The patient is a 22-year-old with a systolic and diastolic murmur with the following echo images (Fig. below A and B).
A. Parasternal short-axis view. B. Parasternal short-axis view with color Doppler.
These images demonstrate:
Supracristal VSD. This image demonstrates a supracristal VSD. The VSD is located just under the pulmonic valve, best seen in the parasternal shortaxis view (seen at 1 o’clock). A membranous VSD would be seen at 10 or 11 o’clock in short-axis view (Fig. below A). Ebstein anomaly involves apical displacement of the tricuspid valve with atrialization of some of the RV (Fig. below B). Patent ductus can also be seen in the parasternal shortaxis view seen best by color Doppler showing a flow entering the PA (from the aorta) (Fig. below C). PS is seen on 2D in the parasternal short-axis view with doming pulmonic valve leaflets with color acceleration across the valve. In diastole there may also be some PI as the leaflets may have restricted closing.
A. Parasternal short-axis view (both 2D and with color Doppler). B. Apical fourchamber view (pediatric display with atria at the top of the screen). C. Parasternal short-axis view.
A 46-year-old woman with dyspnea on exertion with occasional palpitations has the following surface echo images (Fig. below A–D).
A. Parasternal long-axis view. B. Parasternal long-axis view with color Doppler. C. Apical four-chamber view with color Doppler of the mitral valve. D. Continuous-wave Doppler through the mitral valve.
Her dyspnea on exertion can be explained by:
Rheumatic MV disease with MS and MR. The images shown demonstrate a doming anterior mitral leaflet and a fixed posterior leaflet. There is color acceleration across the MV, suggestive of MS, which is supported by the high gradients found by continuous-wave Doppler through the MV. There is also significant MR (posteriorly directed) seen in the systolic frame with color Doppler. The mechanism of MR in this case is restricted leaflet motion. Myxomatous MV disease (Fig. below), in contrast, is characterized by markedly redundant, prolapsing leaflets, which prolapse back into the LA, occasionally with a torn chord causing a flail leaflet. Typically, the jet of MR is very eccentric if only one leaflet is involved (the jet is in the opposite direction from the most involved leaflet). If there is balanced bileaflet prolapse, the jet is usually centrally directed.
Parasternal long-axis view of a patient with mitral valve prolapse.
This parasternal short-axis view (Fig. below)
would be most consistent with which of the following patients?
Patient with severe tricuspid regurgitation (TR). The parasternal short-axis still frame in diastole demonstrates a patient with diastolic septal flattening. This is found in a patient with right-sided volume overload. You can also see patients with systolic septal flattening, which is consistent with right-sided pressure overload. The patient with severe TR has right-sided volume overload and would have diastolic septal flattening as shown. Patients often have both diastolic and systolic septal flattening if they have both volume and pressure overload on the right side, for example, in a patient with chronic pulmonary embolisms who has developed pulmonary hypertension and also developed significant TR. The lesions of MR and AI are volume loads for the LV, and the subaortic membrane is a pressure load on the LV.
The TEE images below are from a patient who has marked dyspnea on exertion and one episode of presyncope (Fig. below A–C).
A. Mid-esophageal four-chamber view (TEE). B. Mid-esophageal long-axis view (TEE). C. Mid-esophageal four-chamber view with color Doppler.
The patient is now in the operating room for a procedure. The most appropriate operation for this patient would be:
Septal myectomy. The TEE images demonstrate a patient with HOCM. There is septal hypertrophy and the systolic frame demonstrates SAM, which is SAM of the mitral leaflets (Fig. below). The color Doppler images for this patient demonstrate severe MR that is posteriorly directed, which is classic for MR caused by SAM of the mitral leaflets. SAM can involve either the anterior or posterior leaflet alone, or a patient may have bileaflet SAM. Typically, if the mitral leaflet has not been too damaged by years of contact with the septum, performing a septal myectomy can fix the severe MR by eliminating the left ventricular outflow tract (LVOT) obstruction and eliminating the SAM. This type of MR is often hemodynamically labile depending on the loading conditions of the LV. The SAM can be brought out or accentuated by giving the patient amyl nitrite or isuprel. The SAM is decreased by volume loading the ventricle or increasing the systemic pressure. If the mitral leaflets, however, have been scarred by years of contact with the septum, a simultaneous MV repair or replacement may need to be performed. If the MV has to be replaced, often the surgeon has to use a lower-profile valve (typically a bileaflet mechanical valve) because of the narrowed LVOT. Neither a CABG nor an ascending aortic conduit would help this patient unless he had concomitant CAD or an ascending aortic aneurysm, in which case these procedures would have to be performed in addition to the myectomy.
The following TEE images (Fig. below A and B)
A. Mid-esophageal long-axis view (TEE). B. Transgastric short-axis view of the LV (TEE).
demonstrate a large mass noted in the LV apex. This mass is located in a region of myocardial thinning and akinesis in a dilated LV. Although there is some mobility there does not appear to be a stalk. This mass is most likely which of the following possibilities?
Thrombus. This patient had a very large anterior MI and has significant thinning and akinesis of the anterior wall and LV apex. Because of this significant wall motion abnormality, there is stasis of the blood and the patient is at risk for forming a thrombus, which this patient has done. The homogeneous nature of the mass with an echogenicity similar to that of the myocardium (or slightly less echogenic than the myocardium) suggests that the thrombus is relatively fresh. As this heals or organizes over time, calcium may be deposited, and old, organized thrombi in the heart are often quite echogenic. A sarcoma, on the other hand, would be an invasive mass and would not respect the boundaries of the myocardium, but rather would infiltrate the myocardium. Teratomas if found in the heart arise from the pericardium, not within the LV cavity. These are typically benign although may compress the heart. A teratoma would also have a more heterogeneous appearance on echo. Myxomas are the most common benign tumor of the heart and 80% of those are located in the LA, and most of the remaining ones are found in the RA. Papillary fibroelastomas are the second most common benign cardiac tumors and are typically pedunculated (with a stalk) and mobile. Most (>80%) are located on heart valves.
Click to expand