Annuloplasty Ring Echocardiogram Tricuspid

Fig. 7. Apical four-chamber view (A) and subcostal views (B,C) of Chiari's network. It is anatomically related to the Eustachian valve, a remnant of the embryonic right valve of the sinus venosus. It is a common finding in newborn. Transesophageal echocardiography and autopsy studies in adults indicate a prevalence of approx 2%. An undulating Chiari's network should trigger a closer examination of the inferior vena cava/right atrial junction (B, subcostal view) and the interatrial septum (C) for a patent foramen ovale or an atrial septal aneurysm.

Chiari Network Echo Images

Fig. 8. A 72-yr-old man with Methicillin-resistant Staphylococcus aureus bacteremia. Transthoracic images in this patient were suboptimal, therefore a transesophageal echocardiograpahy was performed for persistent bacteremia. A 1.5 X 1.5 cm vegetation (white arrow) is visible on the atrial side of the anterior leaflet of the mitral valve (A,C,D). Color flow Doppler showed mitral regurgitation along with a second color jet (green arrow) that entered the left atrium through a perforation in the posterior mitral leaflet. (Please see companion DVD for corresponding video.)

Fig. 8. A 72-yr-old man with Methicillin-resistant Staphylococcus aureus bacteremia. Transthoracic images in this patient were suboptimal, therefore a transesophageal echocardiograpahy was performed for persistent bacteremia. A 1.5 X 1.5 cm vegetation (white arrow) is visible on the atrial side of the anterior leaflet of the mitral valve (A,C,D). Color flow Doppler showed mitral regurgitation along with a second color jet (green arrow) that entered the left atrium through a perforation in the posterior mitral leaflet. (Please see companion DVD for corresponding video.)

Tricuspid Annuloplasty Rings

Fig. 9. A 40-yr-old heroin user presenting with leg pain, visual disturbances, fever, and a murmur. Transthoracic still frames showing a vegetation on the tip of an aortic valve cusp (arrow, A). This was believed responsible for patient's extracardiac complications. No tricuspid vegetations were observed. Transesophageal images revealed a circumscribed vegetation (arrows, C,D). Mild aortic regurgitation was seen on Color Doppler examination (D).

Fig. 9. A 40-yr-old heroin user presenting with leg pain, visual disturbances, fever, and a murmur. Transthoracic still frames showing a vegetation on the tip of an aortic valve cusp (arrow, A). This was believed responsible for patient's extracardiac complications. No tricuspid vegetations were observed. Transesophageal images revealed a circumscribed vegetation (arrows, C,D). Mild aortic regurgitation was seen on Color Doppler examination (D).

case presentation 5

A 49-yr-old woman with a history of rheumatoid arthritis and intermittent steroid therapy presented with mental status changes, acute renal failure, and blood cultures positive for methicillin-sensitive S. aureus. Investigations were highly suggestive of multiple septic emboli to her brain and the kidneys. Her echocardiography images are shown in Fig. 10; please see companion DVD for corresponding video.

case presentation 6

The images in Fig. 11 belong to a 72-yr-old man who underwent left ventricular aneurysm resection and repair, coronary artery bypass surgery, and mitral valve repair. Fourteen days postsurgery, he was still in the intensive care unit with signs of heart failure and low-grade temperatures, but no bacteremia.

case presentation 7

A 39-yr-old female with a history of congenital heart block treated with dual chamber permanent pacemaker at age 19 presented with fever and malaise. Blood cultures grew methicillin-sensitive S. aureus. Pacemaker was removed under general anesthesia and pus was noted in the pacemaker pocket and along the leads. Chest computed tomography has showed evidence of septic emboli to pulmonary vasculature. Her ECG showed runs of ventricular tachycardia and prolonged QT interval. Images from her echocardiogram appear in Fig. 12.

Transthoracic Pacemaker Leads

Fig. 10. A 49-yr-old woman with Methicillin-resistant Staphylococcus aureus bacteremia. Initial transthoracic images were technically limited (A-C) but suggested a vegetation on the posterior leaflet of the mitral valve. Transesophageal imaging revealed a well-defined mass on the posterior leaflet that intermittently prolapsed into the left ventricle (D,E). This was the most likely cause of the patient's multiple embolic events. Her condition required surgical intervention. (Please see companion DVD for corresponding video.)

Fig. 10. A 49-yr-old woman with Methicillin-resistant Staphylococcus aureus bacteremia. Initial transthoracic images were technically limited (A-C) but suggested a vegetation on the posterior leaflet of the mitral valve. Transesophageal imaging revealed a well-defined mass on the posterior leaflet that intermittently prolapsed into the left ventricle (D,E). This was the most likely cause of the patient's multiple embolic events. Her condition required surgical intervention. (Please see companion DVD for corresponding video.)

Mass Mitral Valve Annulus

Fig. 11. A 74-yr-old man presenting 2 wk following coronary artery bypass graft, mitral valve repair, and left ventricular aneurysm resection. Transthoracic echocardiogram revealed a mitral regurgitant jet that originated from outside the mitral ring annulus (A). Transesophageal echocardiography showed a thickened mass on the anterior mitral leaflet (B-D). At surgery, the mass consisted of a partially loosened mitral annular ring. No vegetations were seen. (D) Shows two commonly used models of annuloplasty rings.

Fig. 11. A 74-yr-old man presenting 2 wk following coronary artery bypass graft, mitral valve repair, and left ventricular aneurysm resection. Transthoracic echocardiogram revealed a mitral regurgitant jet that originated from outside the mitral ring annulus (A). Transesophageal echocardiography showed a thickened mass on the anterior mitral leaflet (B-D). At surgery, the mass consisted of a partially loosened mitral annular ring. No vegetations were seen. (D) Shows two commonly used models of annuloplasty rings.

Tricuspid Annuloplasty Ring

Fig. 12. A 39-yr-old female with permanent pacemaker for congenital heart block presenting with fever and malaise. Parasternal right ventricular inflow view showed a vegetation attached to the septal leaflet of the tricuspid valve that ping-ponged between right atrium and ventricle (arrow, A). Subsequent transesphageal echocardiography revealed multiple echodensities (mural vegetations) that studded the right ventricle, right atrium, and superior vena cava (arrows, B-D).

Fig. 12. A 39-yr-old female with permanent pacemaker for congenital heart block presenting with fever and malaise. Parasternal right ventricular inflow view showed a vegetation attached to the septal leaflet of the tricuspid valve that ping-ponged between right atrium and ventricle (arrow, A). Subsequent transesphageal echocardiography revealed multiple echodensities (mural vegetations) that studded the right ventricle, right atrium, and superior vena cava (arrows, B-D).

Bioprosthetic Tricuspid Valve
Fig. 13. (Continued)
Blocked Superior Vena Cava

Fig. 13. A 58-yr-old male with previous mitral valve replacement presenting with increasing shortness of breath and suspected endocarditis. The struts of the bioprosthetic (tissue) valve (white arrows; A-D) can be visualized on echocardiography. This patient's anterior mitral leaflet was not excised (arrowhead), and caused dynamic obstruction of left ventricular outflow obstruction (arrowhead, A-C). The offending leaflet was excised. Histology reported mxyomatous degeneration and chronic inflammatory changes, but no evidence of infection. Bioprosthetic valves (D). (Please see companion DVD for corresponding video.)

Fig. 13. A 58-yr-old male with previous mitral valve replacement presenting with increasing shortness of breath and suspected endocarditis. The struts of the bioprosthetic (tissue) valve (white arrows; A-D) can be visualized on echocardiography. This patient's anterior mitral leaflet was not excised (arrowhead), and caused dynamic obstruction of left ventricular outflow obstruction (arrowhead, A-C). The offending leaflet was excised. Histology reported mxyomatous degeneration and chronic inflammatory changes, but no evidence of infection. Bioprosthetic valves (D). (Please see companion DVD for corresponding video.)

case presentation 8

A 58-yr-old male underwent mitral valve replacement with a tissue valve prosthesis several years earlier, but now presented with increasing shortness of breath and suspected endocarditis. His echocardiogram images are shown in Fig. 13 (please see companion DVD for corresponding video).

role of echocardiography in ie

Echocardiography features prominently in the diagnosis and the management of endocarditis, including the following roles:

1. Assists in diagnosis.

2. Detects or documents predisposing lesions.

3. Evaluation of complications.

4. Follow-up and response to therapy.

5. Guide to surgical intervention.

The American College of Cardiology and the American Heart Association Task Force issued its recommendations for echocardiography in IE for both native and prosthetic valves (see Chapter 4; Table 12).

The sensitivity of two-dimensional echocardiography for detecting vegetations is highly dependent on the size, location, and echocardiography windows. TEE has a greater diagnostic yield over the transthoracic approach. TTE is unable to resolve vegetations less than 2 mm in diameter and is poor in evaluating prosthetic valves owing to acoustic shadowing. Overall, the sensitivity for detecting vegetations using transthoracic and TEE is 65-80% and 95%, respectively.

As the sensitivity of TTE for IE is relatively low, the absence of vegetations on TTE does not exclude the diagnosis of IE. Where clinical suspicion remains high, several limitations may mask or hinder TTE interpretation. These include: prosthetic valves, calcification, and sclerosis. Given the diagnostic advantages of TEE over TTE, many advocate that TEE be used routinely in all patients with suspected IE. This, however, is not a cost effective strategy, and TEE is not without risk.

Overall, TEE is the imaging modality of choice in patients with prosthetic valves or intracardiac devices. Deteriorating clinical status including referral for possible surgery may mandate an emergency TEE. Other indications for an emergent TEE examination include:

1. Rapidly worsening clinical status of a patient with known or suspected IE.

a. Progressive conduction disturbances on ECG suggestive of aortic root involvement (Fig. 14A,B).

b. Overwhelming sepsis despite appropriate antibiotic therapy.

Prosthetic Valve Endocarditis TeeEchocardiogram Aortic Root Abscess

Fig. 14. Sketches showing relationship of the cardiac conduction system (left bundle branch) to a potential peri-aortic abscess (lateral and basal views). Conduction system involvement requires emergent TEE evaluation and possible surgical intervention.

2. Severe heart failure possibly related to acute valve dysfunction.

3. Embolic phenomena.

Choice of echocardiography modality in evaluating suspected endocarditis in native valves is influenced by the likelihood of the diagnosis based on the clinical scenario and cost considerations. One recommendation based on a cost-effectiveness analysis is summarized below:

Pre-examination likelihood

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