Echo Case: A Contrasting Opinion

Ronald H Wharton, MD


January 15, 2016

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Dr Wharton: Hello, and thank you for tuning in. This is Dr Ronald Wharton from Montefiore Medical Center. I am an assistant professor of medicine at the Albert Einstein College of Medicine, Bronx, New York. I titled this case study, “A Contrasting Opinion.”

At some point in the remote past, there was this 70-year-old gentleman who underwent a mitral-valve repair. There was no bypass involved, it was just a repair for myxomatous disease. There was a pacemaker also present as well. Three months after his initial operation, he was seen at a hospital close to where he lives because he had had two syncopal episodes. The transferring hospital did an echocardiogram and they were very concerned about the echocardiographic findings, and for that he was referred to Montefiore for further evaluation.

If you look here, we have a parasternal long axis, and there are some things that are very obviously wrong. There is a large left pleural effusion, not surprising. You can see there’s a mitral-valve repair. If you look closely, you can also see that there seems to be a loculated pericardial effusion, with maybe some clot compressing the right ventricular outflow tract (RVOT) tamponading it.

Here, we see the same image with color. You can see some turbulence, which is not unexpected through the mitral-valve-ring annuloplasty during diastole. You can also see some turbulent flow during systole in the right ventricular outflow tract. If you look at the mitral inflow, it’s also interesting that you can see the flow going through the valve, but you don’t really see the flow in the left atrium as it approaches the valve, which is not at all the norm.

Here, you see another view of the parasternal long axis, but it’s a little focused on the right ventricular outflow tract. And you can see how much the right ventricular outflow tract is compressed by this large effusion compressing it anteriorly. Again, you can see the mitral-valve prosthesis. I’m not exactly sure where the left atrium starts and where the left atrium finishes. You get the impression that there may be a large effusion around the left atrium as well, and that the flow coming through the mitral valve is limited to a very, very, small area just posterior to the aortic root.

Here we now see a parasternal short-axis window with an aortic valve that is thickened commensurate with the patient’s age. As well, you see again this large clot compressing the right ventricular outflow tract all the way anteriorly. In the next slide, you can see something else that I think is worth commenting upon.

This is a short axis of the left ventricle (LV) at the papillary-muscle level. You can see a little apical pseudotendon coming in and out there. And then, there’s this large cavity that is compressing the lateral wall of the left ventricle during diastole. Look very closely at the lateral wall itself, because we’re going to come back to that later. You’ll agree I think that the systolic function is normal.

Here again, is another view of the parasternal short axis. This gives you an idea of how truly compressed the right ventricular outflow tract is. In the next slide, we now see that same view with color flow.

You can see again the turbulence in the right ventricular outflow tract and on the side you can also see the laminar flow during diastole in the left main coronary artery. A little red jet that’s confined to diastole.

The result of that compression here on the pulsed-wave Doppler through the pulmonic valve with a velocity of about 2.1 to 2.2 m/s.

And the continuous-wave Doppler through the pulmonic valve and pulmonary artery as well. That all reflects the compression of the right ventricular outflow tract by the hematoma anteriorly. Now I’m going to show you some apical shots.

This is where I think it gets really interesting.

Here is an apical four-chamber view with the flow. The image on the left is 2D, the image on the right is with color. You can see again that there is this large cavity compressing the lateral wall of the LV during diastole. There’s also color flow coming in through the mitral prosthesis into the left ventricle. But, you don’t really see the flow in the left atrium. You see it coming through the prosthesis into the LV, but you really can’t see the proximal portion of the flow.

So, what’s going on? Well, there’s a loculated effusion compressing the RVOT. We’ve seen that, and the manifestations of that would be high velocities to the pulmonic valve and pulmonary artery. Are there loculated effusions everywhere else, or is there a pseudoaneurysm around the lateral wall of the left ventricle? That’s really the most concerning finding that prompted the physicians at the transferring facility to send the patient to Montefiore. Because it sure looks like there’s a large pseudoaneurysm lateral to the LV. Can you get a pseudoaneurysm from mitral-valve surgery? Absolutely, I’ve seen it before. It’s a well-known complication, especially if you take too big a bite and during your surgery you ligate the left circumflex artery, it can cause a localized infarct. Well, let’s take a look and see what’s really going on here.

Here again in the next slide, the parasternal long-axis view to the image with the hematoma compressing the RVOT. That we know is there, that’s fairly established. There’s no argument about that, and that’s going to have to be surgically evacuated. But what’s going on here?

Well, if we take a second look, it sure looks like a pseudoaneurysm in the 2D image, but in the color image, you can’t find any flow really between the cavity and the LV. If that were pseudoaneurysm, you should expect to find to-and-fro flow during systole and diastole—that’s what you usually see. We don’t see that. We also don’t see any flow between the left atrium, wherever that is, and that cavity as well. Again, appreciate the fact that the proximal flow coming in through the mitral valve seems to be skirting right up against the interatrial septum, but you don’t really see the flow anywhere else in the left atrium.

Is it a pseudoaneurysm? Well, pseudoaneurysms really occur after infarctions where you have a thinned-out segment of myocardium that then develops a hole in it as a result typically of an infarction. Well, let’s go back to an image we’ve looked at before.

This is again, the short axis of the LV with that same cavity laterally, and if you look at the lateral wall very closely, it’s really thickening normally. It is not thinned out.

In the apical views, it sure looks like it’s thinned out, but in fact, this is normal thickening myocardium. It looks perfectly healthy, but it’s being compressed.

So, what do we do here? We inject intravenous contrast, and this is a very good opportunity to use a contrast. Most people think of contrast as an agent to be used when you can’t see, and the American Society of Echocardiography guidelines typically use contrast when you can’t see two or more myocardial segments. But here, we’re using it for a different reason. Not because we can’t see, but because we can see. Because the concern here is that this is a pseudoaneurysm and if so, then the contrast should fill it.

If you look at the next slide, in fact it doesn’t. You also notice that that large cavity proximal to the mitral valve is not the left atrium. There is a left atrium there, but you see how thin the contrast is in the left atrium? That whole area is a large hematoma tamponading, not just the RV, but the LV as well.

On the next slide, we come back to the short-axis image again, but now with contrast. You can see that there is no communication between the LV and that cavity. It’s just all a large massive anterior and posterior hematoma that had to be evacuated.

To summarize, there was no pseudoaneurysm, this is all loculated postsurgical effusions. I thought I’d show this to you because this is an excellent use of intravenous contrast in a situation where you might not think to use it.

This is Ronald Wharton from the Albert Einstein College of Medicine, Montefiore Medical Center for on Medscape Cardiology.

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