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Open access

Hitesh C Patel and Justin A Mariani

This case describes an iatrogenic cause of heart failure: the pacemaker syndrome. The diagnosis was initially overlooked but in retrospect could have easily been made by reviewing the rhythm strip recorded during the echocardiogram. The patient eventually received the correct treatment to restore atrioventricular synchrony and experienced rapid resolution to her disabling symptoms.

Learning points:

  • New-onset heart failure following a pacemaker implant should be evaluated with an echocardiogram.

  • Alongside pacing-induced left ventricular systolic dysfunction and pacing wire-related cardiac valve disruption, pacemaker syndrome should be considered.

  • Interpreting a good-quality (showing both P waves and QRS complexes) rhythm strip can greatly aid in the diagnosis of pacemaker syndrome.

Open access

Kelly Victor, Michael M Sabetai, and John B Chambers

This case report highlights the utility of paravertebral (PV) imaging in the diagnosis of aortic dissection, the evaluation of left ventricular systolic function and drawing the distinction between pleural and pericardial effusions. In this case, less attenuation of the ultrasound beam, reduced lung viscosity due to pleural effusions and less impedance mismatch between media led to images of superior quality and high diagnostic value. This supports the use of paravertebral imaging as an adjunct to conventional echocardiography windows, particularly when conventional transthoracic imaging proves challenging.

Learning points:

  • PV images provide superior resolution when interrogating the descending aorta and thus can reveal incidental findings such as aortic dissection.

  • PV imaging provides clearer delineation between pericardial and pleural effusions.

  • Additional information may be obtained from the PV window in relation to left ventricular systolic function particularly in the setting of suboptimal transthoracic image quality.

Open access

Rienzi Díaz-Navarro and Petros Nihoyannopoulos

A 54-year-old male developed a left ventricular pseudoaneurysm (Ps) along the lateral wall of the left ventricle (LV), which was diagnosed incidentally by two-dimensional transthoracic echocardiography (2DTTE) 6 months after an acute myocardial infarction. Color flow imaging (CFI) showed blood flow from the LV into the aneurysmal cavity and invasive coronary angiography revealed sub-occlusion of the circumflex artery. A complementary study using cardiovascular magnetic resonance (CMR) confirmed a dilated left ventricle with depressed ejection fraction, thin dyskinetic anterolateral and inferolateral walls, a Ps adjacent to the lateral wall of the LV contained by the pericardium and blood passing in and out through a small defect in the LV mid-anterolateral wall. Late gadolinium-enhanced imaging demonstrated transmural myocardial infarction in the lateral wall and delayed enhancement of the pericardium, which formed the walls of the Ps. A conservative approach was adopted in this case, optimizing the patient’s heart failure medications, including cardioselective beta-blocker agents, angiotensin-converting enzyme inhibitors, spironolactone and chronic anticoagulation therapy because of a high risk of ischemic stroke in these patients. At the 13-month follow-up, the patient remained stable with New York Heart Association class II heart failure. In conclusion, 2DTTE and CFI seem to be suitable initial methods for diagnosing Ps of the LV, but CMR is an excellent complementary method for characterizing further this cardiac entity. Furthermore, the long-term outcome of patients with Ps of the LV who are treated medically appears to be relatively benign.

Learning points:

  • Left ventricular pseudoaneurysms are uncommon but severe complications of acute myocardial infarction.

  • Transthoracic two-dimensional echocardiography and CFI are suitable non-invasive diagnostic methods for diagnosing left ventricular pseudoaneurysms.

  • Cardiac magnetic resonance is an excellent complementary method, as it offers additional information for further characterization of this cardiac complication.

  • Despite the fact that surgery is the treatment of choice to avoid a risk of fatal rupture, the long-term outcome of patients with left ventricular pseudoaneurysm who are treated medically appears to be relatively benign.

Open access

L D Hunter, M Monaghan, G Lloyd, A J K Pecoraro, A F Doubell, and P G Herbst

This focused review presents a critical appraisal of the World Heart Federation criteria for the echocardiographic diagnosis of rheumatic heart disease (RHD) and its performance in African RHD screening programmes. It identifies various logistical and methodological problems that negatively influence the current guideline’s performance. The authors explore novel RHD screening methodology that could address some of these shortcomings and if proven to be of merit, would require a paradigm shift in the approach to the echocardiographic diagnosis of subclinical RHD.

Open access

Renuka Jain, Daniel P O’Hair, Tanvir K Bajwa, Denise Ignatowski, Daniel Harland, Amanda M Kirby, Tracy Hammonds, Suhail Q Allaqaband, Jonathan Kay, and Bijoy K Khandheria


While transcatheter aortic valve implantation (TAVI) has traditionally been supported intraprocedurally by transoesophageal echocardiography (TOE), transthoracic echocardiography (TTE) is increasingly being used. We evaluated echocardiographic imaging characteristics and clinical outcomes in patients who underwent TTE during TAVI (TTE-TAVI).

Methods and results

A select team of dedicated sonographers and interventional echocardiographers performed TTE-TAVI in 278 patients, all of whom underwent TAVI through transfemoral access. We implanted the Medtronic EVOLUT R valve in 258 patients (92.8%). TTE images were acquired immediately pre-procedure by a dedicated sonographer in the cardiac catheterization laboratory with the patient in the supine position. TTE was then performed post deployment of TAVI. In the procedure, TTE image quality was fair or better in 249 (89.6%) cases. Color-flow Doppler was adequate or better in 275 (98.9%) cases. In 2 cases, paravalvular regurgitation (PVL) could not be assessed confidently by echocardiography due to poor image quality; in those cases, PVL was assessed by fluoroscopy, aortic root injection and invasive hemodynamics. Both TTE and invasive hemodynamics were used in the assessment of need for post-deployment stent ballooning (n = 23, 8.3%). TTE adequately recognized new pericardial effusion in 3 cases. No case required TOE conversion for image quality. There was only 1 case of intraprocedural TTE failing to recognize moderate PVL, without clinical implication. In 99% of patients, TTE-TAVI adequately assessed PVL compared with 24-h and 1-month follow-up TTE.


With the current generation of TAVI, TTE-TAVI is adequate intraprocedurally when performed by specialized sonographers and dedicated cardiologists in a highly experienced TAVI center.

Open access

Ying X Gue, Sanjay S Bhandari, and Mubarak Ahamed

76-year-old female presented following an episode of collapse. She was hypotensive with the paramedics and remained refractory despite fluid resuscitation. Her initial baseline tests revealed an elevated troponin; she subsequently underwent a coronary angiogram that showed mild coronary artery disease. Left ventriculogram was performed, which showed abnormal mid-wall ballooning and severely impaired systolic function, characteristic of Takotsubo syndrome. Echocardiogram confirmed the presence of diagnosis and presence of left ventricular outflow tract obstruction with high gradient. She was initiated on medical heart failure therapy and improved. Follow-up investigations after 2 months showed complete resolution of systolic dysfunction and symptoms.

Learning points:

  • Takotsubo syndrome can present similarly to ACS.

  • Early use of echocardiography in the acute setting can provide vital information.

  • Takotsubo syndrome can result in hemodynamic instability requiring urgent interventions.

  • Other investigative modalities can be used in conjunction with echocardiography to confirm the diagnosis of Takotsubo syndrome.

  • Prognosis is generally good in patients with Takotsubo syndrome.

Open access

Charlotte Atkinson, Jonathan Hinton, Edmund B Gaisie, Arthur M Yue, Paul R Roberts, Dhrubo J Rakhit, and Benoy N Shah

Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.

Open access

Alice Cowley, Laura Dobson, John Kurian, and Christopher Saunderson

Isolated myocardial involvement in tuberculosis is exceedingly rare but there are reports it can present with sudden cardiac death, atrioventricular block, ventricular arrhythmias or congestive cardiac failure. We report the case of a 33-year-old male, of South Asian descent, who presented with chest pain, shortness of breath and an abnormal ECG. The patient had no significant past medical history and coronary angiogram showed no evidence of coronary artery disease. Of note, the patient had recently been discharged from a local district hospital with an episode of myocarditis. The patient was found to be severely hypoxic with evidence of severe biventricular failure on echocardiography. Computed tomography of the chest demonstrated hilar lymphadenopathy, and the differential diagnosis was thought to be tuberculosis or sarcoidosis. A TB Quantiferon gold test performed at the district hospital was positive; however, fine needle aspiration was negative for acid-fast bacilli. Despite aggressive diuresis, the patient became increasingly hypoxic and suffered a cardiac arrest. Post-mortem confirmed a diagnosis of myocardial tuberculosis – a rare case of acute decompensated heart failure.

Learning points:

  • Tuberculosis myocarditis is a rare diagnosis but should be considered in at risk individuals presenting with acute fulminant myocarditis.

  • Cardiac failure can occur even in the absence of disseminated tubercular disease.

  • TB myocarditis is not just a disease of the immunocompromised.

  • Definitive diagnosis of cardiac tuberculosis during life requires a myocardial biopsy.

  • Echocardiography is a vital tool for the assessment of cardiac function, filling pressures and fluid status in the critically unwell patient.

Open access

H Z R McConkey, M Ghosh-Dastidar, S R Redwood, and V Bapat

This is a case of a precarious thrombotic mass straddling a patent foramen ovale which had already embolised to the pulmonary circulation. The diagnosis was initially deceptive and management challenging.

Learning points:

  • Echocardiography is mandated and can change management in haemodynamically unstable patients with pulmonary emboli.

  • Pulmonary embolism can be life-threatening.

  • The authors propose that urgent cardiac surgery is the safest treatment in the setting of highly mobile, large volume, intra-cardiac thrombus.

Open access

Sveeta Badiani, Jet van Zalen, Saad Saheecha, Lesley Hart, Ann Topham, Nikhil Patel, Lydia Sturridge, Andrew Marshall, Neil Sulke, Stephen Furniss, and Guy Lloyd


The rate of progression of aortic regurgitation (AR) is not well described. Current guidelines state that asymptomatic patients with mild AR should be followed up every 3–5 years and 1–2 yearly for moderate AR. This study describes the lesion and clinical based progression of mild and moderate AR in a population of patients undergoing systematic follow-up.

Methods and results

341 patients with either mild or moderate AR were included. The rates of clinical events (death, aortic valve replacement and cardiac hospitalization) and progression of AR are reported.

341 patients were included; mean age was 71.1 years (IQR 66–80 years) and the median follow-up period was 4.6 (IQR 2–6.7) years. 292 patients did not have any events during follow-up. 3 patients required aortic valve replacement (2 of these due to severe aortic stenosis and 1 due to severe mitral regurgitation and co-existent moderate AR). 44 patients required cardiac hospitalization. 9 patients died during follow-up and 35 patients (10%) showed a progression of AR during follow-up with an average time of 4.0 ± 2.6 years. 8 patients (2.3% of the total) progressed to severe AR.

Patients with mixed valvular pathology showed a greater increase in AR progression (27 (15%) vs 8 (5%); P = 0.004).


Over medium term systematic follow-up progression and clinical events in patients with AR is rare, regardless of etiology. Patients who suffered from AR as an isolated valve pathology were less likely to show AR progression over time.