Follow-up Transesophageal Echocardiogram Research Articles

Abstract 17614: “Watchful Waiting” - Successful Medical Management of an Infected Watchman Device

Description of Case: A 68-year-old male with a past medical history of alcoholic cirrhosis, ischemic cardiomyopathy, atrial fibrillation, ventricular tachycardia, and sick sinus syndrome presented with exertional dyspnea and lower extremity edema consistent with acutely decompensated systolic heart failure. He had multiple implantable cardiac devices including a watchman device. He was subsequently found to have methicillin-sensitive staphylococcus aureus (MSSA) bacteremia and developed sepsis. A transesophageal echocardiogram (TEE) was done to evaluate for infective endocarditis and a 1 cm mobile echodensity attached to the anterior aspect of the watchman device was found. Given active bacteremia, the echocardiographic appearance was felt to be most likely consistent with a vegetation. Due to significant medical and cardiac comorbidities, device extraction was deemed very high risk and deferred in favor of antibiotic therapy by a multi-disciplinary team. The patient was treated with intravenous cefazolin and oral rifampin. Clinical defervescence and clearance of bacteremia were achieved. A follow-up TEE in 6 weeks showed complete resolution of the watchman device vegetation. Discussion: Cardiac implantable devices provide significant morbidity and mortality benefits to patients but incur the potential risk of infection. Watchman device infection, though rare, has been reported. The current guidelines recommend the removal of all hardware in patients with established device infection. However, percutaneous, or surgical extraction of the watchman device bears significant risk and may not be feasible in all patients. Our case demonstrates the potential role of antimicrobial therapy alone with close surveillance in treating high-risk patients with watchman device infection.

Abstract 14737: A Case of an Intracardiac Sarcoma Arising From Metastatic Spread of a Primary Phyllodes Tumor of the Breast

Background: Malignant phyllodes tumors with cardiac involvement are rare, presenting diagnostic and management challenges. The benefits of medical and surgical therapies remain unclear. Large-bore aspiration devices are currently only approved for retrieval of venous thromboemboli but may present a valid option for diagnosis and treatment of intracardiac masses in high risk patients. Case Summary: We present the case of a 57-year-old female with a malignant phyllodes tumor of the breast and bilateral pulmonary emboli who presented with an incidental complex intracardiac mass on transthoracic echocardiography (1). A follow-up transesophageal echocardiogram demonstrated masses within the superior vena cava, right atrium, and right ventricle (2a-2b). Aspiration thrombectomy was performed given clinical stability and concern for thrombi with high risk of worsening clot burden. A large-bore aspiration device was used to retrieve the masses in multiple passes (3), which were pathologically consistent with spindle cell sarcoma. A cardiac MRI was completed following aspiration, and multiple mobile masses persisted in the right ventricle (4). The patient was discharged on day nine of hospitalization with therapeutic chemotherapy planned. She had one session of chemotherapy before a fatal cardiac arrest from unknown cause three months after discharge. Discussion: Phyllodes tumors rarely metastasize to the heart, and effective modalities for their diagnosis and management are unclear. Treatment strategies include wide surgical resection of the primary tumor, however mortality remains high in the setting of metastatic spread. Current guidelines recommend following principles of soft tissue sarcomas with chemotherapy. Large-bore aspiration devices may be an effective way to resect intracardiac tumors for both diagnostic and therapeutic purposes as an alternative to invasive surgical intervention for high-risk patients.

Abstract 15031: Anticoagulation Status and Risk of Stroke Following Leak-Closure Procedure for Residual Leak After Occlusion of the Left Atrial Appendage in Patients With Atrial Fibrillation

Introduction: Studies have shown a correlation between leaks following left atrial appendage occlusion procedure and thromboembolic (TE) events. Hypothesis: We investigated the benefits of leak-closure in terms of safe discontinuation of oral anticoagulation (OAC) and minimization of the stroke-risk. Methods: Consecutive patients undergoing leak-closure procedure at our institution were included in the analysis. Procedures included closure with endovascular coils or Amplatzer plug or by using radiofrequency ablation (RFA). Persistence of the leak was verified by multiplane transesophageal echocardiogram (TEE) using color Doppler. Follow-up TEE were performed 60 ± 15 days post-procedure to evaluate LAA closure and patients were kept on OAC until then. After confirmation of closure, they were transitioned to ASA 81 mg/day. All patients were monitored quarterly for thromboembolic (TE) events. Results: A total of 139 post-Watchman patients undergoing leak-closure were included in the analysis (RFA: 10, Amplatzer plug: 5, coil-closure: 124). Pre-coil closure TE events were reported in 7 (5%) subjects. Moderate (3-4 mm) and severe (≥5 mm) leak were detected in 118 (85%) and 21 (15%) patients respectively. After the leak-closure procedure, complete sealing of the leak was confirmed at the follow-up TEE in 138 (99.2%) patients. Figure 1 shows significant reduction in TE events following the leak-closure procedure (p=0.031). During the 2-year follow-up period, six deaths were reported due to unrelated causes. Of the remaining 133 subjects, two patients were on DAPT because of history of coronary artery disease, two with prior stroke were on half-dose OAC and the remaining 129 (95.8%) were on ASA 81 mg/day. No TE events were reported in patients that transitioned to ASA. Conclusions: In this series, successful percutaneous leak-closure not only minimized the risk of stroke but also enabled the majority of patients to discontinue OAC without any TE events.

ALL OVER THE PLACE: A CASE OF MULTIVALVULAR INFECTIVE ENDOCARDITIS

ALL OVER THE PLACE: A CASE OF MULTIVALVULAR INFECTIVE ENDOCARDITIS

AUSTRIAN SYNDROME IN A VACCINATED PATIENT: THE RARE STREPTOCOCCAL PNEUMONIAE TRIAD

AUSTRIAN SYNDROME IN A VACCINATED PATIENT: THE RARE STREPTOCOCCAL PNEUMONIAE TRIAD

Iatrogenic atrial septal defects after transseptal puncture for percutaneous left atrial appendage occlusion and their hemodynamic effects.

Percutaneous left atrial appendage occlusion (LAAO) requires puncture of the interatrial septum. The immediate hemodynamic effects of iatrogenic atrial septal defects (iASD) after LAAO have not been examined so far. We aimed at evaluating these effects through invasive measurements of pressure and oxygen saturation. Moreover, we assessed the incidence of persistent iASD at three months. Forty-eight patients scheduled for percutaneous LAAO were prospectively included in the study. Pressure and oxygen saturation were measured (1) in the right atrium (RA) before transseptal puncture, (2) in the left atrium (LA) through the transseptal sheath after transseptal puncture, (3) in the LA after removal of introducer sheath, and (4) in the RA after removal of introducer sheath. Transesophageal echocardiography was performed at three months to detect iASD. Pressure in the RA increased significantly after removing the introducer sheath (P = 0.034), whereas no difference was found in oxygen saturation in the RA (P = 0.623). Pressure measurement in the LA showed no significant difference after removing the introducer sheath (P = 0.718). Oxygen saturation in the LA also showed no significant difference (P = 0.129). Follow-up transesophageal echocardiogram at 3 months revealed a persistent iASD in 4 patients (8.5 %). Our study suggests that iASD after percutaneous LAAO does not result in significant shunts directly after the procedure, although a significant increase of mean right atrial pressure can be observed. Persistent iASDs after percutaneous LAAO seem to be relatively rare at three months.

The Comparative Effectiveness and Safety of Different Anticoagulation Strategies for Treatment of Left Atrial Appendage Thrombus in the Setting of Chronic Anticoagulation for Atrial Fibrillation or Flutter

PurposeTo 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).MethodsThis 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.ResultsWe 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.ConclusionLAA 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%.

Use of Direct Oral Anticoagulation Therapy Following Implantation of the Watchman Left Atrial Appendage Occlusion Device

ABSTRACT Background: Previously, the standard of care following left atrial appendage occlusion (LAAO) with the Watchman device (Boston Scientific) was 45 days of warfarin and aspirin followed by dual antiplatelet therapy (DAPT) for a total of 6 months and lifelong aspirin thereafter. The recommendation has recently been updated to include post-implantation oral anticoagulation, but there remains a lack of data supporting the use of direct oral anticoagulation (DOAC) therapy. Methods: This was a single-center retrospective analysis of patients undergoing LAAO between 2016 to 2019. Transesophageal echocardiogram (TEE) was conducted at 45 days post implantation. We reported outcomes for patients receiving warfarin with aspirin, DOAC with aspirin, and DOAC alone. Device thrombosis, device leak, transient ischemic attack (TIA)/stroke, major bleeding, and death were evaluated at 45 days and 1 year follow-up. Results: In total, 213 patients were evaluated, where 61 received warfarin/ASA, 81 received DOAC/ASA, and 71 received DOAC alone. At 45 days follow-up TEE, device thrombus was visualized in 2 (3.3%) patients on warfarin/ASA, one (1.2%) patient on DOAC/ASA, and 4 (5.6%) patients on DOAC (P = 0.34). Rates of device leak at 45 days were similar between the groups, from 7.0% to 8.3% (P > 0.99). Major bleeding event rates were similar at 45 days (P = 0.86) and 1 year (P = 0.50). There were no TIA/strokes at both 45 days and 1 year follow-up. At 45 days, one patient on warfarin/ASA died. Conclusion: The use of DOAC with and without aspirin has safety and efficacy outcomes post Watchman implantation similar to outcomes of warfarin and aspirin. Abbreviations: LAAO: left atrial appendage occlusion; DRT: device-related thrombosis; DAPT: dual antiplatelet therapy; DOAC: direct oral anticoagulant; CVA: cerebrovascular accident (i.e., transient ischemic attack [TIA] and stroke); CAD: coronary artery disease; ASA: aspirin; TEE: transesophageal echocardiogram; GI: gastrointestinal

Prevalence and Risk Factors of Incomplete Surgical Closure of the Left Atrial Appendage on Follow-up Transesophageal Echocardiogram.

In patients with atrial fibrillation, incomplete left atrial appendage (LAA) closure is associated with an increased risk for cardio-embolic events compared to complete closure. In this study, we aimed to determine the prevalence and risk factors for incomplete surgical closure of the LAA in the modern surgical era. Records of 74 patients with surgical LAA closure who underwent follow-up transesophageal echocardiogram for any reason between 2010 and 2016, were assessed for incomplete closure. Complete closure was defined by absence of Doppler or color flow between the left atrial appendage and the left atrial body in more than 2 orthogonal views. Surgical LAA closure was incomplete in 21 patients (28%) and complete in 53 patients (72%). All included cases were completed via oversewing method with a double layer of running suture with or without excision of the LAA. While no individual demographic, echocardiographic, or surgical feature was significantly different between groups, incomplete closure of the LAA was more prevalent in patients with two or more of the risk factors; female sex, hypertension, and hyperlipidemia (OR 5.1, 95%Cl 1.5-17). A significant rate of incomplete surgical LAA closure still exists in the modern surgical era, and the presence of multiple risk factors associate an increased risk of incomplete closure.

Suppurative Thrombophlebitis of the Inferior Vena Cava Resolved with Intravenous Antibiotic Therapy: A Case Report

Inferior vena cava (IVC) thrombosis is a rare medical condition. Suppurative thrombophlebitis of the IVC is even a more uncommon subtype of IVC thrombosis and is mostly associated with IVC filters or venous catheters. We describe a 66-year-old man with persistent fever and history of pyonephrosis secondary to transurethral lithotripsy 1 month before recent admission. Computed tomography scan of the chest and abdomen revealed a filling defect in the IVC protruding into the right atrium. Transesophageal echocardiogram (TEE) revealed a large mass at the origin of the IVC entering into the right atrium, suggestive of a clot. Diagnosis of suppurative thrombophlebitis of the IVC secondary to a retroperitoneal abscess was made, and intravenous antibiotic therapy for 6 weeks without anticoagulation conferred ample thrombus resolution. Follow-up TEE in week 16 showed no residual thrombus in the IVC.

Association of Dietary Factors with Progression of AA in Stroke/TIA Patients.

To investigate the effect of dietary factors such as calorie intake and dietary fats on the progression of aortic arch atheroma (AA). In stroke/TIA patients, progression of AA is associated with recurrent vascular events. Consecutive patients with measurable (>1 mm) AA atheroma on baseline transesophageal echocardiogram (TEE) evaluation consented to a protocol mandated follow-up TEE at 12 months. Patients that had adequate paired AA images were assessed for progression, defined as Δ ≥ 1 grade worsening (based on plaque thickness over 12 months). Stroke risk factors and fasting lipid profile were assessed at baseline. The patient's nutritional intake was measured at baseline using the Gladys Block Food Frequency Questionnaire. One-hundred-nine patients (70 strokes, 33 TIAs) had sequential TEEs, of whom 27% (N=30) progressed and 73% (N=79) did not. Patients with progression had higher daily calorie (1778 ± 623 vs. 1378 ± 406 Calories, p=0.008), fat (76 ± 33 vs. 52 ± 23 grams, p=0.0002), carbohydrate (208 ± 78 vs. 169 ± 57 grams, p=0.01) and protein (73 ± 26 vs. 57 ± 21 grams, p=0.005) intake. On Further analysis among different fats showed a higher consumption of saturated fats (25 ± 12 vs. 17 ±8 grams, p=0.00051) as well as unsaturated fats (44 ± 20 vs. 30 ± 13 grams, p=0.002). These differences remained significant after we adjusted for the medication use. However the significance of these differences was attenuated after adjusting for the calorie intake. Cholesterol consumption did not differ between the progression and no-progression group (262 ± 125 vs. 213 ± 149 mg, p=0.2). Calorie intake plays a significant role in the progression of AA. Further studies are needed to confirm these findings and determine the specific dietary modifications that may prevent AA progression and associated recurrent vascular events.

Abstract 14764: Left Atrial Appendage Function and Risk of Stroke After Left Atrial Appendage Electrical Isolation in Patients With Long-Standing Persistent AF: Results From the BELIEF Randomized Trial

Introduction: The Belief Randomized trial sought to assess whether the empirical isolation of the left atrial appendage (LAA) in addition to an extensive ablation could improve success at follow up in patients with long standing persistent (LSP) atrial fibrillation (AF). The aim of this sub-analysis of the trial aimed to evaluate the LAA contraction at the 6 month repeat Trans-esophageal echocardiogram (TEE). Methods: Patients with LSP AF undergoing ablation were enrolled and randomly assigned to undergo empirical LAA isolation along with an extensive ablation or extensive ablation alone. All patients undergoing LAA isolation received a TEE at the 6 months follow up, irrespective of their underlying rhythm. We evaluated TEE parameters and compared thromboembolic complication between groups. Results: We enrolled 173 pts with average age of 63.8 ± 8.5 years and 85.5% male pts. LAA isolation was performed in 101 pts. LAA was not isolated in 72 pts. Follow-up TEE was performed in all pts with LAA isolation. The peak flow velocity in the appendage was low (<0.4 m/s) in 56.4% (57/101) patients. The doppler across the mitral valve demonstrated E-wave to A-wave ratio (E/A) of 2.64 ± 1.4. All patients had E/A >1, out of which 55.4 %( 56/101) had E/A > 2 (p=0.16). One (1.2%) LAA thrombus [Oral anticoagulant warfarin INR subtherapeutic] and 1 (1.2%) LAA smoke [Oral anticoagulant warfarin, INR : 2.24] were detected in the LAA isolation group as an incidental finding at TEE before redo ablation procedure. One patient (0.99%) had stroke in the LAA isolation group after warfarin discontinuation due to a surgical procedure, while 3 (4.2%) stoke/TIA occurred (p=0.31) in the no LAA isolation group (2 pts on warfarin, 1 pt on aspirin). Conclusion: The results of this study show that LAA isolation does not increase the risk of tia/stroke at follow up. This risk appears to be related to the compliance to oral anticoagulation.

Abstract 14612: Does the Open Smooth Antrum of the Left Atrial Appendage Serve as a Nidus for Thrombus Formation in Patients With Atrial Fibrillation and Surgical Appendage Clip i n situ ?

Introduction: Atrial fibrillation (AF) is a significant risk factor for embolic stroke originating from the left atrial appendage (LAA). LAA occlusion is recommended in patients that are not amenable to anticoagulation therapy because of elevated CHADS 2 or CHA 2 DS 2 -VASC score. We assessed the risk of stroke off anticoagulants in AF patients following LAA occlusion with appendage clip device. Methods: One hundred eighty-five AF patients (age 66±13, males 69%, CHADS 2 2.6± 0.8, CHA 2 DS 2 -VASC 3.5± 1.2) that received surgical left atrial appendage occlusion device (clip) were included in this analysis. Transesophageal echocardiogram (TEE) was performed at the end of the procedure to evaluate successful closure of the antrum of the LAA and was repeated at 1 and 6-month post-procedure. Patients remained on oral anticoagulants for 1-month post-procedure after which it was discontinued. All patients were monitored for thrombo-embolic complications for at least 1 year by TEE, clinic visits at 3-month intervals and phone calls by our research staffs. Result: The follow-up TEE revealed the LAA clip to be stable without any secondary displacement. No LAA thrombus was detected. Interestingly, in 177 (95.6%) patients, TEE revealed the proximal part of the smooth antrum of the LAA neck below the clip, to be still open. At the end of the 24±3 months of follow-up, no stroke or transient ischemic attack (TIA) or other neurological events were observed in the study population (0 of 155, 0%). Conclusions: In patients with AF in whom oral anticoagulation is deemed unsuitable because of high CHADS 2 or CHA 2 DS 2 -VASC score, left atrial appendage closure with surgical clip device seems to be safe and effective in preventing stroke. It is relatively common to find incomplete obliteration of the LAA with the surgical clip with the proximal portion of the smooth antrum still remaining open as the clip is typically seen to be placed higher up in the LAA neck. However, presence of the open smooth-antrum did not increase the risk of stroke even after discontinuation of anticoagulants.

Excavated Duodenal Gastrointestinal Stromal Tumor (GIST) Diagnosed by Standard Endoscopic Biopsy

Introduction: An 83-year-old man presented with 1 month of slow gait associated with 2 weeks of fevers and weakness. He also reported a near syncopal episode associated with chest pain prior to admission. Physical exam revealed a systolic murmur and right upper quadrant abdominal tenderness. His blood work was notable for leukocytosis and an ESR of 102. Transthoracic echocardiogram showed 14mm linear echodensity on the aortic valve. A follow-up transesophageal echocardiogram did not show any evidence of vegetations. Computed tomography of the chest, abdomen and pelvis revealed a 4cm enhancing heterogeneous lesion thought to be in the head of the pancreas. Esophagogastroduodenoscopy with endoscopic ultrasound (EGD-EUS) showed a 3cm lesion in the second portion of the duodenum with a deep excavated necrotic center that was easily friable. There was no evidence of pancreatic mass on EUS. Multiple jumbo biopsies were taken from the edge of excavation using standard endoscopic technique, which showed duodenal mucosa with submucosal proliferation of uniform bland spindle cells with anuclear areas diffusely positive for CD117, negative for S-100, which was compatible with gastrointestinal stromal tumor (GIST). The patient underwent a Whipple procedure, which demonstrated that the GIST did not invade the duodenal mucosa or pancreas on pathology. C-Kit mutation was detected on genetic sequence analysis. This clinical vignette demonstrates a rare case of a duodenal GIST that was diagnosed by standard endoscopic biopsy. Typically, endoscopic forceps do not yield enough tissue for a definitive diagnosis. EUS with fine needle aspiration provides better results with one study showing up 82% sensitivity and 100% specificity for diagnosis of GIST. GISTs occurring in the duodenum represent only approximately 5% of all GISTs as well as 10% to 30% of all malignant duodenal tumors. GISTs are most commonly found in the stomach, accounting for 60-70% of all cases. The clinical presentation of GISTs ranges from incidental discovery on endoscopy to nonspecific symptoms or overt GI bleeding. Interestingly, our patient presented with features suggestive of endocarditis, which were subsequently found to be secondary to the duodenal GIST.Figure 1: Excavated duodenal GIST with necrotic center.

Amplatzer left atrial appendage occlusion through a patent foramen ovale

To assess feasibility and outcomes of left atrial appendage (LAA) closure when using a patent foramen ovale (PFO) for left atrial access. Because of the fear of entering the left atrium too high, using a PFO for left atrial access during LAA occlusion (LAAO) is generally discouraged. We report our single-center experience using a concomitant PFO for LAAO, thereby avoiding transseptal puncture. LAAO was performed with local anesthesia and fluoroscopic guidance only (no echocardiography). The Amplatzer Cardiac Plug (ACP) was used in all patients. After LAAO, the PFO was closed at the same sitting, using an Amplatzer occluder through the ACP delivery sheath. Patients were discharged the same or the following day on dual antiplatelet therapy for 1-6 months, at which time a follow-up transesophageal echocardiogram (TEE) was performed. In 49 (96%) of 51 patients (35 males, age 70.9 ± 11.9 years), LAAO was successful using the PFO for left atrial access. In one patient, a long tunnel PFO precluded LAAO, which was performed via a more caudal transseptal puncture. In a second patient, a previously inserted ASD occluder precluded LAAO, which was abandoned because of pericardial bleeding. PFO closure was successful in all patients. Follow-up TEE was performed in 43 patients 138 ± 34 days after the procedure. It showed proper sitting of both devices in all patients. Using a PFO for LAAO had a high success rate and could be the default access in all patients with a PFO, potentially reducing procedural complications arising from transseptal puncture.

Hyperhomocysteinemia is Associated with Aortic Atheroma Progression in Stroke/TIA Patients

Significance: Aortic arch (AA) atheroma and AA atheroma progression are independent risk factors for recurrent vascular events in stroke/transient ischemic attack (TIA) patients. Total homocysteine level (tHcy) is an independent risk marker for atherosclerosis including that found in AA. The purpose of this study was to prospectively test the association between AA atheroma progression and tHcy. Methods: This is a cohort study of 307 consecutive hospitalized stroke/TIA patients undergoing transesophageal echocardiogram (TEE) as a part of their clinical workup. Measurable AA atheroma was detected in 167 patients of whom 125 consented to a protocol-mandated follow-up TEE at 12 months. Patients had evaluation for vascular risk factors, dietary factors (folate, B12 and pyridoxine), and methylene tetrahydrofolate reductase (MTHFR) polymorphism. One hundred eighteen stroke/TIA patients had tHcy, acceptable paired AA images, and detailed plaque measurements. An increase by ≥1 grade of AA atheroma was defined as progression. Results: Of the 118 patients, 33 (28%) showed progression and 17 (14%) showed regression of their index arch lesion at 1 year. tHcy (≥14.0 μmol/l) was significantly associated with progression on both univariate (RR = 3.4, 95% CI 2.0–5.8) and multivariate analyses (adjusted RR = 3.6, 95% CI 2.2–4.6). The changes in AA plaque thickness (r2 = 0.11; p < 0.001) and AA plaque area (r2 = 0.08; p = 0.002) correlated with tHcy. tHcy was associated with change in plaque thickness over 12 months, independent of age, dietary factors, renal function and MTHFR polymorphism (Standardized β-coefficient 0.335, p = 0.02). Conclusions: Our results validate the association and a linear correlation between tHcy and progression of AA atheroma.

Novel three-dimensional transesophageal echocardiography imaging of a highly mobile left atrial thrombus associated with stroke

A 71-year-old woman initially presented with increasing dizziness and numbness, as well as a mild fever. Her medical history included atrial fibrillation and a mechanical mitral valve replacement (MVR) surgery eight years previously for severe rheumatic mitral stenosis. A transthoracic echocardiogram was unable to rule out a clinical suspicion of endocarditis on the mitral prosthesis, due to inherent shadowing artifact from the valve. Therefore, a transesophageal echocardiogram (TEE) was scheduled to obtain a better image of the valve. In the days preceding the TEE, the patient had a severe stroke with pronounced right-sided paralysis. The subsequent TEE did not show any signs of endocarditis; however, a large, highly mobile thrombus (labelled ‘X’) was detected in the left atrium (LA) (Figure 1 and Video 1). Spontaneous contrast was also noted in the left atrial appendage (LAA), indicating slow-moving blood. The addition of three-dimensional (3D) TEE imaging allowed for unique views of the thrombus compared with standard two-dimensional TEE, and allowed for determining its 3D size, shape and spatial orientation within the chamber (Figure 2 and Video 2). This relatively new imaging modality also helped identify a thin strand of fibrin that loosely attached the thrombus to the LAA, which was unclear from multiple two-dimensional TEE views. The 3D images revealed that the thrombus’ large size prevented it from fitting through the mitral valve prosthesis; however, it was seen repeatedly striking against the valve. The patient was aggressively managed with antithrombotic medication and closely monitored over the course of one month. Due to complaints of severe leg pain, the patient underwent computed tomographic angiography, revealing that the thrombus had embolized into the femoral artery. After the thrombus was surgically removed from the leg, a follow-up TEE showed no residual left atrial thrombus. Figure 1 Figure 2

Stroke in Sickle Cell Anemia After Excellent Response to Hydroxyurea.

Abstract 4622 IntroductionStrokes occur in about 10% of children with sickle cell anemia (SS) less than 10 years old. These strokes are usually ischemic in nature. Stroke due to SS in adults is less common and is usually hemorrhagic in nature. We wish to report an unusual adult patient with SS and excellent response to HU who developed a stroke that was unrelated to SS. Case Report and ResultsA 35-year-old female with sickle cell anemia had mitral valve prolapse and migraine headaches presented 2 days after developing abrupt bilateral blurry vision, left facial numbness and weakness of her left leg. Her SS has been complicated by acute chest syndrome, bilateral hip avascular necrosis and frequent painful crises prior to hydroxyurea (HU) therapy. She was enrolled in the multicenter study of hydroxyurea (MSH) in SS and has been on 2500mg of HU per day for the past 13 years. She had an excellent response to HU with no recurrent acute chest syndrome and decreased need for blood transfusion. After starting HU, the frequency of crises requiring hospital admission decreased from 1 admission every 1 to 2 months to less than 1 admission per year except when hydroxyurea was discontinued for pregnancy. Her fetal hemoglobin increased from 6.1 % before HU to a maximum of 45%. Her MCV increased from 96 fl to a maximum of 132 fl and Hb from 8.0 g/dl to 9.8 g/dl Her exam was remarkable for left lower extremity weakness which was more pronounced proximally. All cranial nerves were intact and there was normal sensation bilaterally. CT scan of the brain showed three foci of hypodensity and MRI of the brain showed increased signal on T2, FLAIR and diffusion weighted images within the frontoparietal deep white matter consistent with infarction in the border zone of the middle cerebral artery (MCA)-anterior cerebral artery (ACA). MR angiography of the intracerebral and extracerebral vessels demonstrated focal narrowing of the right MCA at the trifurcation suggesting an embolic cause. Common causes of stroke were ruled out with routine studies. Her hemoglobin electrophoresis after admission but before blood exchange transfusion showed HbS of 55% and HbF of 45%. She underwent exchange transfusion 2 days after admission and was started on chronic blood exchange transfusions with the assumption that she had ischemic stroke due to SS. Initial transthoracic echocardiogram with contrast injection did not show an atrial shunt. Follow-up transesophageal echocardiogram after discharge showed a secundum atrial septal defect with a defect size of 1.4 cm. Right heart catheterization was performed and the pulmonary flow to systemic flow (Qp/Qs) was 1.7:1. An Amplatzer atrial septal defect (ASD) closure device was deployed with transesophageal echocardiographic guidance and a large thrombus was removed from the right atrium. At the patient's request exchange red cell transfusions were discontinued. The patient has continued treatment with hydroxyurea and aspirin. ConclusionsYoung patients with cryptogenic stroke have a much higher prevalence of atrial shunts and in particular patent foramen ovale than patients with other forms of stroke and therefore a cause-effect association is suggested. Young adults with stroke should be evaluated for common and reversible causes of stroke including paroxysmal emboli. Transesophageal echocardiography is the gold standard for diagnosing atrial shunts. Strokes in patients younger than age 55 are related to paroxysmal emboli and have a risk of recurrence of approximately 30% within one year. High risk features for stroke recurrence with an atrial shunt include hypercoagulable states, large opening and presence of an atrial septal aneurysm. Optimal management of patients with a stroke and an atrial shunt is unknown. Options include surgical closure, percutaneous device closure, anticoagulation and antiplatelet therapy. Patients with sickle cell disease and stroke should receive long term blood transfusions to reduce HbS below 30% if the stroke is felt to be related to sickle cell disease vasculopathy. The patient described with SS had a stroke and had an atrial septal defect that was repaired. The MRI/MRA findings are consistent with paroxysmal emboli. The patient is receiving treatment with hydroxyurea and aspirin having discontinued red cell exchange transfusions and at two years of follow-up has not had a recurrent stroke. Disclosures:No relevant conflicts of interest to declare.

Subepicardial Aneurysm Evaluated by Multiplane 2D and Real-Time 3D Volumetric Transesophageal Echocardiography

A 76-year-old man with a history of hypertension, dyslipidemia, and 90 pack-year smoking, presented to his primary care physician with complaints of worsening dyspnea. His ECG finding did not show any pathological Q-wave or ST-T abnormalities (Online Figure I). A 2D transthoracic echocardiogram revealed normal left ventricular (LV) systolic function with inferior and inferolateral wall motion abnormalities. A suspicious aneurysm was also noted (Figure 1). His adenosine stress nuclear perfusion images showed a moderate-sized area of ischemia or jeopardized myocardium involving the infero-lateral LV (Online Figure II). He underwent cardiac catheterization, which revealed an occluded right coronary artery and significant left-to-right collaterals (Figure 2). Left ventriculography revealed a hypokinetic basal inferior wall and an aneurysm (Figure 3, Movie I). A follow-up transesophageal echocardiogram was performed using an x7–2t …

Aortic Arch Atheroma Progression and Recurrent Vascular Events in Patients With Stroke or Transient Ischemic Attack

It is not known whether progression of aortic arch (AA) atheroma is associated with vascular events in patients with stroke or transient ischemic attack (TIA). AA atheroma was detected on baseline transesophageal echocardiogram in 167 consecutive patients who had prevalent stroke or TIA. Of these, 125 consented to a follow-up transesophageal echocardiogram at 12 months. Adequate paired AA images were obtained in 117 (78 with strokes, 39 with TIAs), which allowed detailed measurements of plaques. On admission for their index stroke or TIA, patients were assessed for stroke risk factors, stroke subtypes, baseline AA plaque characteristics, and laboratory parameters. Progression of AA atheroma was observed in 33 patients (28%) on 12-month follow-up transesophageal echocardiogram. It was determined that the progression group had significantly higher adjusted homocysteine levels (P<0.0001) and neutrophil counts (P<0.0001) than the no-progression group. These patients were followed up for a median of 1.7 years from the index stroke/TIA (range 0.5 to 4.5 years) for vascular events including stroke, TIA, myocardial infarction, and death due to vascular causes. Kaplan-Meier curves showed fewer patients with AA atheroma progression remained free of the composite vascular end point (49% compared with 89% in the no-progression group; P<0.0001). AA atheroma progression was associated with composite vascular events (hazard ratio 5.8, 95% confidence interval 2.3 to 14.5, P=0.0002) after adjustment for a propensity score based on confounders. In this preliminary study of stroke/TIA patients with AA atheroma on transesophageal echocardiogram, AA atheroma progression was associated with recurrent vascular events.