A 22-year male presented with complaints of dyspnea. Multimodality imaging revealed a polypoidal right atrial mass with sub-massive pulmonary embolism. The patient underwent urgent surgery. The pathological examination confirmed it as cardiac myxoma. Cardiac myxoma, a most common primary cardiac tumor, is commonly found in the left atrium. The right atrium is an uncommon site and the usual mode of presentation is the tumor or thrombus embolisation to the pulmonary circulation.

Right atrial appendage aneurysms (RAAAs) are extremely rare in cardiac anomaly. According to the literature, no more than 25 cases have been reported so far, among which only 3 cases were children. Here, we reported an infant with a giant RAAA and severe symptoms. The RAAA was diagnosed by echocardiography and surgically resected under cardiopulmonary bypass. The role of transesophageal echocardiography was very important during the aneurysm resection surgery, which helped surgeons to plan surgical procedures during the surgery and evaluate the surgical effect postoperatively.

Bioprosthetic valve thrombosis is a growing recognized entity, especially with the increasing use of the valve in vale procedures and the advent of new detection technologies (e.g., 4D CT and 4D echocardiography). However, the optimal management strategy in the acute context is not established. This paper presents a case of early thrombosis following the percutaneous tricuspid valve in vale procedure that was successfully managed with thrombolysis.

Ruptured abdominal aortic aneurysms are associated with high mortality rates and require prompt diagnosis with subsequent intervention. CT scan is considered the gold-standard for diagnosis, however, in the acute setting ultrasound may be a reasonable diagnostic test for certain patients. We report a case that demonstrates the utility of bedside ultrasound of rAAA for a patient in extremis. Also, we provide a brief review of literature for the diagnosis of rAAA with ultrasound.

Massive myocardial calcification is a very rare finding. Accurate identification and characterization may help the clinicians to determine the etiology and clinical significance. In this case, the diagnostic pathway excluded previous myocardial infarction, myocarditis and calcium-phosphate disorders. A possible dystrophic etiology was considered. There are no standardized imaging features available to classify specific subtypes of intramyocardial calcifications. The relative merits of cardiac computed tomography and magnetic resonance in providing complimentary diagnostic information for calcific myocardial lesions is shown. Knowledge of the potential etiology and their imaging patterns are important to provide a concise and accurate differential diagnosis.

Aim: To evaluate the prognostic utility of red blood cell distribution width (RDW) and left ventricular mass index (LVMI) in patients with hypertrophic cardiomyopathy (HCM). Patients & methods: This study is a retrospective cohort analysis. Patients diagnosed with hypertrophic cardiomyopathy at the First Affiliated Hospital of Sun Yat-sen University from March 2014 to March 2019 were included . HCM patients were stratified into two groups based on the occurrence of major adverse cardiac events (MACE).Receiver operator characteristic (ROC) curves were then constructed and Cox regression models were employed to gauge the prognostic relevance of RDW and LVMI for HCM patients. Kaplan-Meier analysis evaluated the survival and MACE-free rate in patients with different level of RDW and LVMI. Results: A total of 300 patients with HCM were enrolled in this study and followed up for 40.56±18.33 months. Among them, 117 MACE (39.00%), 40 all-cause deaths (13.33%), 29 cardiovascular deaths (9.67%). The level of RDW, LVMI, creatinine (Cr) and B-type pro-brain natriuretic peptide (NT-ProBNP) were statistically different between the MACE group and Non-MACE group ( P<0.05). Multivariate analysis showed that after adjusting for confounding factors, RDW and LVMI were independent predictors of all-cause mortality and MACE in HCM patients. ROC showed that RDW>0.13 and LVMI>181g/m 2 are the cut-off value to predict all-cause mortality and MACE. The AUC of the combination predicting the occurrence of all-cause mortality and MACE are 0.890 and 0.885 respectively. Kaplan-Meier analysis showed that the survival rate and MACE-free survival rate of group 1 (RDW≦0.13 and LVMI≦181g/m 2) were significantly higher than group 2 (RDW>0.13 or LVMI>181g/m 2), and group 3 (RDW >0.13 and LVMI>181g/m 2) ( P=0.000). Conclusion: We determined that increased RDW and LVMI was independently associated with MACE incidence and risk of mortality in HCM patients. Combined evaluation of RDW and LVMI yielded a more accurate predictive model of HCM patient outcomes relative to the use of either of these metrics in isolation. Our research can provide a theoretical basis in the occurrence of MACE for the high-risk HCM and intervene them properly and timely.

We describe an adult patient who presented with purulent pericarditis in whom two-dimensional transthoracic echocardiography demonstrated a marked decrease in the area of the right ventricular wall together with the overlying fibrin following intrapericardial administration of a fibrinolytic agent. Documentation of this decrease by measurements performed and illustrated on two-dimensional images have not been reported previously in an adult patient with purulent pericarditis, to the best of our knowledge.

Introduction: Cardiac point-of-care ultrasound (c-POCUS) is an increasingly implemented diagnostic tool with the potential to guide clinical management. We sought to characterize and analyze the existing c-POCUS literature with a focus on the temporal trends and differences across specialties. Methods: A literature search for c-POCUS and related terms was conducted using Ovid (MEDLINE and Embase) and Web of Science databases through 2020. Eligible publications were classified by publication type and topic, author specialty, geographical region of senior author, and journal specialty. Results: The initial search produced 1761 potential publications. A strict definition of c-POCUS yielded a final total of 574 cardiac POCUS manuscripts. A yearly increase in c-POCUS publications was observed. Nearly half of publications were original research (48.8%) followed by case report or series (22.8%). Most publications had an emergency medicine senior author (37.5%), followed by cardiology (20.2%), anesthesiology (12.2%), and critical care (12.2%). The proportion authored by emergency medicine and cardiologists has decreased over time while those by anesthesiology and critical care has generally increased, particularly over the last decade. First authorship demonstrated a similar trend. Articles were published at similar numbers in emergency medicine journals (23.0%) and cardiology journals (19.9%). Conclusion: The annual number of c-POCUS publications has steadily increased over time reflecting the increased recognition and utilization of c-POCUS. This study can help inform clinicians of the current state of c-POCUS and augment the discussion surrounding barriers to continued adoption across all specialties.

Objective: Predictors for post-operative reverse remodeling in patients with severe aortic regurgitation (AR) and reduced left ventricular ejection fraction (LVEF) are unknown. We performed low-dose dobutamine stress echocardiography (DSE) in patients with severe AR and reduced LVEF to evaluate the relationship between contractile reserve (CR) and reverse remodeling after surgery. Methods: In 31 patients with chronic severe AR and reduced LVEF (LVEF < 50%), we performed pre-operative DSE, assessed CR and examined whether changes in preoperative DSE were associated with improvement of post-operative LVEF after aortic valve surgery. Results: The pre-operative echocardiographic findings were as follows: left ventricular (LV) end-diastolic dimension: 67 ± 10 mm, LV end-systolic dimension: 52 ± 13 mm and LVEF: 42% ± 8%. All patients underwent aortic valve surgery. Patients with pre-operative LVEF of >45% exhibited a significant increase in LVEF; however, patients with pre-operative LVEF of <45% showed no significant change. When we examined the results of DSE performed in patients with pre-operative LVEF of <45%, ΔLVEF of ≥6% (with CR) during DSE was related to an improvement in post-operative LVEF; ΔLVEF of ≥6% during DSE predicted an improvement in post-operative LVEF, with a sensitivity and specificity of 80% and 85%, respectively. Conclusions: DSE may be a helpful tool for predicting post-operative reverse remodeling in patients with severe AR and moderately reduced LVEF.

Objectives. We sought to evaluate the ability of left atrial strain and derived index to discriminate patients with HFpEF from individuals with risk factors of HFpEF. Methods and results. A total of n=389 patients with risk factors for HFpEF finally was prospectively enrolled into the study, 51 of them were diagnosed with HFpEF by ESC diagnostic criteria. 55 patients were undergone left ventricular catheterization, 35 of them with LVEDP elevated. Left atrial strain was measured in all patients. Compared patients without HFpEF, LASr and LASr/(E/e’) was lower in HFpEF; E/LASr, LAVi/LASr and LVMI/LASrwas higher in patients with HFpEF. After adjusted for hypertension, diabetes, chronic kidney disease, LVEF and NT-proBNP, multivariate logistic regression analyses showed that LASr and derived indexes(E/LASr, LASr/(E/e’), LAVi/LASr and LVMI/LASr) were still the predictors of HFpEF in their respective models. LASr had good diagnostic accuracy for HFpEF. Of the left atrial strain derived parameters, LVMI/LASr was the best discriminatory ability for HFpEF (AUC 0.796, cutoff value 5.2, specificity 82%, sensitivity 73%). LASr, LASr/(E/e’), LAVi/LASr and LVMI/LASr with higher AUC was superior to conventional echocardiographic measures of diagnosing HFpEF. LASr and derived indexes were incorporated into the ESC diagnostic criteria, LASr-HFA-PEF score system (AUC=0.804) had a higher detection rate of LVEDP≥16mmHg than the HFA-PEF score system (AUC=0.781). Conclusion. LASr and derived indexes with good accuracy beyond conventional echocardiographic parameters discriminate HFpEF from patients with risk factors of HFpEF. LASr and derived indexes incorporated into the ESC diagnostic criteria will improve the diagnostic efficiency.

Background: Right ventricular-pulmonary artery coupling (RVPAC) is a predictor of outcome in pulmonary hypertension. However, the role of this parameter in dilated cardiomyopathy (DCM) remains to be established. The aim of this study was to assess the contribution of RVPAC to the occurrence of severe heart failure (HF) symptoms in patients with DCM using three-dimensional (3D) echocardiography. Methods: We prospectively screened 139 outpatients with DCM, 105 of whom were enrolled and underwent 3D echocardiographic assessment. RVPAC was estimated non-invasively as the 3D right ventricular stroke volume (SV) to end-systolic volume (ESV) ratio. Severe HF symptoms were defined by New York Heart Association (NYHA) class III or IV. We evaluated differences in RVPAC across NYHA classes and the ability of RVPAC to predict severe symptoms. Results: Mean left ventricular (LV) ejection fraction was 28±7%. Mean RVPAC was 0.77±0.30 and it was significantly more impaired with increasing symptom severity (p=0.001). RVPAC was the only independent correlate of severe HF symptoms, after adjusting for age, diuretic use, LV systolic function, LV diastolic function and pulmonary artery systolic pressure (OR 0.035 [95% CI, 0.004 – 0.312], p=0.003). By receiver-operating characteristic analysis, the RVPAC cut-off value for predicting severely symptomatic status was 0.54 (area under the curve=0.712, p<0.001). Conclusion: 3D echocardiographic SV/ESV ratio is an independent correlate of severe HF symptoms in patients with DCM. 3D RVPAC might prove to be a useful risk stratification tool for these patients, should it be further validated in larger studies.

Objective: According to Bernoulli Equation, systolic pulmonary artery pressure is obtained echocardiographically by adding estimated right atrial pressure (RAP) to the multiply of square of tricuspid regurgitation flow rate by four. RAP is estimated based on inferior vena cava (IVC) diameter and collapse. Our objective is to investigate usability of coronary sinus(CS) diameter and collapse, measured by echocardiography for estimating RAP. Methods: Our study is a single center, prospective study. 136 patients, over 18 years of age and without exclusion criteria, who admitted to Akdeniz University Hospital Cardiology Department between March 2017 and March 2018 and were scheduled to undergo right heart catheterization for any reason were included study. Results: Patients were divided into two groups as invasively measured RAP ≥10 mmHg (n: 57) and RAP <10 mmHg (n: 79). In group with RAP ≥10 mmHg, maximum IVC and CS diameter were higher than group with RAP <10 mmHg, IVC and CS collapse indices were lower (p <0.001). Optimal cut-off value for maximum IVC diameter was 19.6 mm (sensitivity 63.2%, specificity 87.3%), for IVC collapse index was 46.1 (sensitivity 75%, specificity 79.7%), for maximum CS diameter was 11 mm (sensitivity 64.9%, specificity 77%), for CS collapse index was 39.2 (sensitivity 75.4%, specificity 88.6%). Conclusion: Significant relationship was found between invasively measured RAP and maximum IVC diameter, collapse index and maximum CS diameter and collapse index. Results of CS parameters were as significant as results of IVC parameters therefore it shows that CS can also be used for estimating RAP.

Background: The left ventricle (LV) journey in their transition from hypertrophy to heart failure is marked by many subcellular events partially understood yet. The moment in which the structural abnormalities reach the umbral to induce myocardial dysfunction remains elusive. Aims: To evaluate the anatomic-functional relationship between LV wall thickness and longitudinal systolic dysfunction. Material and Methods: We prospectively performed clinical history and transthoracic echocardiogram on healthy individuals and patients with hypertension, left ventricle ejection fraction (LVEF) ≥50%, and absence of heart failure symptoms. Results: A total of 226 patients and 101 healthy individuals were recruited. The distribution for sex was similar between groups. The mean age was 67±13 years old in the patients, and 44% had concentric LV hypertrophy. LVEF was identical in both groups (63±6%); in contrast, global longitudinal strain (GLS) (-18.8±2.5% vs. -20.4±2%) and mitral annulus plane systolic excursion (MAPSE) (13.8±2.8 vs. 15.5±2mm) were lower. ROC curve classified optimally decreased GLS with LV septum thickness ≥13mm and decreased MAPSE with thickness ≥14mm. Multivariable logistic regression found that LV septum thickness is the only variable associated with longitudinal systolic dysfunction (OR= 1.1, CI95%= 1.05 – 1.15, p= 0.001, R squared= 0.38). Discussion: A progressive increase in LV wall thickness due to myocyte hypertrophy and interstitial expansion is associated with LV systolic longitudinal dysfunction. Conclusions: Patients with moderate or severe ventricular hypertrophy (septum ≥13mm) had longitudinal systolic dysfunction, GLS decreases with minor structural change than MAPSE, and LVEF is insensitive in detecting longitudinal myocardial dysfunction in patients with hypertension.

An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5x2 cm) in the left atrium prolapsing to the right atrium via a patent foramen ovale and another thrombus (white arrow) adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.

Abstract A mediastinal carcinoid is a low-grade malignant tumor, which has low risk of metastasis, and cardiac metastasis is even rarer. When a patient has cardiac metastasis, the primary carcinoid is usually widely metastasized. In this case report, we presented occurrence of isolated left-sided cardiac metastases ten years after surgical removal of left anterior superior mediastinal carcinoid.

In this report, we present a rare case of severe mitral regurgitation due to isolated mitral valve chordal rupture without valve leaflet prolapse in a patient with Fabry cardiomyopathy. This finding could be due to subvalvular apparatus storage of glycosphingolipids rather than fibro-elastic deficiency, underlying how close cardiological follow-up of Fabry patients must be comprehensive and not only focused on left ventricular hypertrophy and arrhythmias. We feel that our finding could be of interest for the readership of your Journal.

Transthoracic and transesophageal imaging of the 30-year-old patient who presented with palpitations and shortness of breath revealed flow from the aorta to the right atrium. Aortic-right atrial fistula, which is a rare anomaly, was evaluated. It was considered congenital, as there was no acquired cause. Since the patient was symptomatic, it was closed percutaneously with the Amplatzer Duct Occluder II device.

Echocardiography is commonly utilized in patients with acute respiratory distress syndrome (ARDS) for assessment of cardiac function, volume status, and the potential development of acute cor pulmonale. In severe ARDS, prone positioning is frequently used, which imposes technical challenges during transthoracic echocardiography (TTE) image acquisition. Moreover, prone positioning can affect cardiopulmonary function in ways that are reflected on the echocardiographic findings in this position. Historically, a transesophageal approach was recommended when a patient is prone, with few studies reporting utility of TTE in this setting. However, recent publications have begun to address this knowledge gap. This review explores recent literature addressing the use of TTE in prone patients with ARDS, with a special focus on the cardiopulmonary effects of proning and potential solutions to the technical difficulties that arise in this position.