (LSE) is a rare cardiovascular manifestation of systemic lupus erythematosus/antiphospholipid syndrome that is described as a sterile verrucous nonbacterial vegetative lesion. These lesions can cause progressive damage to the heart valves leading to valve surgery. The most common valves to be affected are the aortic and mitral valves. Libman-Sacks endocarditis is associated with malignancies, other systemic diseases like systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS). The majority of LSE patients are usually asymptomatic. Case Summary. We describe a 39-year-old male patient who presented with increasing shortness of breath and pulmonary congestion. He was found to have severe mitral valve regurgitation and mitral stenosis. Transesophageal echocardiogram confirmed the diagnosis of Libman-Sacks endocarditis with thickened mitral valve leaflets with symmetrical mass-like structure causing a restriction in the valve function during both cardiac phases later diagnosed with systemic lupus erythematosus by immunology. The patient was started on diuretics, anticoagulants, angiotensin inhibitors, beta-blockers, and hydroxychloroquine. He underwent successful mechanical mitral valve replacement with a 27 mm St. Jude valve. The mitral valve was found to be grossly thickened with friable tissue and complete amalgamation of the leaflets with subvalvular apparatus. The patient suffered some warfarin adverse effects a year later but did well otherwise. Conclusion. This case demonstrates that Libman-Sacks endocarditis can be the first manifestation of systemic lupus erythematosus. Early and prompt diagnosis of LSE can prevent and lessen the many side effects associated with thromboembolism. Additionally, addressing the underlying disease is key to successful treatment.

We report the case of a 41-year-old female patient with symptoms of cerebrovascular accident manifesting with loss of consciousness during episodes of cough. Computed multislice chest tomography showed a 7.3- by 4.15-cm mass in the left atrium. A transesophageal echocardiogram showed a giant mass in the left atrium that passed through the mitral valve to the left ventricle, and severe obstructive stenosis was suggested by the mean transmitral gradient. After a comprehensive assessment of the mass, we decided to perform surgery. The pedunculated and fragile mass was attached to the interatrial septum with its handle, and the majority of it prolapsed through the mitral valve to the left ventricle and became stacked among the mitral valve leaflets. The removed mass was analyzed histopathologically and was found to be a myxoma. It is important for the cardiac surgeon to surgically remove an atrial myxoma because of the risks associated with embolization, including sudden death, as myxoma can block the blood supply from the atrium to the ventricle.

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is expanding owing to advanced age and higher rates of chronic heart disease.1 The standard treatment for stroke reduction in patients with nonvalvular AF is anticoagulation. However, alternative therapy may be advisable in a certain subset of patients, owing to either previous failure of oral anticoagulation or presence of contraindications to anticoagulation.1 The left atrial appendage has been identified as the primary site of thrombus formation in more than 90% of patients with AF.2 The PLAATO3 study in 2002 was the first to demonstrate the use of a device to occlude the left atrial appendage for stroke reduction in patients with AF and provided the fundamental ground for future development in that field. Since its publication several percutaneous left atrial appendage occlusion (LAAO) devices have been developed and tested, including the Watchman, Amulet, and LARIAT, among others.4 The Watchman (Boston Scientific, Marlborough, MA) is the most extensively studied and is the only FDA-approved percutaneous LAAO device currently available in the United States.5 More than 100,000 devices have been implanted since it gained its approval in 2015.6 LAAO devices are approved for use in patients with nonvalvular AF who are not candidates for long-term coagulation with comparable outcomes in terms of risk of stroke, bleeding, and cardiovascular complications.7,8 Percutaneous LAAO has also been used in patients with recurrent cardioembolic stroke while on oral anticoagulation.9 Implantation of any intracardiac device carries the risk of device thrombosis and infection. However, risk of LAAO device infection is low owing to complete endothelialization. Currently, there are no guidelines regarding prophylaxis of bacterial endocarditis with Watchman device placement. Similarly, management of LAAO device infections remains uncertain, with no clear guidelines. We report a case of a 74-year-old man with Watchman device infection that was managed conservatively with a long course of antibiotics without the need for surgical extraction. Key Teaching Points • Left atrial appendage occlusion devices, despite endothelialization, can carry a late risk of device-related infective endocarditis. • Review of literature suggests role of transesophageal echocardiogram in the diagnosis of left atrial appendage occlusion device infections. • While surgical extraction has been previously described, we report a case of successful antibiotic suppression at 6-month follow-up.

Paravalvular leaks (PVL) are well-recognized complications after artificial valve replacement and symptomatic periprosthetic leaks are closely associated with increased mobility and mortality. Owing to the difference in types of prosthetic valve and options of suture technique, echocardiography of PVL can be diverse and challenge to diagnose. Herein, we report a patient with continuous low cardiac output syndrome on the second day after surgery after aortic replacement, which was misdiagnosed as coronary-left ventricular fistula by transthoracic echocardiogram (TTE). However, transesophageal echocardiogram (TEE) detected a perpendicular and turbulent jet flow from the outer side of the sewing ring, which was eventually diagnosed as an acute aortic PVL combined with cardiac angiography. The significant PVLs were treated by reoperation previously, while they are recommended for transcatheter closure recently. This patient was received successful percutaneous closure by the Cardi-O-Fix Plug. The cardiac symptom was relieved without additional complications. This report highlights the important role of multi-modality imaging, including the combination of TTE, TEE and cardiac angiography, in the diagnosis and treatment of PVL. Percutaneous closure is an appropriate option for the repair of PVL with long-term symptom relief and reduced mortality compared to reoperation. Therefore, this article describes the diagnosis and treatment of this patient with acute aortic PVL.

Patent foramen ovale might cause cryptogenic strokes, including retinal artery occlusion. Herein, we describe a previously healthy young man who presented with central retinal artery occlusion in the setting of patent foramen ovale and explore the need for transesophageal echocardiogram for its diagnosis. Cardiovascular workup and neuroimaging were unremarkable. Transthoracic echocardiogram bubble study revealed a right to left atrial shunt and subsequent transesophageal echocardiogram disclosed patent foramen ovale. This congenital cardiac anomaly was the likely conduit for a thrombo-embolic central retinal artery occlusion. We identified seven patients with patent foramen ovale associated with central retinal artery occlusion in the literature. Transthoracic echocardiogram was diagnostic in only one patient (14.3%), whereas transesophageal echocardiogram was required to reveal patent foramen ovale in the remaining six (85.7%). Our case and the previous reports support the link between central retinal artery occlusion and patent foramen ovale. Therefore, providers should consider the more sensitive transesophageal echocardiogram during the initial evaluation of young patients without immediately identifiable causes of retinal artery occlusion.

We aimed to describe a case of neovascular glaucoma (NVG) as a first presenting sign of catastrophic antiphospholipid syndrome (CAPS) with heart valve aseptic vegetations known as Libman-Sacks endocarditis. A 39-year-old man was referred for left eye decreased visual acuity and pain, upon examination left eye high intraocular pressure; rubeosis iridis of both eyes (BE); and prominent retinal ischemia. Clinical and fluorescein angiography findings established the diagnosis of left eye NVG with vaso-occlusive disease in BE. Magnetic resonance imaging of the head showed widespread ischemic lesions and hemorrhagic foci. The transesophageal echocardiogram showed 2 big mitral valve lesions consistent with the diagnosis of Libman-Sacks endocarditis. Laboratory and clinical diagnosis of CAPS and suspected SLE was confirmed, and treatment with anticoagulants and IV steroids was initiated. This case demonstrates that severe vaso-occlusive retinopathy with severe brain ischemia should raise the suspicion of systemic autoimmune pro-coagulative diseases with heart valve aseptic vegetations.

Objectives To investigate how virtual reality (VR) imaging impacts decision-making in atrioventricular valve surgery. Methods This was a single-center retrospective study involving 15 children and adolescents, median age 6 years (range, 0.33-16) requiring surgical repair of the atrioventricular valves between the years 2016 and 2019. The patients' preoperative 3-dimesnional (3D) echocardiographic data were used to create 3D visualization in a VR application. Five pediatric cardiothoracic surgeons completed a questionnaire formulated to compare their surgical decisions regarding the cases after reviewing conventionally presented 2-dimesnional and 3D echocardiographic images and again after visualization of 3D echocardiograms using the VR platform. Finally, intraoperative findings were shared with surgeons to confirm assessment of the pathology. Results In 67% of cases presented with VR, surgeons reported having “more” or “much more” confidence in their understanding of each patient's pathology and their surgical approach. In all but one case, surgeons were at least as confident after reviewing the VR compared with standard imaging. The case where surgeons reported to be least confident on VR had the worst technical quality of data used. After viewing patient cases on VR, surgeons reported that they would have made minor modifications to surgical approach in 53% and major modifications in 7% of cases. Conclusions The main impact of viewing imaging on VR is the improved clarity of the anatomical structures. Surgeons reported that this would have impacted the surgical approach in the majority of cases. Poor-quality 3D echocardiographic data were associated with a negative impact of VR visualization; thus. quality assessment of imaging is necessary before projecting in a VR format.

Left atrial appendage closure (LAAC) is an increasingly common procedure for patients with nonvalvular atrial fibrillation and contraindications to long-term anticoagulation. Traditionally, LAAC has been performed under transesophageal echocardiography (TEE) guidance. Although most operators have become experienced and comfortable with TEE-guided appendage closure, there has been a growing interest in the use of intracardiac echocardiography (ICE) for LAAC. This article describes the rationale and technique for ICE-guided LAAC.

Background Although systemic lupus erythematosus (SLE) can affect the cardiovascular system in many ways with diverse presentations, a severe cardiogenic shock secondary to SLE myocarditis is infrequently described in the medical literature. Variable presenting features of SLE myocarditis can also make the diagnosis challenging. This case report will allow learners to consider SLE myocarditis in the differential and appreciate the diagnostic uncertainty. Case presentation A 20-year-old Filipino male presented with acute dyspnea, pleuritic chest pain, fevers, and diffuse rash after being diagnosed with SLE six months ago and treated with hydroxychloroquine. Labs were notable for leukopenia, non-nephrotic range proteinuria, elevated cardiac biomarkers, inflammatory markers, low complements, and serologies suggestive of active SLE. Broad-spectrum IV antibiotics and corticosteroids were initiated for sepsis and SLE activity. Blood cultures were positive for MSSA with likely skin source. An electrocardiogram showed diffuse ST-segment elevations without ischemic changes. CT chest demonstrated bilateral pleural and pericardial effusions with dense consolidations. Transthoracic and transesophageal echocardiogram demonstrated reduced left ventricular ejection fraction (LVEF) 45% with no valvular pathology suggestive of endocarditis. Although MSSA bacteremia resolved, the patient rapidly developed cardiopulmonary decline with a repeat echocardiogram demonstrating LVEF Conclusion Although myocarditis during SLE flare is a well-described cardiac manifestation, progression to cardiogenic shock is infrequent and fatal. As such, SLE myocarditis should be promptly considered. Given the heterogenous presentation of SLE, combination of serologic evaluation, advanced imaging, and myocardial biopsies can be helpful when diagnostic uncertainty exists. Our case highlights diagnostic methods and clinical course of a de novo presentation of cardiogenic shock from SLE myocarditis, then rapid improvement.

Objective Unrecognized left ventricular thrombi (LVT) can have devastating clinical implications and precludes patients with end-stage heart failure from undergoing left ventricular assist device (LVAD) implantation without cardiopulmonary bypass assistance. We assessed the reliability of an echocardiogram to diagnose LVT in patients with end-stage heart disease who underwent LVAD implantation. Methods A single-center retrospective study evaluated 232 consecutive adult patients requiring implantation of durable LVADs between 2005 and 2019. The validity of preoperative transthoracic echocardiogram (TTE) and intraoperative transesophageal echocardiogram (TEE) for diagnosing LVT was compared to direct inspection at the time of LVAD implantation. Results There were 232 patients that underwent LVAD implantation, with 226 patients (97%) receiving a preoperative TTE. Of those 226 patients, 32 patients (14%) received ultrasound enhancing agents (UEA). Intraoperative TEE images were available in 195 patients (84%). The sensitivity of TTE without UEA was 22% and specificity was 90% for detecting LVT, compared to 50% and 86%, respectively, for TTE with UEA. For intraoperative TEE, the sensitivity and specificity were 46% and 96%, respectively. The false omission rate ranged from 4% to 8% for all modalities of echocardiography. Conclusion Among patients undergoing LVAD implantation, preoperative TTE and intraoperative TEE had poor sensitivity for LVT detection. Up to 8% of echocardiograms were incorrectly concluded to be negative for LVT on surgical validation. The low sensitivity and positive predictive value for diagnosing LVT suggest that echocardiography has limited reliability in this cohort of patients who are at high risk of LVT formation and its subsequent complications.

We report two cases of Brazilian patients (a 22-year-old male and a 48-year-old male) with ischemic stroke, whose arterial vascular study and echocardiographic investigation did not reveal any steno-occlusive arterial disease or typical cardioembolic finding, such as atrial fibrillation or myocardial dysfunction. A transcranial Doppler ultrasound and a transesophageal echocardiogram showed a patent foramen ovale (PFO), and the laboratory screening for coagulation abnormalities showed heterozygosity for MTHFR C677T and A1298C in one of the patients and heterozygosity for factor V Leiden gene mutations in the other patient. The significance of the association of PFO with Methylenetetrahydrofolate (MTHFR) C677T and A1298C variants or factor V Leiden mutation is discussed as a possible cause of ischemic stroke through paradoxical embolism from a venous source. There is a high prevalence of these two mentioned conditions in the general population, so we discuss two cases in which indication for anticoagulant therapy or percutaneous closure of PFO prevails.

Brucellosis is a multisystemic disease with serious cardiac involvement mainly endocarditis. It is a lethal but rare complication involving congenital, prosthetic and even native valves. Positive hemoculture confirm the diagnosis. Brucella endocarditis is known for large vegetations and surgery is the treatment of choice. Abscess formation can be seen in untreated patients. An 80-year-old male patient presented with fever, cough and progressive shortness of breath for 14 days. His known history revealed a poorly treated brucellosis 18 months ago due to noncompliance. Four months later, he presented for recurrent fever. Physical examination showed a systolic aortic murmur radiating to the carotid. Blood cultures were negative; however, blocking antibodies were 1/2560. Echocardiography showed calcified aortic stenosis. Transesophageal echocardiogram (TEE) showed an abscess formation at the level of the non-coronary cusp. A quadritherapy was initiated involving Ceftriaxone, gentamicin, doxycycline, and trimethoprim-sulfamethoxazole (shortage in molecule replaced by ciprofloxacin). Patient underwent surgery. An aortic valve bioprostheses was successfully implanted one week after initiating antibiotics. Intraoperative cultures were negative. A post-operative transthoracic echocardiography revealed a moderate periprosthetic aortic leak with a mean gradient of 18mmHg. He was discharged 18 days following surgery on doxycycline, rifampicin, and ciprofloxacin for 3 more months, with adequate follow up. The challenge remains in the timing of diagnosis which affects the prognosis of the disease. Early diagnosis and effective medical and surgical management are essential.

Introduction Acute ischemic stroke (AIS) in the young age (≤50 years) is a major cause of disability. The underlying mechanism of AIS in this age group is usually different from elderly. Transthoracic echocardiography (TTE) is used to detect the potential cardiac sources of embolism in AIS patients. Transthoracic echocardiogram (TEE) is superior to detect specific underlying cardio-aortic source of embolism when compared to TTE. We aim to evaluate the diagnostic yield and therapeutic impact of TEE in AIS of young adults. Methods We retrospectively reviewed the consecutive patients with AIS in our comprehensive center in a 5-year period from our prospectively collected registry. We selected patients with age ≤50 years who had acute infarcts on brain magnetic resonance imaging or head computed tomography and underwent TEE as part of their diagnostic workup. Demographic details including, age, gender, body mass index, cardiovascular risk factors profile, and TEE findings were collected. Results Among a total 7,930 patients, 876 (11.04%) were found to be ≤50 years old. Among those, TEE was done in 113 patients (12.8%) in addition to TTE. Those who underwent TEE had a mean age of 40.4 ± 7.9 years, 60 were male (53%), 7 (6.2%) had a history of coronary artery disease, 38 (33%) had a history of diabetes, and 45 (40%) had a history of smoking. TEE showed new abnormal findings in a total of 15 patients (13.2%) that were not reported in their TTEs. Out of these, left atrial appendage thrombus was found in 5, infective endocarditis in 4, atrial septal aneurysms associated with patent foramen ovale (PFO) in 3, and spontaneous mobile echo density in three patients. Overall, new findings from TEE resulted in change in the secondary stroke prevention strategy in 14 patients of those who underwent TEE (12.3%). TEE also confirmed the presence of PFO, which was present on TTE with bubble study in 20 (17.6%) patients. Conclusion TEE may provide additional information in the evaluation of the AIS in young adults, which could lead to change of the secondary stroke prevention strategy.

Patients with patent foramen ovale can manifest in a variety of ways. These presentations and their resolution are discussed in this article.

BACKGROUND AND PURPOSE Investigation for patent foramen ovale (PFO) is warranted in patients with cryptogenic stroke (CS), as PFO closure is recommended in select CS patients for secondary stroke prevention. Transcranial Doppler (TCD) is noninvasive and has high sensitivity for PFO screening. However, 10% of the population has insufficient temporal bone windows to perform standard TCD monitoring of the middle cerebral arteries (MCAs). Prior reports showed similar diagnostic accuracy between the basilar artery and MCAs insonation. Our objective was to assess the accuracy of transforaminal insonation of the basilar artery (TIBA) in diagnosis of right-to-left shunt (RLS) in patients with inadequate temporal windows. METHODS We performed a retrospective, single-center, observational study of TIBA in patients with CS and inadequate temporal windows. We compared the PFO screening accuracy using TIBA versus echocardiogram, either transthoracic (TTE) or transesophageal echocardiogram (TEE). RESULTS Sixteen females and four males were included (mean age 63.2). All patients underwent TTE, 10 (50%) underwent gold-standard TEE. Nine patients had positive PFO with both TCD and echocardiogram. Two patients with negative echocardiogram had TCD-positive shunt. Three patients had PFO present on echocardiogram, whereas TCD was negative. Six patients had absent shunt with both TCD and echocardiogram. The sensitivity and specificity of TIBA for RLS detection were 75%, positive predictive value 82%, and negative predictive value 67%. CONCLUSION PFO screening accuracy using TIBA was 75%. Prospective evaluation of CS patients with TIBA and comparison to the gold-standard TEE should be performed to further guide clinical practice.

Background. Central venous catheters (CVCs) have been frequently associated with septic thrombophlebitis, bacteremia, and septic emboli. Right-sided infective endocarditis is seen concurrently in patients with septic pulmonary emboli. A case of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and septic pulmonary emboli secondary to infected peripheral venous catheter (PVC) is reported. Transesophageal echocardiogram (TEE) showed no evidence of infective endocarditis. Case Presentation. A 44-year-old female presented to E.R. with left upper extremity pain and swelling at the previously inserted peripheral 18-gauge intravenous catheter site. She also had chest pain, which worsened with inspiration. The patient was found to be in septic shock. Her clinical condition deteriorated acutely. Right upper extremity deep venous thrombosis (DVT) and pulmonary emboli were seen on imaging. Blood cultures grew MRSA. Transthoracic and transesophageal echocardiograms showed no vegetations. The patient responded well to appropriate antibiotics and anticoagulation. Conclusion. Peripherally inserted catheters are an important portal for pathogen entry and need periodic site assessment and frequent evaluation of their need for insertion. Septic pulmonary emboli can also be seen without any evidence of right-sided infective endocarditis.

A 50-year-old woman underwent coronary artery bypass graft (CABG) for multivessel coronary artery disease. Due to hemodynamic instability, the patient could not be weaned from cardiopulmonary bypass without mechanical support, even after multiple attempts. Subsequently, a right ventricular intramyocardial hematoma (IH) was found during postoperative coronary angiography. The IH was felt to be the main contributing factor leading to right ventricular failure and cardiogenic shock, which, to the authors' knowledge, has not been previously reported after CABG. An IH is a rare complication postoperatively that often requires a high level of suspicion to identify on transesophageal echocardiogram. It should be suspected when there is hemodynamic instability intraoperatively or postoperatively in the intensive care unit that cannot be explained easily. There currently is no standard treatment. Treatment often is based on the individual patient and degree of hemodynamic instability.

Saphenous vein graft aneurysm is an uncommon condition and knowledge about its natural history, and a multi‐specialty heart team approach is of utmost importance for better clinical outcomes. This case highlights importance of percutaneous intervention as a viable therapeutic option in the case of saphenous vein graft aneurysms.

OBJECTIVES To evaluate the effectiveness of anticoagulant therapies in patients with clinical transcatheter heart valve (THV) thrombosis, to describe complications, and to assess their risk profile was the objectives. BACKGROUND Little research has been conducted on clinical THV thrombosis. METHODS Patients with clinical THV thrombosis were identified based on greater than 50% increased transvalvular gradient on transthoracic echocardiogram confirmed by 4-dimensional computed tomography, transesophageal echocardiogram, or regression with anticoagulant therapy. A cohort free from thrombosis for more than 1,100 days postprocedure was used for comparison. RESULTS Fifty-four patients with clinical THV thrombosis were identified. Most subjects (98.1%) received anticoagulant therapy which was effective (≥50% reduction in transvalvular gradient or return to postprocedure value) in 96%. The rate of serious hemodynamic or embolic complications in the thrombosis population was 31.5%. A multivariate analysis of subjects with and without thrombosis indicated a significantly increased risk of thrombosis from preexisting thrombocytopenia (odds ratio [OR] 9.96), absence of predilatation (OR = 5.67), renal insufficiency (OR = 4.84), and >10 mmHg mean transvalvular gradient postprocedure (OR = 3.36). No recurrence of thrombosis was identified during on average 685 days follow-up. CONCLUSIONS These data, from one of the largest cohorts with clinical THV thrombosis confirm anticoagulants appear effective. The rate of serious associated complications was high. The findings underline the importance of recognizing risk factors for thrombosis.

BACKGROUND Nonchicken wing left atrial appendage (LAA) morphology is associated with higher risk for stroke in patients with atrial fibrillation (AF) than chicken wing (CW) morphology. OBJECTIVE Assess whether LAA morphology predicts the formation of LAA thrombus independent of age, sex, presenting rhythm, left ventricular ejection fraction (LVEF), or anticoagulant use. METHODS A cross-sectional analysis was performed on patients prospectively enrolled in the Vanderbilt LAA Registry or presenting for transesophageal echocardiogram (TEE) between January 1, 2015, and November 1, 2017 (n = 306). Two physicians independently reviewed TEEs interpreted as having LAA thrombus. Determination of LAA morphology, ejection velocity, and presence of thrombus (n = 102) were based on 0°, 45°, 90°, and 135° TEE views. The control cohort (n = 204) included consecutive AF patients undergoing TEE without LAA thrombus. RESULTS LAA morphology in patients with LAA thrombus was: 35% windsock, 47% broccoli, and 12% CW. Windsock (odds ratio [OR], 4.0; 95% confidence interval [CI]: 1.7-9.3, p = .001) and broccoli (OR, 6.6; 95% CI: 2.6-16.6; p

Objectives To evaluate intraprocedural assessments using transesophageal echocardiography (TEE) and fluoroscopy during left atrial appendage occlusion (LAAO) with the WATCHMAN device. Method A total of 208 patients with non-valvular atrial fibrillation (AF) undergoing LAAO were included in this study[101 standard procedures (retrospective cohort) and 107 with fluoroscopy-alone approach (prospective cohort). Individual device position, anchoring, compression and peri-device leak (PDL) were successively analyzed based on TEE and fluoroscopy in the retrospective cohort to summarize detailed fluoroscopic assessments for prospective application. Clinical outcomes were assessed between two cohorts. Results For retrospective cohort, TEE and fluoroscopy agreed on device position and anchoring. Compression upon fluoroscopy was well correlated with 2D-TEE (r = 0.908) and the difference in overall detection of PDL was not statistically significant between two imaging modalities (p = 0.304). For the prospective cohort with fluoroscopy-guidance alone, implantation success was similar to that of the retrospective cohort (98.13% vs 100%, p = 0.498). The incidence rate of major clinical adverse events was relatively higher in prospective cohort during hospitalization and follow-up but did not reach significant difference (5.61% vs 1.98%; 0.99% vs 0.93%, p > 0.05). Moreover, the prospective group presented with shorter procedural duration, shorter in-hospital stay and lower total hospitalization cost than retrospective group. Conclusion LAAO performed by experienced operators in large volume centers is feasible under fluoroscopy guidance. However, there is still a trend in favor of TEE for greater procedural safety and more complete LAA seal. We suggest that this minimalist approach could be proposed in cases with contraindication to general anesthesia and/or TEE.

Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18 years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7 days, IQR 23.4–48.6 vs. 43.8 days, IQR 33.3–49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.

Purpose : Fenestrated atrial septal defects (F-ASDs) in the pediatric population pose a challenge for transcatheter device closure since multiple devices are not preferred in small hearts. Oversizing the Amplatzer Septal Occluder (ASO) to cover the surrounding fenestrations usually distorts the central waist as well as the disc profile and often defeats the purpose. This is a retrospective observational study with an aim to assess the feasibility and safety of cribriform ASO in closing F-ASDs in small children. Methods : Sixteen children with F-ASD who underwent device closure with cribriform ASO were included in the study. The fenestrated septal length (FSL) and the total septal length (TSL) were measured on transesophageal echocardiogram. A device size which was 1.5–2 times the FSL but smaller than the TSL was selected. The defect was closed with a device passed through a relatively centrally placed smaller fenestration. Results : The median age of the cohort was 5 years (2.5–10.5). Majority (14/16) required 25 or 30 mm cribriform ASO. Aneurysmal interatrial septum was seen in most of our patients (11/15). All the patients had successful device implantation. Complete closure of the defect was seen in 11 patients while 5 patients had insignificant residual shunt at a median follow-up of 40 months (1–60 months). There were no other complications. Conclusions : Cribriform ASO can be used safely and effectively in closing F-ASDs in children. Deployment of the device through a small central hole allows covering maximum fenestrations and gives more stability to the device. Residual shunts, although not infrequent, are insignificant.

Structural heart disease (SHD) is a new field within cardiovascular medicine. Traditional imaging modalities fall short in supporting the needs of SHD interventions, as they have been constructed around the concept of disease diagnosis. SHD interventions disrupt traditional concepts of imaging in requiring imaging to plan, simulate, and predict intraprocedural outcomes. In transcatheter SHD interventions, the absence of a gold-standard open cavity surgical field deprives physicians of the opportunity for tactile feedback and visual confirmation of cardiac anatomy. Hence, dependency on imaging in periprocedural guidance has led to evolution of a new generation of procedural skillsets, concept of a visual field, and technologies in the periprocedural planning period to accelerate preclinical device development, physician, and patient education. Adaptation of 3-dimensional (3D) printing in clinical care and procedural planning has demonstrated a reduction in early-operator learning curve for transcatheter interventions. Integration of computation modeling to 3D printing has accelerated research and development understanding of fluid mechanics within device testing. Application of 3D printing, computational modeling, and ultimately incorporation of artificial intelligence is changing the landscape of physician training and delivery of patient-centric care. Transcatheter structural heart interventions are requiring in-depth periprocedural understanding of cardiac pathophysiology and device interactions not afforded by traditional imaging metrics.

We present a case of percutaneous closure of a prior incomplete surgical left atrial appendage (LAA) ligation after a failed closure attempt using the first-generation Watchman device. The new generation Watchman FLX device (Boston Scientific) was implanted in this technically and anatomically challenging LAA patient using multimodality fusion imaging. (Level of Difficulty: Advanced.), Central Illustration

An 18-year-old male subject presented with recurrent strokes 3 years after percutaneous patent foramen ovale (PFO) closure with an PFO occluder device for presumed PFO-related stroke. A transesophageal echocardiogram revealed apparent device displacement during dynamic cardiac cycle. This case highlights an unusual but important delayed complication of transcatheter PFO closure. (Level of Difficulty: Intermediate.), Central Illustration

Although uncommon, aortic dissection can be rapidly fatal with a 20% out-of-hospital mortality which increases at a rate of 1 to 3% every hour [1]. An expeditious diagnosis of acute aortic dissection is therefore imperative. One of the most advantageous diagnostic modalities utilized in the setting of acute aortic dissection is a transesophageal echocardiogram (TEE). In an acute setting, TEE is preferred because of its ability to provide a timely and definitive diagnosis [2]. Despite its diagnostic convenience, clinicians must be aware that there are several entities that may mimic aortic dissection. One of these entities includes a dilated accessory hemiazygos vein. In this report, we present a case of a 66-year-old woman who was found to have a possible Stanford type B dissection in the descending thoracic aorta on a TEE exam in the context of work up prior to an elective electrophysiology study and ablation for paroxysmal atrial fibrillation. CT angiography, however, revealed a dilated accessory hemiazygos vein, a rare congenital vascular anomaly that could potentially mimic aortic dissection leading to misdiagnosis and potentially unnecessary interventions.

Austrian Syndrome is the rare combination of a triad of endocarditis, meningitis, and pneumonia in the context of pneumococcal infection. Due to the involvement of several anatomical sites, the Austrian syndrome has a high mortality. Importantly, endocarditis is usually not considered during pneumococcal infection. We present a case of Austrian syndrome in a previously healthy 67-year-old woman. She featured with mental state alteration, respiratory failure, and shock, and was diagnosed with ceftriaxone-sensitive pneumococcal bacteremia, meningitis, and pneumonia. A transesophageal echocardiogram revealed vegetation of the mitral valve. Despite an improvement in her medical condition, she remained in a coma and died due to neurological complications. Even though the major cause of mortality in Austrian syndrome is cardiac involvement, meningitis is also linked with high morbidity and eventually death. We emphasize the relevance of an early diagnosis of the triad in order to decrease the very high mortality associated with this syndrome.

A 68 year's old man with permanent atrial fibrillation, underwent a left atrial appendage closure because of high bleeding risk. However, after one month, an incomplete occlusion of the left atrial appendage due to a too deep position of the device, was detected by a transesophageal echocardiogram. Considering the residual high risk of thrombi formation, a new different device was successfully implanted with a correct closure of the appendage.

A man in his 70s presents with fatigue, dyspnoea and recurrent atrial fibrillation. Pertinent history includes coronary artery disease status post coronary artery bypass grafting, concomitant Maze procedure, mitral valve repair with a 26 mm Edwards mitral annuloplasty ring 9 years earlier and a recent extended beta-lactimase Escherichia coli urinary tract infection that was treated with cefoxitin. Admission was permitted for suspected acute on chronic heart failure with reduced ejection fraction exacerbation and repeat radiofrequency ablation. Physical exam revealed an irregularly, irregular rhythm, holosystolic, murmur best heard at the apex and an S3 gallop. A transesophageal echocardiogram was obtained (see figure 1). Figure 1 3D …

Introduction Patent foramen ovale is a common congenital cardiac abnormality. An association with acute ischemic stroke is well described. Extension of renal cell carcinoma (RCC) into the adjacent veins is common. Surgical resection is felt to be an effective approach to treatment, even in the setting of extensive venous involvement. Case report A 55-year-old woman with recently diagnosed right renal mass and cavoatrial tumor thrombus was transferred to our facility for surgical resection. She subsequently underwent open radical right nephrectomy, regional lymph node dissection, inferior vena cava and right atrial tumor thrombectomy, and resection of the infrahepatic vena cava. An intraoperative transesophageal echocardiogram confirmed the absence of tumor thrombus from the inferior vena cava and right atrium and also identified a patent foramen ovale (PFO). Upon weaning sedation, she was noted to be agitated and have left hemiplegia. Her National Institutes of Health Stroke Scale (NIHSS) was 30 and Glasgow Coma Scale (GCS) 6. The computerized tomography scan of head revealed extensive hypoattenuation right in the middle and left posterior cerebral artery territories. There was associated cerebral edema and 5-mm midline shift. In the setting of devastating neurological injury, her family elected to transition to comfort care and the patient died on the postoperative day 7. Conclusions This is the first reported case of intraoperative paradoxical embolism in the setting of RCC with cavoatrial extension and PFO. The presence of PFO may be a risk factor for severe cerebrovascular complications in the surgical management of RCC with venous involvement.

Background Acute coronary syndrome (ACS) is a rare, but serious complication of infective endocarditis, and diagnosis can be challenging given clinical overlap with other syndromes. A rare cause of ACS in infective endocarditis is mechanical obstruction of the coronary artery. We present the case of a patient with infective endocarditis who developed ST segment myocardial infarction due to occlusion of the right coronary artery ostium by a vegetation. Case presentation A 53-year-old female with no prior history of coronary artery disease was transferred to our tertiary care facility for evaluation and treatment of suspected myopericarditis. After transfer she developed inferior ST segment elevations on ECG along with fever and positive blood cultures for methicillin susceptible Staphylococcus aureus (MSSA). A transesophageal echocardiogram revealed a vegetation on the aortic valve that intermittently prolapsed into the right coronary ostium. She decompensated from a hemorrhagic brain infarct and subsequently transferred to the intensive care unit. She underwent surgical aortic valve debridement without prior cardiac catheterization given the danger of septic coronary embolization. After a prolonged hospital course with multiple complications, she was able to discharge home, with no neurologic deficits on follow-up. Conclusions ACS presents a diagnostic and therapeutic challenge in the setting of infective endocarditis. Careful attention to the history, physical exam and testing can help differentiate infective endocarditis from other conditions sharing similar symptoms. Traditional atherosclerotic ACS management may cause great harm when treating patients with infective endocarditis. The presence of a multidisciplinary endocarditis team is ideal to provide the best clinical outcomes for this population.

Purpose The purpose of the present study was to compare the long-term effectiveness and safety of newly initiated anticoagulation with edoxaban (EDO) versus uninterrupted vitamin K antagonist (VKA) therapy in patients with atrial fibrillation (AF) scheduled for transesophageal echocardiogram (TEE)-guided direct electrical current cardioversion (DCC). Methods A propensity score-matched cohort observational study was performed comparing the safety and effectiveness of edoxaban versus well-controlled VKA therapy among a cohort of consecutive non-valvular AF patients scheduled for DCC. The primary safety outcome was major bleeding. The primary efficacy outcome was the composite of stroke, transient ischemic attack (TIA), and systemic embolism (SE). Findings A total of 130 AF patients receiving edoxaban 60-mg (EDO) treatment were compared with the same number of VKA recipients. The cumulative incidence of major bleedings was 1.54% in the EDO group and 3.08% in the VKA group (P = 0.4). The cumulative incidence of thromboembolic events was 1.54% in the EDO group and 2.31% in the VKA group (P = 0.9). A non-significant trend in improved adherence was observed between the EDO and VKA groups with a total anticoagulant therapy discontinuation rate of 4.62% (6/130) vs 6.15% (8/130), respectively (P = 0.06). Implications Our study provides the evidence of a safe and effective use of edoxaban in this clinical setting, justified by no significant difference in major bleedings and thromboembolic events between edoxaban and well-controlled VKA treatments.

Objectives Left atrial appendage occlusion (LAAO) in non-valvar atrial fibrillation (AF) reduces cardioembolic strokes. Despite increased risk, trials exclude valvar AF in structural heart diseases where clots extend beyond appendage. Methods Patients with AF and relative risks for oral anticoagulation (OAC) needing structural interventions underwent concomitant LAAO. After six months of OAC, aspirin was continued. Transesophageal echocardiogram was done three monthly till one year and yearly thereafter. The patient demographics, procedural details, post-procedural follow-up were analyzed. Results Nine patients aged 51.5 ± 6.3 years with AF underwent LAAO concomitantly with balloon mitral valvotomy in four patients, atrial septal defect device closure in four and periprosthetic mitral leak closure in one patient. Six patients had heart failure, four had prior embolic events, and two had documented LAA thrombus. The mean CHADS2VASc score was 2.44 ± 0.8 and mean HASBLED score was 3.0 ± 0.8. Devices included Amplatzer Cardiac Plug™ in six patients, LAmbre™ Lifetech device in two and Watchman™ device in one. All procedures were successful without acute complications. A patient developed pericardial effusion at six months requiring pericardiocentesis. Early device-associated thrombus in one patient resolved after OAC for six months. No embolic events occurred on follow-up. Conclusion On a detailed literature search, this largest LAAO experience in structural heart diseases indicates its utility. OAC for six months followed by aspirin seems to prevent thrombus formation in these patients. The only incidence of early thrombus formation indicates immunity from clot formation after device endothelialisation. Larger multicenter trials combining LAAO with structural interventions in valvular AF are warranted in developing nations.