Transesophageal Echocardiography Research Articles

Découverte fortuite d’un Fibroélastome Mitro-aortique

Papillary fibroelastoma is a rare, benign primary tumor that can remain asymptomatic for a long time. The clinical presentation can include embolic events (ischemic stroke, mesenteric ischemia, limb ischemia) or valvular obstruction. The diagnosis is made using transthoracic and transesophageal echocardiography, as well as cardiac MRI. Surgical treatment is the only curative therapeutic option, preventing the risk of embolic recurrence. We report the case of a 65-year-old diabetic female patient hospitalized in neurology due to a hemorrhagic stroke, who was referred to cardiology for an etiological workup. The patient had untreated, previously unknown hypertension, which was the cause of the cerebral hemorrhage. In the echocardiogram, we found two masses : one on the anterior mitral valve and the other on the anterior right aortic sigmoid valve. A mitro-aortic fibroelastoma was suspected and confirmed by cardiac MRI. This is a serendipitous discovery of this benign tumor. We will review this rare entity, its diagnostic modalities, and therapeutic approaches.

Management and outcome of high-risk pulmonary embolism in intensive care units: results from a retrospective single-center analysis

Abstract Funding Acknowledgements None. Background High-risk pulmonary embolism (PE) patients are exposed to hemodynamic/multiorgan compromise including hypotension, cardiogenic shock and/or cardiac arrest (CA). Few data exist on management and outcome in patients admitted to intensive care units (ICU) with high-risk PE. Purpose We sought to analyse the epidemiology, management and outcome of patients admitted to ICU due to high-risk PE. Methods Retrospective monocentric analysis of adult patients with high-risk PE admitted from 2017 to 2023; COVID-19 patients were excluded. Demographic, clinical presentation, management and outcome data have been collected. Descriptive analysis comparing means adjusted for organ involvement severity and Cox regression were performed. Results 85 patients (55 male, 63±12 years old, BMI 29.06± 6) were included in the analysis. All patients received the diagnosis through the computed tomography angiography except 4 of them who underwent extra-corporeal cardiopulmonary resuscitation (eCPR) and the diagnosis was made with trans-oesophageal echocardiography. Overall mortality was 32%, eCPR rate was 9%. 92% were treated with adrenergic drugs (norepinephrine 78%, dobutamine 65%, epinephrine 35%); 7 patients required VA-ECMO due to CA. 42 patients received mechanical ventilation (MV) during the first 12 hours; those patients had higher rate of CS (p <0.001), higher lactates (mean difference 1.45±3.2; p <0.001), higher SOFA and SAPS II scores (respectively, mean difference 12.5±0.49 and 7.9±3.4; p 0.004). 75 patients underwent systemic thrombolysis. 10 patients with contraindication to systemic thrombolysis, underwent catheter directed thrombolysis (CDT); in 6 cases CDT was preceded by mechanical suction thrombectomy. Patients undertaking CDT had higher SOFA score at admission (mean difference 2.45±1.6; p 0.04), worsen creatinine (p <0.001), lower PaCO2 (mean difference -0.54±5.3; p 0.01), higher PaO2 (mean difference 28.7±6.5; p 0.009), higher bilirubin (mean difference 3.2±1.6; p <0.001) and lower systolic blood pressure (mean difference -6.8±3.36; p 0.01). At the Cox regression, higher lactates (HR 1.45 [0.40-0.99], p 0.004, panel A), lower glomerular filtration rate (HR 1.1 [1.02-1.09], p 0.001, panel B), higher bilirubin (HR 2.6 [1.20-6.03,] p 0.016), higher ALT (HR 1.07 [0.95-0.99], p 0.04), lower PaO2/FiO2 ratio (HR 1.1 [0.97-0.99], p 0.024, panel C), MV (HR 1.1 [0.78-7.58], p 0.04, panel D) and VA-ECMO (HR 2.5 [1.25-3.54], p 0.002) were associated with increased mortality; CDT was associated with lower mortality (HR 0.82 [0.68-1.89], p 0.04). Conclusions High-risk PE was burdened by high mortality. Signs of worsen organ failure and respiratory and mechanical support are associated with increased mortality. In this monocentric population the use of CDT was performed when systemic thrombolysis contraindicated and it was associated with favourable outcome, although the small sample (10%) should warn contextualization in results’ interpretation.

Transesophageal echocardiography before atrial fibrillation ablation: To do or not to do?

Transesophageal echocardiography before atrial fibrillation ablation: To do or not to do?

Anomalous circumflex artery encircling the aortic annulus: implications for mitral valve repair

Injury to coronary arteries during mitral surgery is a rare but life-threatening procedural complication, an anomalous origin and course of the left circumflex artery (LCx) increase this risk. Recognizing the anomaly by the characteristic angiographic pattern and identifying its relationship with the surrounding anatomical structure using imaging techniques, mainly transesophageal echocardiography (TOE) or coronary computed tomography angiography (CCTA), is of crucial importance in setting up the best surgical strategy. We report a case of anomalous origin of a circumflex artery (LCx) from the proximal portion of the right coronary artery (RCA) with a pathway running retroaortically through the mitro-aortic space. An integrated diagnostic approach using a multidisciplinary team with a cardiologist and an imaging radiologist allowed us to decide the surgical strategy. We successfully performed a mitral valvular repair using a minimally invasive minithoracotomic approach and implanting a complete semirigid ring.

Lipomatous Interatrial Septum Detected During Cardioversion Evaluation for Atrial Fibrillation

Primary cardiac tumors are rare, with an estimated prevalence in autopsy series ranging from 0,001 to 0,28%. Benign tumors are the most common type, with lipoma being the second most frequent among these, following myxoma. Lipoma can pose a differential diagnostic problem with lipomatous hypertrophy of the interatrial septum (IAS). This entity is rare and often asymptomatic, requiring no surgical treatment unless it causes obstruction of surrounding anatomical structures. In practice, cardiac CT and MRI are frequently used to confirm echocardiographic suspicions, both transthoracic and transesophageal. We present the case of a 72-year-old patient referred for management of recent atrial fibrillation, with heart rate control proving difficult despite maximum dose medical treatment. We opted for electrical cardioversion to improve the patient's hemodynamic state in the short term and to prevent progression to atrial cardiomyopathy in the medium and long term. In the transesophageal echocardiogram (TEE), the patient exhibited significant thickening of the interatrial septum, measuring 22 mm, without compression of the superior vena cava, and with the fossa ovalis remaining intact. Through this case, we discuss the diagnostic and therapeutic approaches to lipomatous hypertrophy of the IAS.

Upper gastrointestinal bleeding after transesophageal echocardiography—common things are common?

Upper gastrointestinal bleeding after transesophageal echocardiography—common things are common?

An unusual presentation of subacute Haemophilus parainfluenzae endocarditis in a low-risk woman treated by minimally invasive mitral valve repair: a case report

BackgroundHACEK endocarditis is usually insidious and can often be difficult to diagnose due to the slow-growing nature of the organisms. This report presents our experience in treating a patient with Haemophilus parainfluenzae endocarditis.Case presentationWe describe the case of a previously fit and well 23 year-old woman who presented to her local emergency department with a four-week history of persistent febrile illness. She had associated nausea, vomiting, and lethargy. This was preceded by an episode of mucopurulent rhinorrhoea. She was treated empirically with oral amoxicillin for a putative diagnosis of rhinosinusitis. Initially, her symptoms abated, however, she was readmitted with high fevers and a new pansystolic murmur. Transthoracic echocardiography revealed a large, mobile, echogenic mass, tethered to the posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (MR). On examination, she had multiple non-tender, erythematous macules on the plantar surface of her feet, consistent with Janeway lesions. Two separate blood cultures grew H. parainfluenzae. Infectious diseases recommended a four-week course of intravenous ceftriaxone. Transesophageal echocardiography demonstrated a perforation within the P3 segment of the PMVL. Subsequently, the patient underwent mitral valve repair surgery with an uneventful recovery.ConclusionsOur case highlights the importance of promptly diagnosing HACEK endocarditis. A prolonged course of antibiotic therapy can be lifesaving, and surgery is often necessary to address complications such as perforation within the mitral valve leaflets. In our patient, we were able to perform a sliding P2 leaflet plasty for good quality repair of the mitral valve, through a minimally invasive right anterior thoracotomy.

Mycotic pulmonary artery pseudoaneurysm following total arch replacement: a case report

BackgroundAlthough the true prevalence and incidence are not clearly known, mycotic pulmonary artery aneurysm is a potentially devastating condition that leads to high mortality, over 60% if untreated. Among them, mycotic pulmonary artery pseudoaneurysm, which occurs in relatively central areas, has rarely been reported. We report an extremely rare case of a late complication with a mycotic pulmonary artery pseudoaneurysm, presumably due to infective endocarditis, in a 68-year-old woman 4 months after total arch replacement.Case presentationA 68-year-old woman was referred to our department for 2 weeks with fever of unknown origin. She had a history of emergency total arch replacement for an acute type A aortic dissection 4 months earlier and chronic rheumatoid arthritis on monthly subcutaneous tocilizumab treatment for several years. Blood culture was positive for Enterococcus faecalis. Transthoracic and transesophageal echocardiography revealed a left ventricular ejection fraction of 58%, severe mitral regurgitation with a 15-mm diameter vegetation on the anterior mitral leaflet, and severe aortic insufficiency with string-like structures. Contrast computed tomography showed a focal saccular outpouching from the right pulmonary artery. On 18F-fluorodeoxyglucose (FDG) positron emission tomography, focal uptake of FDGs was observed along the same lesion of the pulmonary artery and ascending-arch graft. The patient eventually recovered after the surgical intervention of mitral and aortic valve replacement, re-total arch replacement, pulmonary artery repair, application of omental flap, and antibiotics without any evidence of re-infection after 1 year.ConclusionsWe report a successful surgical repair of mycotic pulmonary artery pseudoaneurysm 4 months after total arch replacement for acute type A aortic dissection. This report describes an effective treatment for an extremely rare postoperative condition.

Valvulitis: un nuevo criterio ecocardiográfico para el diagnóstico de endocarditis infecciosa de bioprótesis de válvula aórtica

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Impact of Left Atrial Appendage Flow Velocity on Thrombus Resolution and Clinical Outcomes in Patients with Atrial Fibrillation and Silent Left Atrial Thrombi: Insights from the LAT Study.

Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk. However, its impact on LA thrombus resolution and clinical outcomes remains unclear. The LAT study was a multicenter observational study investigating patients with atrial fibrillation (AF) and silent LA thrombi detected by transesophageal echocardiography (TEE). Among 17,436 TEE procedures for patients with AF, 297 patients (1.7%) had silent LA thrombi. Excluding patients without follow-up examinations, we enrolled 169 whose baseline LAAFV was available. Oral anticoagulation use increased from 85.7% at baseline to 97.0% at the final follow-up (p < 0.001). During 1-year, LA thrombus resolution was confirmed in 130 (76.9%) patients within 76 (34-138) days. Conversely, 26 had residual LA thrombi, 8 had thromboembolisms, and 5 required surgical removal. These patients with failed thrombus resolution had lower baseline LAAFV than those with successful resolution (18.0 [15.8-22.0] vs. 22.2 [17.0-35.0], p = 0.003). Despite limited predictive power (area under the curve, 0.659; p = 0.001), LAAFV ≤20.0 cm/s (best cutoff) significantly predicted failed LA thrombus resolution, even after adjusting for potential confounders (odds ratio, 2.72; 95% confidence interval, 1.22-6.09; p = 0.015). The incidence of adverse outcomes including ischemic stroke/systemic embolism, major bleeding, or all-cause death was significantly higher in patients with reduced LAAFV than in those with preserved LAAFV (28.4% vs. 11.6%, log-rank p = 0.005). Failed LA thrombus resolution was not rare in patients with AF and silent LA thrombi. Reduced LAAFV was associated with failed LA thrombus resolution and adverse clinical outcomes.

Proteomic biomarkers for noninvasive left atrial appendage thrombus prediction in patients with atrial fibrillation

IntroductionThe CHA2DS2-VASc score, used to assess the risk of left atrial appendage thrombus (LAAT) formation in patients with atrial fibrillation (AF), has limited predictive value. Moreover, transesophageal echocardiography imaging, the gold standard diagnostic method to identify thrombi, is semi-invasive. Consequently, there is a need for alternative and noninvasive diagnostic methods for LAAT risk assessment. MethodsDeep proteomic analysis was conducted in plasma samples from 8 patients with nonvalvular AF, divided into thrombus and control groups (4 patients in each group) based on the presence or absence of LAAT. Biomarkers associated with LAAT were validated using an enzyme-linked immunosorbent assay in a cohort of 179 patients with available clinical, transthoracic, and transesophageal echocardiography data. Predictive models were developed to assess the improvement in LAAT identification. ResultsThe LAAT group had higher CHA2DS2-VASc scores, larger LA diameter, and lower LAA flow velocities. Deep proteomic analysis identified 30 differentially expressed proteins, including myosin light chain 4, prenylcysteine oxidase 1 (PCYOX1), and decorin as potential diagnostic biomarkers of LAAT. The model showed that PCYOX1 and decorin provided an area under the curve (AUC) of 0.970 for LAAT prediction compared with 0.672 in a model including the CHA2DS2-VASc score and LAA cauliflower morphology. The incremental value of proteomic biomarkers for LAAT in patients with nonvalvular AF was further confirmed with the net reclassification improvement and integrated discrimination improvement indices. ConclusionsProtein levels of PCYOX1 and decorin improve the predictive performance for LAAT in patients with nonvalvular AF.

C-6 | Safety of transesophageal echocardiography in patients referred for tricuspid valve disease prior to structural cardiac interventions

C-6 | Safety of transesophageal echocardiography in patients referred for tricuspid valve disease prior to structural cardiac interventions

Abnormal Color Flow Jet in Left Ventricular Outflow Tract Mimicking a Ventricular Septal Defect: Establishing Differentials and Diagnosis and Role of Transesophageal Echocardiography.

Abnormal Color Flow Jet in Left Ventricular Outflow Tract Mimicking a Ventricular Septal Defect: Establishing Differentials and Diagnosis and Role of Transesophageal Echocardiography.

Contemporary Valvular Mechanisms of Aortic Regurgitation in Tricuspid Aortic Valves: Importance in Repair Versus Replacement Strategy.

This study was performed to determine cusp causes of aortic regurgitation in patients with tricuspid aortic valves without significant aortic dilatation and define cusp pathologies amenable to surgical repair (aortic valve repair [AVr]) versus aortic valve replacement. We retrospectively reviewed surgical reports of consecutive adults with tricuspid aortic valves undergoing surgery for clinically significant aortic regurgitation within a prospective registry from January 2005 to September 2019. Valvular mechanisms were determined by systematic invivo intraoperative quantification methods. Of 516 patients, 287 (56%) underwent repair (AVr; mean±SD age, 59.9±12.4 years; 81% men) and 229 (44%) underwent replacement (aortic valve replacement; mean±SD age, 62.8±13.8 years [P=0.01 compared to AVr]; 67% men). A single valvular mechanism was present in 454 patients (88%), with cusp prolapse (46%), retraction (24%), and perforation (18%) being the most common. Prolapse involved the right cusp in 86% of cases and was more frequent in men (P<0.001). Two-dimensional transesophageal echocardiography accuracy for predicting mechanisms was 73% to 82% for the right cusp, 55% to 61% for the noncoronary cusp, and 0% for the left-coronary cusp. Cusp prolapse, younger age, and larger patient size were associated with successful AVr (all P<0.03), whereas retraction, perforation, older age, and concomitant mitral repair were associated with aortic valve replacement (all P<0.03). Right cusp prolapse is the most frequent single valvular mechanism in patients with tricuspid aortic valve aortic regurgitation, followed by cusp retraction and perforation. The accuracy of 2-dimensional transesophageal echocardiography is limited for left and noncoronary cusp mechanistic assessment. Prolapse is associated with successful AVr, whereas retraction and perforation are associated with aortic valve replacement. With systematic intraoperative quantification methods and current surgical techniques, more than half of tricuspid aortic valve aortic regurgitation cases may be successfully repaired.

Serum 25(OH)D Levels and Mitral Valve Calcification in Patients with Severe Rheumatic Mitral Stenosis

Background: Rheumatic heart disease (RHD) imposes a significant burden on patients and the health system, especially in the developing countries. Recently, the role of vitamin D deficiency in increasing the severity of valve involvement and calcification in patients with RHD has been suggested. However, its role in the severe stenosis of the mitral valve is unknown. The aim of this study was to determine the relationship between serum levels of 25(OH)D and mitral involvement severity scores in patients with severe mitral stenosis (MS). Materials and Methods: In this cross-sectional study conducted in Shahid Madani Heart Center, Tabriz, Iran, 104 patients with severe rheumatic MS were reviewed, in the absence of other underlying diseases. Trans-esophageal Echocardiography was performed for all patients, and mitral valve Wilkins score and mitral valve area were calculated. Blood samples were taken from patients and levels of 25(OH)D, total calcium, phosphorus, and i-PTH were measured. Results: Eighty eight cases were female and 16 were male. Eighty-one patients had mild to moderate mitral calcification and in 23 patients with mitral valve was severely calcified. Furthermore, 54 were vitamin D deficient, while 35 had insufficient vitamin D levels, and only 15 had normal blood levels of vitamin D. In addition high serum iPTH levels were present in 83 patients (80%). The levels of 25(OH)D, calcium, phosphorous, and iPTH with total Wilkins score, calcification score and mitral valve area were not significantly correlated (p&gt;0.05 for all above). Conclusions: Although no correlation was found between the severity of mitral valve involvement, and vitamin D and iPTH levels, vitamin D deficiency and secondary hyperparathyroidism tend to be common among patients with severe rheumatic MS, which may play a role in the progression of the disease.

Persistent iatrogenic atrial septal defect after cryoballoon ablation for atrial fibrillation

Aims: Pulmonary vein isolation (PVI) by cryoballoon ablation (CB) technology is effective and safe treatment option for atrial fibrillation (AF). CB is performed by large diameter, 15Fr (4.95mm) transseptal sheath that may lead to creation of iatrogenic atrial septal defect (iASD). The objective of this study was to assess the incidence of iASD in patients who had undergone CB. Methods: Patients with AF having undergone Arctic Front® CB ablation and a subsequent transesophageal echocardiography (TEE) examination during post-ablation follow up period were consecutively enrolled. During all CB procedures, 15Fr transseptal sheath (Flex Cath, Medtronic, Minneapolis, MN) was utilized via single transseptal puncture (TsP). Results: Twenty-eight patients (15 females, mean age 55.8+15.5) with paroxysmal (n=24) or persistent (n=4) AF formed study group. iASD was present 11 (39.3%) of them after mean follow-up time of 17.3+6.2 months. The procedural time is significantly longer in patient with iASD (119.0+8.8 minutes, p=0.01). No patients died or suffered from any clinically significant cerebral ischemic event. There was no sign of increase in systolic pulmonary arterial pressure (sPAP). Conclusion: iASD after CB was found to be present in 39.3% of patient during a mean follow-up time of 17.3+6.2 months. The prolonged CB procedural time was the only factor that predicted iASD in our study. No adverse clinic events that might be related to iASD was observed during follow-up period.

Prevalence of left atrial appendage thrombus and spontaneous echo contrast on transesophageal echocardiography in patients scheduled for pulmonary vein isolation.

To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior to the procedure. Despite being on anticoagulants, some patients develop a left atrial appendage thrombus (LAAT). To exclude the presence of LAAT, transesophageal ultrasound (TEE) is performed in all patients prior to the procedure. We hypothesized continuous treatment with anticoagulants would result in a low prevalence of LAAT, in patients with low CHA2DS2-VASc score. Medical records of consecutive patients planned to undergo AF ablation at Lund University Hospital during the years 2018-2020 were reviewed retrospectively. Examination protocols from transesophageal and transthoracic echocardiography were examined for LAAT and spontaneous echo contrast (SEC). Patients with LAAT and SEC were compared to patients without using Mann-Whitney U-test and Pearson Chi-squared analysis to test for correlation. Of 553 patients, three patients (0.54%) had LAAT, and 18 (3.25%) had spontaneous contrast (SEC). Patients with LAAT or SEC had a higher CHA2DS2-VASc score, more often presented in AF at TEE and less often had a normal sized left atrium. There is a low prevalence of LAAT and SEC in patients with AF scheduled for pulmonary vein isolation. Patients with SEC or LAAT tend to have paroxysmal AF less often and more often presented in AF at admission. No patients with CHA2DS2-VASc 0, paroxysmal AF, normal sized left atrium and sinus rhythm at TEE were found to have LAAT or SEC.

Managing a Challenge Case: Transesophageal Echocardiography-Guided Transcatheter Closure of a Large Secundum Atrial Septal Defect in a Pregnant Woman

Background: The management of complex cardiovascular conditions during pregnancy poses unique challenges, and in the case of a large secundum atrial septal defect (ASD), achieving successful closure through a transcatheter approach guided by transesophageal echocardiography (TEE) requires careful navigation and expertise. This study sought to present a case that exemplifies the contemporary approach of using TEE guidance for the closure of an ASD in pregnant women Case presentation: A 31-year-old woman with multigravida, diagnosed with secundum ASD and pulmonary hypertension, underwent TEE. The TEE examination revealed a significant ASD measuring 2.8-3.1 cm with inadequate surrounding rims. Subsequently, our intention was to employ a device to address this defect. TEE was utilized to guide the placement of a 14F delivery sheath into the left upper pulmonary vein and left atrium. Using a catheter, we successfully deployed a 40 mm ASD Occluder (MemoPart), concluding the intervention without any complications. Given the concerns regarding the potential risks of radiation exposure and teratogenic effects on fetal development, particularly in young patients and during pregnancy, it is crucial to prioritize TEE-guided closure of ASD for the safety of both the mother and the fetus. Conclusion: Closure of ASD with zero fluoroscopy proved to be a safe and effective procedure, demonstrating feasibility and significant benefits for pregnant women with ASD. Keyword: Atrial Septal Defect, Pregnant Woman, Transcatheter Closure, Transesophageal Echocardiography.

Management of Pregnant Women with Atrial Septal Defect and Pulmonary Hypertension: A Case Report

Background: Pulmonary Hypertension (PH) is a condition where there is an increase in Pulmonary Vascular Resistance (PVR) and an increase in the mean Pulmonary Arterial Pressure (mPAP) to more than 20 mmHg. PH can occur in someone with Congenital Heart Disease (CHD). PH conditions can aggravate pregnancy in women with CHD. Women with PH are recommended not to undergo pregnancy. However, it is possible for women with CHD with PH conditions to undergo pregnancy. In these conditions, optimizing PH therapy is essential so that pregnant women with PH do not experience a worsening of the condition and can carry out their pregnancy well until delivery. Case presentation: A 38-year-old female patient with a history of Atrial Septal Defect-Pulmonary Hypertension came for common control to the cardiac clinic with the pregnancy condition of her 4th child, who was just discovered when she was six months pregnant. Since giving birth to her third child, the patient began complaining of being quickly tired when doing activities accompanied by swollen legs that disappeared with rest. The patient went to a cardiologist for an echocardiography examination and was diagnosed with Atrial Septal Defect (ASD)-Pulmonary Hypertension (PH). Since then, the patient has been routinely treated by a cardiologist with Pulmonary Hypertension drugs, including Phospodiesterase5 (PDE5) inhibitors (Sildenafil) and Prostacyclin Analogue (Dorner). The patient had done Transesophageal Echocardiography (TEE) with the results of ASD secundum suitable for closure by the device. Patients with Right Heart Catheterization (RHC) results, ASD secundum with PH High Flow High Resistance reactive to Vasoreactivity Test. Since the patient was found to be pregnant, the patient continued to use Sildenafil and discontinued the use of Dorner. The patient then continued treatment in a multidisciplinary team. Conclusion: Management of pregnant women with CHD and PH is essential because the condition of PH itself further aggravates the condition of pregnancy. Medical management for PH in pregnant women follows the guidelines for the safety of drugs in pregnancy so that the choice of therapy is crucially related to the goal of treatment to control the PH condition in the patient but still pay attention to safety in pregnancy conditions. Keyword: Congenital Heart Disease, Phosphodiesterase-5 (PDE-5)- Inhibitor, Prostacyclin Analogue, Pulmonary Hypertension.

Echocardiographic Features in Patient Rheumatic Mitral Stenosis

Rheumatic mitral stenosis (RMS) is a progressive valvular heart disease that can lead to significant morbidity and mortality, especially in developing countries. Echocardiography plays a crucial role in the diagnosis, assessment, and management of patients with RMS. This study aims to review the utility echocardiography feature in patient RMS. We discuss the key echocardiographic parameters used for assessment and severity of RMS, and associated valvular abnormalities. Additionally, we explore the role of multimodality imaging, such as transesophageal echocardiography in enhancing the diagnostic accuracy and therapeutic decision-making in RMS. A thorough understanding of echocardiographic findings in RMS is essential for clinicians involved in the care of these patients, as it aids in risk stratification, treatment planning, and monitoring of disease progression. Integrating echocardiography is a widely used non-invasive method for comprehensive assessment, monitoring disease progression and evaluating treatment efficacy, ensuring optimal management for patient with RMS. Keyword: Echocardiography, Rheumatic Heart Disease, Mitral Stenosis.