Let's do some echo:

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sethco said:
Long story short, 40 y/o male with no significant past medical history admitted for weakness, fever/chills, and shortness of breath. TTE performed found a Mitral vegetation. TEE performed with some images below. Surgeon wants to know what he has to do and if he can do the case at a community hospital that does about 150-200 hearts per year, but no ECMO or other advanced capabilities available.

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Nice. I’d take a real good look at the aorto/mitral curtain- looks like abcess. Bicuspid AV. Root looks aneurysmal. Replace AV/MV.
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* do it at a place that has ecmo/mechanical support.
 
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Hork Bajir said:
Looks like a degenerated bio prosthetic mitral with mixed stenosis and regurgitation?
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You so smart bro-tatochip. 👌🏾

Redo-redo mvr/failed bpv.

Mean gradient 11 mmHg and severe MR.
 
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C615D78E-5E56-401D-8423-BB2E185C71FB.jpeg
 
Agree with sevo- would want a better look at the ascending. Could be as little as AVR/MVR, or as extensive as commando procedure + Bentall, depending on root dimensions and how things look when you get in there… but at the end of the day, it needs to be explored surgically (at a place that has ECMO capability)
 
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40 yo, preserved BiV function, and if he's not not on deaths door with florid sepsis, intubated, multiple pressors, in pulmonary edema, etc, then I don't think it absolutely has to go to an ecmo center. I sure would prefer it to be at a quaternary place, but everywhere nowadays has iNO (or inhaled flolan) and impellas.

One of the biggest factors is how good is the surgeon. Some can bang out a double valve with a 90 min pump time, and for others the whole case is a 8-10 hr blood letting with stoneheart cross clamp times...
 
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@sevoflurane FTW. Pt had MV endocarditis with involvement of the Aorto-mitral curtain, Bicuspid AV, and Aortic Root Aneurysm with Abscess. Transferred and ended up having an AVR/MVR, Aortic Root debridement, LA wall and Aortomitral curtain debridement, and Ascending reconstruction. Better known as a Commando Procedure.

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Sorry, couldn't help myself, haha

I must admit that I did not take these TEE images. CT surgeon was consulted on this pt to fix the MV and possibly the AV, which the Cardiologist thought might be a Unicuspid. Unfortunately, there were some things that I wish were better imaged like the AV and the Root, but I basically gave him an opinion on the images I had to look at. I'm not trying to throw shade at Cardiologists, but most just don't have the same level of TEE experience/practice to guide surgical management.

This patient was transferred out to a hospital where we do ~2000 hearts per year and handle the sickest patients (ECMO, iNO/Flolan, Impella, etc capabilites). Unfortunately, none of these modalities were available at the patients current hospital.
 
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sethco said:
@sevoflurane FTW. Pt had MV endocarditis with involvement of the Aorto-mitral curtain, Bicuspid AV, and Aortic Root Aneurysm with Abscess. Transferred and ended up having an AVR/MVR, Aortic Root debridement, LA wall and Aortomitral curtain debridement, and Ascending reconstruction. Better known as a Commando Procedure.

Arnold Schwarzenegger Reaction GIF


Sorry, couldn't help myself, haha

I must admit that I did not take these TEE images. CT surgeon was consulted on this pt to fix the MV and possibly the AV, which the Cardiologist thought might be a Unicuspid. Unfortunately, there were some things that I wish were better imaged like the AV and the Root, but I basically gave him an opinion on the images I had to look at. I'm not trying to throw shade at Cardiologists, but most just don't have the same level of TEE experience/practice to guide surgical management.

This patient was transferred out to a hospital where we do ~2000 hearts per year and handle the sickest patients (ECMO, iNO/Flolan, Impella, etc capabilites). Unfortunately, none of these modalities were available at the patients current hospital.
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You always have great cases. thanks for posting @sethco

Lol at commando procedure... I should watch that again. Great flick.
 
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sethco said:
Surgeon wants to know what he has to do and if he can do the case at a community hospital that does about 150-200 hearts per year, but no ECMO or other advanced capabilities available.

Click to expand...

150 per year? If half are cabg only thats about 80 valves. Per year. Wow... Thats... Wow

Yeah no
 
sethco said:
@sevoflurane FTW. Pt had MV endocarditis with involvement of the Aorto-mitral curtain, Bicuspid AV, and Aortic Root Aneurysm with Abscess. Transferred and ended up having an AVR/MVR, Aortic Root debridement, LA wall and Aortomitral curtain debridement, and Ascending reconstruction. Better known as a Commando Procedure.

Arnold Schwarzenegger Reaction GIF


Sorry, couldn't help myself, haha

I must admit that I did not take these TEE images. CT surgeon was consulted on this pt to fix the MV and possibly the AV, which the Cardiologist thought might be a Unicuspid. Unfortunately, there were some things that I wish were better imaged like the AV and the Root, but I basically gave him an opinion on the images I had to look at. I'm not trying to throw shade at Cardiologists, but most just don't have the same level of TEE experience/practice to guide surgical management.

This patient was transferred out to a hospital where we do ~2000 hearts per year and handle the sickest patients (ECMO, iNO/Flolan, Impella, etc capabilites). Unfortunately, none of these modalities were available at the patients current hospital.
Click to expand...
Remember Sully when I promised to kill you last? ….I lied
 
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My turn. Case from a few weeks back… Otherwise healthy lady, transferred from OSH with reported type A dissection. Would you agree? What to tell the surgeon?

1628199309182.gif



1628199459024.gif

1628199508454.gif

1628199575517.gif
 
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Hork Bajir said:
My turn. Case from a few weeks back… Otherwise healthy lady, transferred from OSH with reported type A dissection. Would you agree? What to tell the surgeon?

View attachment 341666


View attachment 341667
View attachment 341668
View attachment 341669
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Very cool. Looks like NCC leaflet destruction or ?bicuspid with sequelae of endocarditis, annular/LVOT involvement, SoV aneurysm, and multiple perforations causing some funky communications.

My thoughts:

There is primary AI from Ao to LVOT.

There is also a fistula between the SoV aneurysm and the LVOT with possible flow in both phases of the cardiac cycle based on the 2d shot, but CFD shows primarily diastolic flow. Seems the total of amount of regurgitation from all sources is so much that a big PISA is forming.
 
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vector2 said:
Very cool. Looks like NCC leaflet destruction or ?bicuspid with sequelae of endocarditis, annular/LVOT involvement, SoV aneurysm, and multiple perforations causing some funky communications.

My thoughts:

There is primary AI from Ao to LVOT.

There is also a fistula between the SoV aneurysm and the LVOT with possible flow in both phases of the cardiac cycle based on the 2d shot, but CFD shows primarily diastolic flow. Seems the total of amount of regurgitation from all sources is so much that a big PISA is forming.
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Nice, @vector2 - close. No endocarditis, and tricuspid aortic valve. This was a SOV pseudoaneurysm (NOT a classic SOVA) that ruptured into the LVOT, resulting in severe regurgitation. Not that the “neck”of the pseudoaneurysm sack is narrow, and that the remainder of the ruptured sinus looks relatively normal. Two jets can be seen in diastole, one filling the pseudoaneurysm sack from the aortic root and the other flowing back into the LVOT. There was mild valvular AI as well, likely from architectural distortion of the AV annulus. Interestingly I thought that it was the left sinus which was ruptured, but the surgeon found that it was actually the non… I assume that the whole thing got so twisted up and distorted that it threw off our usual landmarks and relationship to the IAS.

And @sevoflurane I did get some great cases as a fellow, but this was one of the last! I am now a few weeks into my new PP job : )
 
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Hork Bajir said:
And @sevoflurane I did get some great cases as a fellow, but this was one of the last! I am now a few weeks into my new PP job : )
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Super pumped for you!
Congrats on finishing a long and hard road. These next few years are especially delicious. 👊🏽
 
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Hork Bajir said:
Nice, @vector2 - close. No endocarditis, and tricuspid aortic valve. This was a SOV pseudoaneurysm (NOT a classic SOVA) that ruptured into the LVOT, resulting in severe regurgitation. Not that the “neck”of the pseudoaneurysm sack is narrow, and that the remainder of the ruptured sinus looks relatively normal. Two jets can be seen in diastole, one filling the pseudoaneurysm sack from the aortic root and the other flowing back into the LVOT. There was mild valvular AI as well, likely from architectural distortion of the AV annulus. Interestingly I thought that it was the left sinus which was ruptured, but the surgeon found that it was actually the non… I assume that the whole thing got so twisted up and distorted that it threw off our usual landmarks and relationship to the IAS.

And @sevoflurane I did get some great cases as a fellow, but this was one of the last! I am now a few weeks into my new PP job : )
Click to expand...
Any idea what caused it?
 
Beeftenderloin said:
Any idea what caused it?
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Nope. A bunch of tests still pending, last I checked, including RPR (syphilis). I should mention the ascending aorta was ratty and aneurysmal as well, supporting that theory in this young and otherwise healthy non-smoker. Otherwise just bad luck I guess? I’ve lost access to my old hospital’s EMR, so I’m unable to follow up on the results and path at this point
 
Hork Bajir said:
Nice, @vector2 - close. No endocarditis, and tricuspid aortic valve. This was a SOV pseudoaneurysm (NOT a classic SOVA) that ruptured into the LVOT, resulting in severe regurgitation. Not that the “neck”of the pseudoaneurysm sack is narrow, and that the remainder of the ruptured sinus looks relatively normal. Two jets can be seen in diastole, one filling the pseudoaneurysm sack from the aortic root and the other flowing back into the LVOT. There was mild valvular AI as well, likely from architectural distortion of the AV annulus. Interestingly I thought that it was the left sinus which was ruptured, but the surgeon found that it was actually the non… I assume that the whole thing got so twisted up and distorted that it threw off our usual landmarks and relationship to the IAS.

And @sevoflurane I did get some great cases as a fellow, but this was one of the last! I am now a few weeks into my new PP job : )
Click to expand...
What did the surgeon do? Attempted repair at all?
Great images.


Does pseudo aneurysm sov vs true aneurysm alter mgt at all?
Thank you and congratulations!
 
dchz said:
What part of the country you working? what's the practice setup?
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New England. Privademic kind of set up (PP group, but have residents/fellows/grand rounds/etc). Supervision outside of cardiac, solo or with fellows/residents in the heart room.
 
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First case back after a 6 week hiatus from work. 😂
Someone mentioned earlier that EF’s of 15% don’t exist.





What is truly remarkable is that this patient’s first bp in the room was 195/110.
 
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Patients really suprise me sometimes.
 
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sevoflurane said:
First case back after a 6 week hiatus from work. 😂
Someone mentioned earlier that EF’s of 15% don’t exist.





What is truly remarkable is that this patient’s first bp in the room was 195/110.
Click to expand...



IME that scenario is fairly common. They tolerate anesthesia well too as long as they’re not overdosed.
 
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needs at least 3 months before you actually see a real difference, but at least he came off the pump lol
 
Time to revive this thread, one of my favorites. This case is for the echo nerds…

60ish yo lady, BAV and ascending aneurysm. Got an AVR with a 25mm Inspiris valve, and ascending aorta replaced with a 34mm Gelweave graft.

This clip was taken after the aortic cross clamp was removed, but before separation from bypass. What do we see, what do we think it is, what to tell the surgeon?

1636682752794.gif
 
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Since nobody is taking the bait, I’ll give a hint- does it matter what kind of valve the surgeon used here?
 
Fine, I’ll bite. In addition to what you’ve got above, I’d take a look at the ME LAX, AV SAX, check a 3D if I’m feeling extra. Once I’d convinced myself it wasn’t paravalvular I’d tell the surgeon valve looks good.

The new inspiris valves frequently have a non-trivial appearing, eccentric, intravalvular leak that is transiently present after separation from bypass. That’s probably what this is.
 
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@Beeftenderloin bingo! You nailed it.

This is also known as a “wire frame leak”. Can be fooled into thinking this is a small PVL if you’re not familiar with it. This image shows where the leak comes from (perforations at the base of the stent post, but still technically inside of the sewing ring… so outside of the valve leaflets, but not really paravalvular):
1636748843299.jpeg


We came off of bypass, and the leak resolved:

1636748922435.gif


This issue is only seen with Inspiris valves smaller than a 27; if you see a leak in a 27 or 29 Inspiris, it’s more likely a real para
 
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Final comment in reply to @Beeftenderloin - this leak was hard to see in any of the mid-esophageal views (just a suggestion of a little jet in the ME LAX). It also didn’t show up in the deep TG view without X-planing… A nice illustration of why X-plane through the DTG view is my favorite way to exclude AV PVLs. But I’ll get off my soap box now : )
 
Beeftenderloin said:
Okay, my turn. Just pictures. Anyone want to take a stab at what the hell is going on here?

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Not sure. Left image I figured that it was just pretty standard wire and moderator band there in the RV. Looking at the x-plane though? No serious idea. It's big and bright. My mind goes down a series of ideas like, embolized IVC filter or artificial tricuspid valve that moved after being poorly sutured. Perhaps a pulmonic valve that was released at the wrong location during interventional procedure? Or like above just some big ugly thrombus I guess, but doesn't have that look to me and my non-expert eyes. I know, these are just wild guesses.
 
Beeftenderloin said:
Okay, my turn. Just pictures. Anyone want to take a stab at what the hell is going on here?

Click to expand...

looks like an AV canal defect vs atrial septal rupture on the 4C ME view with an RVAD or other cannula in the RV. Other posters pointed out possible embolized valve or misdeployed PV, which would also make sense. There is a tricuspid valve in the correct position.
 
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