Intraoperative Transesophageal Echocardiogram Research Articles

Prognostic value of left ventricular global longitudinal strain in patients with moderate ischemic mitral regurgitation who underwent coronary revascularization

Abstract Background Patients with severe ischemic mitral regurgitation are indicated to undergo mitral valve surgery during CABG. For moderate ischemic mitral regurgitation, however, doing mitral valve intervention during revascularization is still controversial. Guidelines recommend the use of LVEF as a parameter for LV dysfunction as an indication to do intervention, but studies have showed that LV GLS is a sensitive tool to detect even subclinical left ventricular dysfunction. This study aimed to determine the prognostic value of left ventricular global longitudinal strain in patients with moderate ischemic mitral regurgitation who underwent coronary revascularization without mitral valve surgery in predicting MACE. Methodology Baseline clinical and echocardiographic characteristics were retrospectively studied among patients with moderate ischemic mitral regurgitation who underwent surgical revascularization without mitral valve surgery. Speckle tracking using VVI was done on pre-operative echocardiograms to determine the left ventricular global longitudinal strain and intraoperative transesophageal echocardiograms were reviewed to assess for persistence of moderate mitral regurgitation. Occurrence of major adverse cardiovascular events during the hospital stay were reviewed in the medical records as well. Results Among the 36 patients with moderate ischemic mitral regurgitation, 16 (44.4%) had persistent moderate mitral regurgitation. There was no statistical difference in the outcome of moderate mitral regurgitation postoperatively between LV GLS >7% and <7%. In terms of major adverse cardiovascular events, 58% (21/36) had occurrence of MACE. There was no significant difference in the occurrence of MACE between patients with LV GLS of >7% and <7%. However, it was noted that for every unit decrease in LV GLS, the odds of having MACE increases by 17.02% with crude odds ratio of 1.17 (p-value 0.041). Patients with history of ACS were 11.69 times more likely to have MACE with odds ratio of 11.69 (p-value of 0.002). Ejection fraction was not found to be a significant factor associated with MACE. Conclusion Left ventricular global longitudinal strain can be used as an additional parameter in prognosticating patients with moderate ischemic mitral regurgitation who will undergo revascularization. Patients with more impaired LV GLS would have higher odds of having MACE. Methodology Factors Associated with MACE

Abstract 4135360: Eosinophilic Myocarditis: An Atypical Presentation with a Labile Course: A Case Report

Case presentation: A 64-year-old man presented with one day of chest pain. Initial evaluation showed elevated cardiac enzymes (CE) and normal eosinophil count. Electrocardiogram (EKG) was unremarkable. Transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 40% and a moderate-large pericardial effusion with signs of tamponade. Pericardiocentesis was deferred due to the lack of a safe window. Left and right heart catheterization showed no occlusive disease or chamber pressure equalization. The patient developed worsening shock, raising suspicion for myocarditis and prompting an endomyocardial biopsy (EMB). He was placed on extracorporeal membrane oxygenation (ECMO) on day 3. The EMB resulted as eosinophilic myocarditis (EM), and high dose Methylprednisolone was started. He was decannulated from ECMO on day 10. Intra-operative transesophageal echocardiogram (TEE) post-decannulation showed a normal EF without segmental abnormalities. Three hours later, a rise in CEs was noted, and EKG showed ST elevations inferiorly. TTE showed a reduced EF with multiple segmental abnormalities concerning for myocardial infarction. A repeat coronary angiogram was unremarkable. Due to the residual pericardial effusion, the patient underwent a pericardial window draining 200 cc of serosanguinous fluid. Intra-operative TEE showed an EF of 20% with no improvement after drainage. He had a cardiac arrest during the procedure and was placed back on ECMO. High-dose steroids were resumed along with intravenous immunoglobulin. Despite interventions, the patient continued to deteriorate and he ultimately expired. Discussion: EM has high mortality and a variable course, often requiring EMB for diagnosis. As in our case, about 25% of cases present without peripheral eosinophilia. Pericardial effusion occurs in 34% of cases and tamponade in 6%. A distinct feature of this case is the decompensation associated with ST elevation and segmental abnormalities, thought initially to be myocardial infarction (MI), after an initial response to steroids. While the etiology of such decompensation is unclear, relapsing EM in the setting of tapering steroids is one explanation, as myocarditis and MI can share similar clinical features. Another explanation is cardiac tamponade, which has also been reported to mimic MI and myocarditis. Air embolism from ECMO decannulation is another possibility, though air embolisms may include cerebrovascular pathology, which was not observed.

Restricted cusp motion in newly implanted tricuspid bioprostheses: Incidence, predictors, and impact on survival

ObjectiveTo investigate the occurrence of restricted cusp motion (RCM) at the time of bioprosthetic tricuspid valve replacement (TVR) and analyze associated risk factors and outcomes. MethodsThis study involved adult patients who underwent TVR with a bioprosthesis at our institution between 2012 and 2022. Bioprosthetic cusp motion was analyzed de novo through a detailed review of intraoperative transesophageal echocardiograms (TEE). Two models of porcine valves were implanted: the Medtronic Hancock II bioprosthesis and the St Jude Medical Epic bioprosthesis. ResultsAmong the 476 patients who met the inclusion criteria, RCM was identified on immediate post-bypass TEE in 150 (31.5%); there was complete immobility of the cusp in 63 patients (13.2%) and limited movement of a cusp in 87 patients (18.3%). In a multivariable logistic regression analysis, the Hancock II model (odds ratio [OR], 6.15; P < .001), a larger orifice area (per IQR increase: OR, 1.58; P = .017), a smaller body surface area (per IQR increase: OR, .68; P = .040), and a lower ejection fraction (per IQR increase: OR, .60; P = .033) were independently associated with having RCM. Cox regression adjusting for 15 covariates revealed that RCM at the time of TVR was independently associated with an increased risk of mortality (hazard ratio, 1.35; P = .049). ConclusionsThis study revealed a high incidence of RCM in bioprosthetic valves in the tricuspid position detected shortly postimplantation, which was associated with increased late mortality. To reduce the probability of RCM, it is important to select the appropriate prosthesis model and size, particularly in small patients.

Recognition and management of left atrial dissection during mitral repair

BackgroundLeft atrial dissection (LAtD) is a rare but potentially life-threatening complication of mitral valve surgery. Its management is not well stablished in the literature. However, early recognition through intraoperative TEE and attention to changes in the left atrial free wall during saline leak testing can lead to avoidance of severe complications.Case presentationWe report a case of LAtD detected by intraoperative transesophageal echocardiogram (TEE) following mitral valve repair for primary mitral valve regurgitation secondary to degenerative mitral valve disease with MAZE IV procedure for atrial fibrillation. LAtD was noted on TEE as an expanding double density along the wall of the left atrium with a jet originating at the posterior annulus flowing into the LAtD which was repaired. Separation from bypass following LAtD repair was complicated by severe biventricular dysfunction requiring significant inotropic support and placement of an intra-aortic balloon pump (IABP). Patient’s post-operative course was further complicated by right sided heart failure requiring placement of a right sided impella which was subsequently removed on POD 4. Patient was discharged home on POD 17. Transthoracic echo at 1 month, 3 months demonstrated resolution of the LAtD. A follow up echo at 4 years showed complete resolution of the LAtD with an intact mitral repair, trace mitral regurgitation, and a mean gradient across the repair of 3 mm Hg.ConclusionsLeft atrial dissection is a rare but serious complication of mitral valve surgery. We provide a review of the current literature regarding LAtD, emphasizing the need to consider this complication early during mitral surgery to allow for uncomplicated repair.

Abstract 17670: Double Trouble: Exploring the Rare Coexistence of Right and Left Atrial Thrombus After Left Atrial Appendage Ligation and Maze Procedure

Introduction: Left atrial appendage (LAA) harbors around 90% of thrombus in patients with Atrial Fibrillation(AF) related strokes. Incomplete surgical ligation and LAA stump are independent risk factors for stroke and thromboembolism in AF patients. To our knowledge, we report the first case of biatrial thrombus occurring within 1 week of surgery. Case Presentation: A 76-year-old man with Paroxysmal AF and three-vessel coronary artery disease presented with 3-week exertional and resting shortness of breath and chest pain. Troponins were negative, and EKG revealed AF. Cardiothoracic surgery planned coronary bypass, MAZE procedure, and LAA clipping. Intra-operative transoesophageal echocardiogram(TEE) showed ejection fraction of 35% without LAA clot. Post-operatively, despite anticoagulation(AC) and beta blocker therapy, AF recurred within a week. Subsequent TEE prior to anticipated cardioversion(CV) revealed thrombus on the superior vena cava border of right atrium, anterolateral wall of left atrium and near the mitral valve annulus. CV was deferred, and he was sent to rehab with AC. We hypothesize that the thrombus may be attributed to a stunned atrium caused by ischemic myocardial injury. Our case underscores the need for heightened suspicion of thrombus in individual cases. Discussion: Left atrial appendage occlusion (LAAO) was implemented as stroke prophylaxis strategy in AF during surgical interventions like maze and coronary bypass. while the European Society of Cardiology advises continuing AC after LAAO, studies suggest discontinuing AC in high-risk bleeding patients after successful surgical AF ablation and LAAO if sinus rhythm is maintained for ≥3 months. LAAOS III study shows economic benefit of concomitant surgical LAAO during cardiac surgery in AF patients with CHA2DS2-VASc score ≥2 for stroke prevention. When used alongside AC, it offers incremental benefits. Safety of discontinuing AC after LAAO requires further investigation.

Abstract 17356: Recurrent Hemorrhagic Pericardial Effusion Requiring a Multimodality Imaging Approach: A Case Report

Background: A 24-year-old female with no medical history presented to the ED with chest pain and dyspnea. Vitals were notable for tachycardia to 120s. Physical examination was unremarkable. Clinical Course: Initial evaluation was notable for thrombocytopenia, NT-proBNP of 151 and high sensitivity troponin T of 18. Transthoracic echocardiogram (TTE) revealed a small pericardial effusion with tamponade physiology prompting urgent pericardiocentesis. Bloody pericardial fluid was drained and fluid studies were consistent with hemorrhagic effusion with no evidence of infection or malignancy on cytology. Surveillance TTEs showed rapid reaccumulation of pericardial fluid within 72 hours of the initial intervention. Urgent pericardial window with drain placement was performed and intraoperative transesophageal echocardiogram (TEE) revealed a right atrial (RA) mass not detected on prior TTE. Cardiac MRI confirmed the presence of a large (50 mm x 31 mm) immobile and heterogeneous mass in the superior aspect of the RA suggestive of a malignant etiology with invasion to the adjacent pericardium. Positron Emission Tomography (PET) scan demonstrated hypermetabolic activity concerning for malignancy with no evidence of mediastinal, hilar adenopathy, or distant disease. She underwent mini-sternotomy and biopsy with pathology suggestive of primary cardiac angiosarcoma. Due to the high-risk nature and location of the tumor, she was unable to undergo primary surgical resection. Neoadjuvant chemotherapy was initiated with plan for subsequent surgical reassessment. Conclusion: Workup of recurrent hemorrhagic pericardial effusions require a multimodal imaging approach.

Abstract 13693: Left Atrial Sarcoma Mimicking Myxoma in Embolic Stroke

Background: Myxomas cause about 0.5% of strokes. Cardiac sarcomas are rare, may mimic myxomas, and are also associated with stroke. Imaging can provide clues to diagnosis. Case: A 53-year-old woman with diabetes, hypertension and prior strokes was admitted with new left hemiparesis. Computed tomography (CT) of the head revealed large middle cerebral artery infarct with petechial hemorrhages. Transthoracic echocardiogram (TTE; panel A) revealed large left atrial (LA) mass suspicious for myxoma protruding through the mitral valve. CT of the chest (panel B) revealed hilar adenopathy and LA mass concerning for myxoma or thrombus with stalk attachment to the right pulmonary vein (PV). Decision-making: Following heart team meeting decision was to remove the mass surgically given its embolic potential. Intraoperative transesophageal echocardiogram (TEE; panel C) revealed a large LA mass with multiple papillary protrusions and attachment via a stalk to the right lower PV. The mass was successfully removed and the patient recovered and was discharged. Follow up pathology returned as cardiac sarcoma. Conclusion: Pulmonary vein intimal sarcomas are rare tumors with poor prognosis, presenting early with chest pain, dyspnea and hemoptysis, or late with stroke. They can mimic myxomas and are therefore often diagnosed post-operatively. Preoperative diagnosis however is imperative to plan treatment and for prognostication. TEE and cardiac magnetic resonance imaging are the modalities of choice to diagnose sarcomas and evaluate extent of cardiac structure involvement.

Study of right ventricular outflow tract gradient in immediate postoperative period following intracardiac repair for tetralogy of Fallot

ABSTRACT Background: Surgical repair of tetralogy of Fallot (TOF) consists of adequate ventricular septal defect closure and relief of right ventricular outflow tract (RVOT) obstruction to the greatest extent possible. The residual RVOT gradient can be due to dynamic and fixed obstruction, and high gradient is sometimes seen even after a satisfactory RVOT resection often confirmed with intraoperative TransEsophageal Echocardiogram (TEE). Aim: The present study was conducted to study the changes in RVOT residual gradient in the early postoperative period. We analyzed the change in residual gradient by invasive monitoring intraoperatively after separating from cardiopulmonary bypass (CPB) in a case of intracardiac repair (ICR) for TOF and compared the readings 24 h after extubating the patients in intensive care unit (ICU). Materials and Methods: This was an observation study done in the Department of CTVS, Advanced Cardiac Centre, PGIMER, and Chandigarh from February 2018 to March 2019. A total of thirty patients with preoperative diagnosis of TOF were included in the study. After ICR for TOF, postseparation from CPB, RVOT gradient was measured using 23G needle connected to pressure transducer and compared with RVOT gradient measured 24 h postextubating using invasive line kept intraoperatively in pulmonary artery and RVOT. Results: There was a significant decrease in residual RVOT gradient postoperatively in ICU after 24 h of extubating, in comparison to intraoperative postbypass residual RVOT gradient. Postbypass residual RVOT gradient was 11.33 ± 1.39 that decreased to 7.81 ± 1.29 24 h after extubating (P &lt; 0.05). Patients in whom pulmonary valve was preserved had greater postbypass residual RVOT gradient (12.44 ± 1.13) than patients with transannular patch (10.5 ± 0.90). However, both decreased after 24 h of extubating (9 ± 0.7 and 6.9 ± 0.8, respectively). Conclusion: Once satisfactory RVOT resection for fixed obstruction is done and is confirmed using TEE, the residual gradient, if marginally high, can be ignored as residual gradient significantly decreases after extubation and hemodynamic improvement is seen in postoperative period.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Cocaine user with chest pain.

A 52-year-old male presented to the emergency department with a past medical history of active cocaine use and a chief complaint of chest pain that radiated to the back. Physical exam revealed a well-appearing, comfortable male with normal cardiac sounds, regular rate and rhythm, bilateral equal pulses in all four extremities, and intact motor and sensation in the extremities. A bedside ultrasound was performed and revealed an ascending aorta dissection (Figure 1 and Video 1). This was confirmed on intraoperative transesophageal echocardiogram that demonstrated the proximity of the aortic dissection flap to the aortic valve (Figure 2). Computed tomography angiography (CTA) of the chest confirmed the diagnosis of Stanford A (type 1) aortic dissection extending from the supravalvular region to the level of the renal arteries. The patient was placed on nicardipine and esmolol drips and cardiothoracic surgery was emergently consulted. The patient underwent surgery where he had an intraoperative transesophageal echocardiogram, stenting of the aortic root, ascending aorta, and descending aorta. He recovered from his surgery and was ultimately discharged to home. Aortic dissection is a relatively rare disease with an estimated global death rate of 2.78 per 100,000.1 The diagnosis is typically made with CTA of the chest. Thoracic aortic dissection is classified into two categories: Stanford type A that involves the proximal ascending aorta before the left subclavian and Stanford type B that involves the aorta only distal to the left subclavian.2 The treatment of aortic dissection includes blood pressure and heart rate reduction. Early surgical consultation is important because type A aortic dissection is a true surgical emergency.

Left Atrioventricular Transvalvular Pressure Gradients Derived from Intraoperative and Postoperative Echocardiograms following Atrioventricular Septal Defect Repair.

Left atrioventricular valve (LAVV) stenosis following an atrioventricular septal defect (AVSD) repair is a rare but potentially life-threatening complication. While echocardiographic quantification of diastolic transvalvular pressure gradients is paramount in the evaluation of a newly corrected valve function, it is hypothesized that these measured gradients are overestimated immediately following a cardiopulmonary bypass (CPB) due to the altered hemodynamics when compared to postoperative valve assessments using awake transthoracic echocardiography (TTE) upon recovery after surgery. Out of the 72 patients screened for inclusion at a tertiary center, 39 patients undergoing an AVSD repair with both intraoperative transesophageal echocardiograms (TEE, performed immediately after a CPB) and an awake TTE (performed prior to hospital discharge) were retrospectively selected. The mean (MPGs) and peak pressure gradients (PPGs) were quantified using a Doppler echocardiography and other measures of interest were recorded (e.g., a non-invasive surrogate of the cardiac output and index (CI), left ventricular ejection fraction, blood pressures and airway pressures). The variables were analyzed using the paired Student's t-tests and Spearman's correlation coefficients. The MPGs were significantly higher in the intraoperative measurements when compared to the awake TTE (3.0 ± 1.2 vs. 2.3 ± 1.1 mmHg; p < 0.01); however, the PPGs did not significantly differ (6.6 ± 2.7 vs. 5.7 ± 2.8 mmHg; p = 0.06). Although the assessed intraoperative heart rates (HRs) were also higher (132 ± 17 vs. 114 ± 21 bpm; p < 0.001), there was no correlation found between the MPG and the HR, or any other parameter of interest, at either time-point. In a further analysis, a moderate to strong correlation was observed in the linear relationship between the CI and the MPG (r = 0.60; p < 0.001). During the in-hospital follow-up period, no patients died or required an intervention due to LAVV stenosis. The Doppler-based quantification of diastolic transvalvular LAVV mean pressure gradients using intraoperative transesophageal echocardiography seems to be prone to overestimation due to altered hemodynamics immediately after an AVSD repair. Thus, the current hemodynamic state should be taken into consideration during the intraoperative interpretation of these gradients.

Improved Right Ventricular Diastolic Function Assessed by Hepatic Vein Flow After Pectus Excavatum Repair

BackgroundThe cardiovascular benefits of surgical repair in pectus excavatum (PEx) continue to be debated, with limited data supporting repair in adult patients. Hepatic vein flow is used to identify right-sided diastolic dysfunction in cardiovascular disorders, including tricuspid stenosis, cardiac tamponade, and constrictive pericarditis. This study evaluates the effects of cardiac compression on diastolic function (as assessed by hepatic vein flow patterns and velocities) before and after repair of PEx. MethodsA retrospective study was performed of intraoperative transesophageal echocardiograms including hepatic vein assessments of adult patients who underwent preoperative and postoperative evaluations during repair of PEx from 2018 to 2021. ResultsIn total, 127 patients were included (median age, 29.0 [15.4] years; median Haller index, 4.2 [1.7]; 60.6% male). Statistically significant improvements were seen after pectus repair of right ventricular stroke volume and diastolic function as measured by increased postoperative velocities for hepatic vein waves (P < .001 for all comparisons). Preoperatively, 5.5% of patients had constrictive-like physiology with end-diastolic retrograde flow that normalized postoperatively (P = .016). Approximately 10% of patients changed their pattern of hepatic vein flow after surgical procedure. Patients with more proximal cardiac compression had greater improvements in hepatic vein velocities after repair. ConclusionsSurgical relief of cardiac compression resulted in an immediate improvement in hepatic vein flow and right ventricle stroke volume in patients with PEx. These results support diastolic dysfunction in a large number of patients, with improvement in function and compliance after the surgical relief of cardiac compression.

Comparison of Echocardiographic and Catheter Mean Gradient to Assess Stenosis After Transcatheter Aortic Valve Implantation

Discordance exists between Doppler-derived and left heart catheterization (LHC)-derived mean gradient (MG) in transcatheter aortic valve implantation (TAVI). We compared echocardiographic parameters of prosthetic valve stenosis and LHC-derived MG in new TAVIs. In a retrospective, single-center study, intraoperative transesophageal echocardiogram (TEE)-derived MG, LHC-derived MG, and acceleration time (AT) were obtained before and after TAVI in 362 patients. Discharge MG, AT, and Doppler velocity index (DVI) using transthoracic echocardiogram (TTE) were also obtained. MG ≥10 mm Hg was defined as abnormal. During native valve assessment with pre-TAVI TEE and pre-TAVI LHC, Pearson correlation coefficient revealed a nearly perfect linear relation between both methods' MGs (r=0.97, p <0.0001). Intraoperatively, after TAVI, Spearman correlation coefficient revealed a weak-to-moderate relation between post-TAVI TEE and LHC MGs (r=0.33, p <0.0001). Significant differences were observed in categorizations between post-TAVI TEE MG and post-TAVI AT (McNemar test p=0.0003) and between post-TAVI TEE MG and post-TAVI LHC MG (signed-rank test p <0.0001), with TEE MG more likely to misclassify a patient as abnormal. At discharge, 30% of patients had abnormal TTE MG, whereas 0% and 0.8% of patients had abnormal DVI and AT, respectively. Discharge TTE MG was not associated with death or hospitalization for heart failure at a median follow-up of 862days. Post-TAVI Doppler-derived MG by intraoperative TEE was higher than LHC, despite being virtually identical before implantation. At discharge, patients were more likely to be classified as abnormal using MG than DVI and AT. Elevated MG at discharge was not associated with death or hospitalization for heart failure.

Complications Associated With Transesophageal Echocardiography in Transcatheter Structural Cardiac Interventions

Transesophageal echocardiograms (TEEs) performed during transcatheter structural cardiac interventions may result in greater complications than those performed in the nonoperative setting or even those performed during cardiac surgery. However, there are limited data on complications associated with TEE during these procedures. We evaluated the prevalence of major complications among these patients in the United States. A retrospective cohort study was conducted using an electronic health record database (TriNetX Research Network) from large academic medical centers across the United States for patients undergoing TEE during transcatheter structural interventions from January 2012 to January 2022. Using the American Society of Echocardiography-endorsed International Statistical Classification of Diseases and Related Health Problems Clinical Modifications (10th edition) codes, patients undergoing TEE during a transcatheter structural cardiac intervention, including transaortic, mitral or tricuspid valve repair, left atrial appendage occlusion, atrial septal defect closure, patent foramen ovale closure, and paravalvular leak repair, were identified. The primary outcome was major complications within 72hours of the procedure (composite of bleeding and esophageal and upper respiratory tract injury). The secondary aim was the frequency of major complications, death, or cardiac arrest within 72hours in patients who completed intraoperative TEE during surgical valve replacement. Among 12,043 adult patients (mean age, 74years old; 42% female) undergoing TEE for transcatheter structural cardiac interventions, 429 (3.6%) patients had a major complication. Complication frequency was higher in patients on anticoagulation or antiplatelet therapy compared with those not on therapy (3.9% vs 0.5%; risk ratio [RR]= 8.09, P<.001). Compared with those patients <65years of age, patients ≥65years of age had a higher frequency of major complications (3.9% vs 2.2%; RR= 1.75, P<.001). Complication frequency was similar among male and female patients (3.5% vs 3.7%; RR= 0.96, P=.67). Among 28,848 patients who completed surgical valve replacement with TEE guidance, 728 (2.5%) experienced a major complication. This study found that more than 3% of patients undergoing TEE during transcatheter structural cardiac interventions have a major complication, which is more common among those on anticoagulant or antiplatelet therapy or who are elderly. With a shift of poor surgical candidates to less invasive percutaneous procedures, the future of TEE-guided procedures relies on comprehensive risk discussion and updating practices beyond conventional methods to minimize risk for TEE-related complications.

Abstract 15639: Infected Thrombus - An Unusual Etiology of Acute Coronary Syndrome in a Patient With New Onset Atrial Fibrillation

Background: Coronary embolism (CE) is an uncommon (3%) cause of acute coronary syndromes (ACS) and is often missed. Case Presentation: A 68-year-old woman with a h/o hypertension &amp; breast cancer post lumpectomy 10 yrs ago, presented with generalized weakness, fever (101F), &amp; vomiting without chest pain, dyspnea, or palpitations. She was afebrile, tachycardic (158 beats/min), tachypneic (26 breaths/min) with BP of 98/64 mmHg. Cardiac exam revealed irregularly irregular rhythm, 5 cm jugular venous distension &amp; 3+ bilateral pretibial edema. Labs revealed thrombocytopenia, lactic acidosis, &amp; hyponatremia. High sensitivity-Troponin was 1023 &amp; NT-pro-BNP 19854. EKG showed atrial fibrillation (AF), diffuse ST elevations in the precordial leads &amp; aVR, poor R wave progression &amp; inferior Q waves. Her cardiac cath revealed a large thrombus from mid-left main extending into the LAD with minimal atherosclerotic burden. Intraoperative transesophageal echocardiogram for emergent surgical resection of the thrombus revealed a highly mobile thrombus 2.32x0.6 cm on the aortic aspect originating between L and R coronary cusps and a left atrial appendage thrombus (1.1 cm) with marked spontaneous contrast in LA appendage &amp; LA which was surgically resected. Blood cultures &amp; of coronary thrombus grew Methicillin sensitive Staphylococcus Aureus (MSSA) . Anticoagulation &amp; appropriate antibiotics were initiated. but after a protracted, complicated ICU stay, patient was made comfort care. Discussion/Conclusion: CE should be considered in cases of recurrent coronary thrombus or in the setting of heavy thrombus burden despite a relatively normal coronary vessel. AF is the most common underlying cause of CE causing ACS. Aspiration or surgical thrombectomy should be performed with a high thrombus burden. Thrombus should be sent for pathology to further delineate the source of thrombus.

Abstract 9492: Transcatheter Amplatzer Occluder Device Closure of Post-Myocardial Infarct Pseudoaneurysm: A Case Report

Introduction: Left Ventricular Pseudoaneurysm (LVP) is defined as cardiac wall rupture leading to a formation of wall with thrombus, pericardial, or scar tissue functioning as a pouch for blood. A loculated pericardial effusion (LPE), and right ventricular pericardial fistula (RVPF) have never been reported in literature. Here, we report the first case of a 70 year old male who developed a LVP, LPE, and RVPF. Case Description: A 70 year old male with a past medical history of hypertension presented with inferior wall STEMI. Cardiac catheterization demonstrated left anterior descending (LAD) with 80% occlusion and right coronary artery (RCA) with 100% occlusion. Percutaneous intervention of RCA with aspiration thrombectomy and two drug eluting stents was performed. Echocardiogram the following day demonstrated a LVP. A transesophageal echocardiogram (TEE) demonstrated LVP near the mid-inferior interventricular septum draining into the pericardial space, and LPE from the apical inferior left ventricle (LV) extending to the apical cap of the right ventricle (RV). Computed tomography angiography (CTA) demonstrated a multiloculated collection at the inferior septal aspect of LV contained by the pericardial space. Patient was a high risk for surgery. LVP was closed via a 24 mm atrial septal defect (ASD) occluder device. Intraoperative TEE demonstrated an ASD occluder device at the mid inferior septum at the location of the LVP neck with minimal residual flow into the LPE and a fistula connecting the LPE space with RV. RVFP was managed conservatively. LAD was managed medically. Patient was discharged home safely on guideline directed medical therapy. Discussion: LVP rate is 0.0026% following myocardial injury. It is reported that untreated LVP have a rupture risk of about 30% and a mortality rate of 50%. Prompt treatment is required to prevent mortality. Surgical management is the standard of care. A multidisciplinary heart team deemed the patient a high risk. Therefore, transcatheter treatment was sought in the patient above. Conclusions: Surgical treatment is standard of care for LVP, but transcatheter wall closure with an ASD device is a promising technique not only for high-risk surgical candidates such as above, but as a gold standard of treatment for LVP.

Immediately improved LA function demonstrated with pulmonic vein Doppler-intraoperative TEE in TAVR patients

Abstract Background Recent studies exhibited the immediately improved left atrium (LA) function by Doppler mitral inflow and mitral annular velocity by tissue Doppler and left atrial appendage flow velocity. This study aims to investigate the improvement of LA function by pulmonic vein Doppler parameters performing by an intraoperative transesophageal echocardiogram (TEE) during transcatheter aortic valve replacement (TAVR). Material and methods Patients who underwent TAVR from January 2020 to September 2021 and pulmonic vein Doppler were acquired by TEE (right upper pulmonic vein from 90–110° mid-esophageal view) during TAVR with the explicit image. We obtained S-, D-, A-wave velocity; LV end-diastolic pressure (LVEDP) and mean pressure gradient across aortic valve (mean-AVPG) from invasive catheter both pre-TAVR and immediate post-TAVR. All parameters between pre-TAVR and post-TAVR were compared with paired t-test. Results 38 patients (mean age 79.7±5.6 years, 17 female) were enrolled in this study. S-wave was only significant parameter with increased velocity from baseline (30.3±24.6 cm/s vs 50.2±23.2 cm/s, p&amp;lt;0.001), whereas D-wave and A-wave were not significantly changed from baseline (35.1±15.2 cm/s vs 33.7±11.0 cm/s, p=0.6; and 14.3±8.6 cm/s vs 13.0±8.9 cm/s, p=0.4, respectively). LVEDP was not significantly changed from baseline (19.6±9.5 mmHg vs 18.7±8.1 mmHg, p=0.49) but mean-AVPG was significantly decreased after TAVR (53.8±11.8 mmHg vs 6.1±5.6 mmHg, p&amp;lt;0.001). We also noted 25 patients who had S/D ratio &amp;lt;1 at baseline, 19 of 25 patients were changed to S/D ratio &amp;gt;1 immediately post TAVR. Conclusion This study demonstrated the improved LA function with pulmonic vein Doppler after TAVR. S-wave is the only parameter to be improvement immediately post TAVR and change to S/D ratio &amp;gt;1 in majority of patients. Funding Acknowledgement Type of funding sources: None.

Large Free-Floating Right Atrial Thrombus

We present the images of a 67-year-old man who came to the emergency department with bilateral lower extremity pain and shortness of breath. Our images include an intraoperative transesophageal echocardiogram that shows a large, continuous free-floating right atrial mass and a large 31 cm × 1 cm thrombus that was successfully extracted. The thrombus likely could not embolize because of the patient's severe heart failure.

Right ventricular volume-strain loops using 3D echocardiography-derived mesh models: proof-of-concept application on patients undergoing different types of open-heart surgery.

Right ventricular (RV) function can be quantified by right heart catheterization-derived pressure-volume loops. While this technique is invasive, echocardiography-based volume-strain loops (VSLs) potentially reflect a non-invasive alternative. In this study, an approach to generate VSLs from volume and multidimensional strain data of 3D echocardiography-derived RV mesh models is evaluated with regard to feasibility and reproducibility. In a retrospective cohort study design, 3D intraoperative transesophageal echocardiograms of twenty-three patients undergoing aortic valve surgery (AVS) and eighteen patients undergoing off-pump coronary artery bypass (OPCAB) grafting were available prior to sternotomy and after sternal closure. RV meshes were generated using 3D speckle-tracking. Custom-made software quantified the meshes' volumes, global longitudinal (RV-GLS) and global circumferential strain (RV-GCS) for VSL generation. Linear regression of systolic VSLs yielded slopes, intercepts and systolic areas. Polynomial regression of two orders was used to analyze systolic-diastolic coupling at 10% increments of the RV end-diastolic volume (RVEDV). Reproducibility was analyzed by fourfold double-measurements of four datasets. VSL calculation was feasible from all included 3D datasets. RV-GLS remained unaltered, but RV-GCS worsened in AVS [abs. diff. (∆) 3.9%, P<0.01] and OPCAB patients (∆4.5%, P<0.001). While RV-GCS systolic areas were markedly reduced at the end of AVS (∆268mL%, P<0.01) and OPCAB (∆185mL%, P<0.001), RV-GCS slopes did not change. Systolic-diastolic uncoupling was not observed, but in trend, decreased diastolic RV-GCS after AVS (P=0.06) and increased diastolic RV-GCS after OPCAB (P=0.06) were observed. Intraclass correlation coefficients (0.84-0.98) and coefficients of variation (6.4-11.8%) indicated good reproducibility. RV VSL generation using 3D echocardiography-derived mesh models is feasible. Longitudinal and circumferential strain vectors yield intrinsically different VSL indices. In future investigations, VSLs of multidimensional strains could provide further insight into periprocedural changes of RV mechanics.

Acute Right Ventricular Failure Immediately Following Subxiphoid Pericardial Window Requiring Temporary Cardiopulmonary Bypass Support: A Case Report of Pericardial Decompression Syndrome

Cardiac tamponade is a life-threatening condition requiring emergent intervention, such as a pericardial window, to drain the pericardial effusion, subsequently improving cardiac output. A rare complication of this procedure is pericardial decompression syndrome which results in a paradoxical cardiovascular collapse. A 65-year-old male with bacterial endocarditis status posts mitral and aortic valve replacement presented for an emergent subxiphoid pericardial window to relieve cardiac tamponade. After draining 850mL of pericardial fluid, the patient suffered a cardiac arrest secondary to acute right ventricular failure seen on an intraoperative transesophageal echocardiogram (TEE). Despite manual compressions and high-dose vasopressors, hemodynamics did not improve, and the patient was emergently placed on cardiopulmonary bypass (CPB) support. Within two hours, CPB support was successfully weaned. Temporary CPB can improve acute right ventricular failure following pericardial decompression without needing longer-term extracorporeal support.