Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging

A 69-year-old male with a long-standing diagnosis of interstitial lung disease and on domiciliary oxygen therapy was evaluated by echocardiography. His supine oxygen saturation ranged between 77% and 86% and upright oxygen saturation was 93%–94%. Two-dimensional transthoracic echocardiography showed a secundum atrial septal defect of 15 mm diameter with left-to-right shunting but without dilatation of right-sided chambers. Air bubble contrast echocardiography showed no air bubbles crossing the atrial septum but bubbles appeared in left-sided chambers through pulmonary veins after five cardiac cycles indicating intra-pulmonary shunting. Computed tomography of the chest demonstrated a mosaic pattern of the lung parenchyma, characterized by the presence of alternating geographic areas of low attenuation with regions of relatively increased attenuation typical of diffuse pulmonary arteriovenous fistulae. This is a rare case of reverse platypnea-orthodexia with possible contribution of two different pathophysiologic mechanisms but precise mechanism remains elusive.

Madhu Shukla

Jagdish Chander Mohan

Reverse Platypnea–Orthodeoxia with Atrial Septal Defect and Diffuse Pulmonary Arteriovenous Fistulae in Hepatopulmonary Syndrome

肝肺综合征中房间隔缺损及弥漫性肺动静脉畸形导致的反常性直立性低氧血症

Right ventricular myocardial infarction (RVMI) occurs in up to half of the patients of inferior wall myocardial infarction. RVMI results in edema and increased right ventricular (RV) mass, and hence, it should be possible to visualize microvascular obstruction as a manifestation of reperfusion injury. Reperfusion injury of the RV myocardium following primary percutaneous coronary intervention has been rarely reported. This report describes a patient with the left ventricular inferior and RVMI who showed echocardiographically detected reperfusion injury of the RV-free wall and left ventricular basal inferolateral wall and conformed by myocardial contrast perfusion study despite successful percutaneous revascularization of the right coronary artery.

Combined Right and Left Ventricular Reperfusion Injury following Percutaneous Coronary Intervention: Role of Myocardial Contrast Echocardiography

经皮冠状动脉介入术后左右心室再灌注损伤的联合研究：心肌声学造影的作用

To The Editor, Aortic valve (AV) stenosis is one of the common valvular pathologies with higher prevalence in the older age group. Standard treatment involves AV replacement (AVR) with conventional techniques. However, in high-risk patients, techniques such as transcatheter AV implantation (TAVI) and sutureless AVR are available.[1,2] A 64-year-old female presented with chief complaints of syncope. She was a known bronchial asthmatic and hypothyroid not on any medications. She had a history of cholecystectomy and open reduction of trochanteric fracture in the past. On general physical examination, she was moderately built, conscious, and well oriented. Systemic examination revealed ejection systolic murmur at the aortic area. Hematological investigations were within the normal limits. However, transthoracic echocardiography revealed a tricuspid AV with thick calcific leaflets. Pressure gradients of 45/25 mmHg (peak/mean) across AV and AV area by planimetry were 0.8 cm2 stating moderately severe aortic stenosis. The aortic annulus was 1.8 cm and the sinotubular junction was 2.4 cm with poststenotic dilatation of the ascending aorta (3.4 cm). A coronary angiogram revealed normal coronary arteries. The pulmonary function test showed a moderately severe obstructive pattern. Keeping in view of her symptoms, small aortic annulus, and other comorbidities, she was advised AVR with a sutureless valve. After optimization of the respiratory system and informed consent, she was scheduled for AVR. General anesthesia was induced as per our protocol with standard doses and standard monitoring as per the American Society of Anesthesiologists protocol, along with invasive hemodynamic monitoring such as arterial blood pressure and central venous pressure was done. Precardiopulmonary bypass (CPB) transesophageal echocardiography (TEE) revealed a bicuspid valve with thickened leaflets and aortic annulus of 1.8 cm with poststenotic dilatation and mild-to-moderate left ventricular hypertrophy [Video 1 and Figure 1]. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_xgbjyy6z"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Video 1: Precardiopulmonary bypass transesophageal echocardiography aortic valve short-axis view showing bicuspid aortic valve.Figure 1: Transesophageal echocardiography long-axis view showing aortic dimensionsCPB was initiated after heparinization and achieving adequate activated clotting time. After aortotomy, the native AV was excised and replaced with a sutureless valve size 19–21 after putting the anchoring sutures (Perceval S, Sorin, Saluggia, Italy). CPB and aortic cross-clamp time were 110 and 93 min, respectively. Weaning from CPB was uneventful with mild doses of inotropes and vasopressors. Post-CPB TEE revealed a prosthetic heart valve (PHV) at the aortic position with normal leaflet movements and the gradient across PHV was 13/7 mmHg (peak/mean) without any paravalvular leak (PVL) [Video 2 and Figure 2]. However, after a few minutes, it was observed that there was an excessive motion of the PHV in the midesophageal long-axis view with mild PVL [Videos 3, 4 and Figure 3]. Therefore, it was decided to reestablish CPB and examine the PHV. There was a gap at the annular plane and PHV was slightly displaced from the plane. Efforts were made to rectify the issue but optimal placement could not be achieved even after an incremental sizer was used. Finally, the sutureless PHV was replaced with a conventional bioprosthetic valve size 19 (Sorin, Saluggia, Italy). The post-CPB period and rest of the postoperative course were uneventful. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 2","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_8pstlsni"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Video 2: Postcardiopulmonary bypass transesophageal echocardiography aortic valve short-axis view showing prosthetic heart valve at aortic position.Figure 2: Postcardiopulmonary bypass transesophageal echocardiography with continuous wave Doppler showing gradient across the prosthetic heart valve {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 3","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_qzyfqghq"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Video 3: Postcardiopulmonary bypass transesophageal echocardiography long-axis view showing mobility of the prosthetic heart valve. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 4","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_d71b1rlj"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Video 4: Postcardiopulmonary bypass transesophageal echocardiography long-axis view with color Doppler showing paravalvular leak.Figure 3: Postcardiopulmonary bypass transesophageal echocardiography long-axis view with color Doppler showing paravalvular leakSutureless AVs, also known as rapid deployment valves, anchor within the aortic annulus. It is basically a biological valve and requires at least three sutures for anchoring. The primary advantage of this valve is lesser CPB time, thereby reducing the duration of surgery. It is a good technique in patients with gray zone for AVR and TAVI. Apart from reducing surgery duration, other advantages are better hemodynamic outcomes and lower transvalvular gradients, thereby reducing patient-prosthesis mismatch.[3] However, there are various problems reported with sutureless PHV such as PVL, early degradation, and calcium deposition.[4] Therefore, anchoring sutures are required for proper placement of the prosthesis at aortic annulus. However, it was done in our patient but most likely cause of displacement was bicuspid aortic valve. There should be low threshold for any abnormal mobility of PHV and PVL for these valves and should be addressed immediately. Author contributions This manuscript has only one author who is responsible for the entire work. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Dheeraj Arora

Dilemma with Sutureless Aortic Valve

无缝合主动脉瓣的困境

Background: Acute heart failure (HF) is initially diagnosed and managed in the large part in the emergency care setting. Lung ultrasound (LUS) and chest X-ray (CXR) are the most common diagnostic and prognostic techniques for people with HF. It has been observed that lung ultrasonography has a higher sensitivity for diagnosing HF than CXR. In this review, we assess the comparison between the use of LUS and CXR in diagnosing HF. Methods: An extended search was done in the databases of PubMed, Medline, Wiley library, and Google Scholar between 2012 and 2022. Fifteen studies were included in this systematic review. Studies, in which the sensitivity of LUS and CXR was noted, were included. Results: Fifteen studies were included. The majority of the studies showed that LUS had high sensitivity and accuracy for detecting HF. Conclusion: The result of the present review shows that the sensitivity of the LUS was higher than those of the CXR in detecting HF. Ultrasound has certain advantages over CXR.

Rushikesh S. Haridas

Sheetal Shelke

Girish Patrike

Deepak Patil

Sainath Dhumal

Use of Lung Ultrasound versus Chest X-ray in Diagnosing Heart Failure in the Emergency Care Setting: A Systematic Review

急诊护理环境中使用肺超声与胸部X射线诊断心力衰竭的系统评价

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Alev Kiliçgedik

Cevat Kirma

Three-dimensional Echocardiography during Percutaneous Mitral Balloon Valvuloplasty

经皮二尖瓣球囊成形术中的三维超声心动图

Abstract A 70-year-old male presented with a history of pedal edema, abdominal distension, and dyspnea on exertion New York Heart Association Class III for cardiology evaluation. He was a known case of a neuroendocrine tumor of the small intestine diagnosed 3 years back and was on octreotide injection monthly for 20 months, now presented with features of the right heart failure. Transthoracic echocardiography showed thickened shortened immobile tricuspid valve leaflet with severe tricuspid regurgitation, and transesophageal echocardiography also confirmed the same. Three-dimensional (3D) echocardiography showed a tricuspid valve thickened and retracted with restricted mobility called a club-shaped leaflet, and with this, a diagnosis of carcinoid heart disease was made. This case mainly aims at stressing the need for early echo in neuroendocrine patients, which helps with early diagnosis and intervention to improve their survival significantly, and the application of 3D echo which will provide detailed anatomical information, particularly if tricuspid and pulmonary valves are involved.

Abhiman Balakrishna Shetty

Sam Jacob Chiramel

Rajesh Gopalan Nair

Two- and Three-dimensional Imaging in Carcinoid Heart Disease

类癌性心脏病中的二维和三维成像

Abstract Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare cardiomyopathy. Early diagnosis is important to prevent mortality. They have a high risk of sudden cardiac death due to ventricular arrhythmia, which requires the implantation of a cardioverter-defibrillator. We describe the case of a cardiac arrest survivor with background electrocardiography (ECG) findings suggestive of ventricular tachycardia. The new 2020 international criteria for ARVC made it possible to easily detect such cases. We suspected right ventricular cardiomyopathy based on the patient’s history, ECG, and echocardiography findings, who later underwent cardiac magnetic resonance imaging. This was a “Definitive ARVC” case based on 2020 International criteria for ARVC. Clinicians should be aware of these criteria to detect such cases easily.

Neelesh Damor

Nitin Modi

Atul Karande

Ashish Mishra

Sunil Sharma

Arrhythmogenic Right Ventricular Cardiomyopathy Diagnosed with 2020 International Criteria

2020年国际标准诊断的致心律失常性右室心肌病

Abstract Pulmonary embolism (PE) is a relatively common cardiovascular disorder with high early mortality rates, despite advances in diagnosis and treatment. The risk of mortality is quite high in case the diagnosis is missed. High clinical suspicion is crucial in the diagnosis, more so in the young. Rarely, systemic embolism can occur in a patient with PE through a preexisting patent foramen ovale (PFO) (paradoxical embolism). Paradoxical embolism is associated with very high mortality rates. We report the case of a 31-year-old male, who was diagnosed with massive PE by echocardiography along with a thrombus-in-transit, trapped in a PFO, but without systemic embolization.

Raj Kumar

Rahul Mehrotra

Almost a Double Whammy! Acute Pulmonary Embolism and an Impending Paradoxical Embolism

几乎双重打击！急性肺栓塞与即将发生的矛盾性栓塞

Abstract Coronary sinus (CS) is the largest coronary vein that receives blood from all the venous tributaries of the heart. Its variations in anatomy are significant from the surgical point of view, especially in patients with complex congenital heart diseases (CHDs). CS anomalies are rare, but with increasing advancements in imaging, they are often diagnosed with cardiac computed tomography (CT). These are associated with other CHDs, so the radiologists are alerted to look further for different anomalies. The data in this study were collected from the routine contrast-enhanced CT examinations of the patients referred to the Department of Radiology, Narayana Hrudayalaya Hospital, Bengaluru, from January 2019 to August 2023. It was observed that the anomalies were seldom seen as a single entity and instead were seen as a part of the spectrum of anomalies such as persistent left superior vena cava (LSVC), Raghib complex, total anomalous pulmonary venous connection, and interrupted inferior vena cava. Out of these, the most common associated anomaly was found to be persistent LSVC. These anomalies are essential to detect in the preoperative assessment because they may cause significant morbidity in some cases if left uncorrected. Therefore, we must search for other cardiac anomalies when encountering CS anomalies.

Akshata J. Chauhan

Richa Jayesh Kothari

Coronary Sinus Anomalies with Case Illustrations

冠状窦异常病例图解

Abstract A 59-year-old male presented with syncope and nonsustained ventricular tachycardia and was diagnosed to have hypertrophic obstructive cardiomyopathy. He underwent dual-chamber implantable converter defibrillator (ICD) insertion. Following ICD insertion, in view of some red flags, routine cardiac magnetic resonance imaging was performed, which showed biventricular hypertrophy, diffuse subendocardial gadolinium enhancement of both the ventricles, prolonged T1 and T2, and left ventricular extracellular volume fraction of 50%. A pyrophosphate scan of the heart was strongly positive both at 1 and 3 h intervals. M-band was observed on plasma protein electrophoresis. Serum and urinary immunofixation studies suggested lambda light-chain gammopathy. Multiparametric flow cytometry of the bone marrow aspirate revealed 20% plasma cells immunophenotyped to produce only light-chain immunoglobulins. The patient is on specific chemotherapy for the past 7 months and is asymptomatic.

Cardiac Amyloidosis Masquerading as Hypertrophic Obstructive Cardiomyopathy: Co-existence or Coincidence?

心脏淀粉样变伪装成肥厚型梗阻性心肌病：共存还是巧合？

涉及主题	echocardiographycardiovascular imagingcardiac anesthesiologypulmonology
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