Collection: case_catalog

Thoracic aneurysms may involve one or more aortic segments (aortic root, ascending aorta, arch, or descending aorta). The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve.

_{www.ahajournals.org/doi/10.1161/01.CIR.0000154569.08857.7A}

Bicuspid aortic valve (BAV) is a congenital heart defect characterized by the fusion of two valve cusps resulting in an ecentric closure line and raphe (fish-mouth) appearance on echo. BAV can lead to potential complications such as aortic stenosis, aortic regurgitation, and endocarditis. Calcification commonly accompanies BAV, further complicating matters. Even when functioning normally, the BAV can experience gradual damage due to abnormal stresses, resulting in abnormal folding and creasing throughout the cardiac cycle, increased turbulence, and restricted motion. Additionally, BAV may be associated with aortopathy and coarctation, which can impact the prognosis. Management of BAV often involves monitoring for complications and considering interventions to address associated issues.

Coarctation of the aorta refers to a narrowing of the aorta, typically occurring just beyond the blood vessels supplying the head and neck, known as the aortic isthmus. Diagnosis often involves using the suprasternal notch view to visualize the aortic anatomy and measure Doppler-based gradients across the site of the coarctation. Color flow Doppler helps identify turbulence associated with the narrowing, while pulsed and continuous wave Doppler can measure peak velocity and flow characteristics in the descending aorta. A characteristic feature of coarctation is a diastolic run-off or "tail" seen in the Doppler waveform. Additionally, assessing the abdominal aorta with Doppler can reveal a lack of pulsatility, indicating severe coarctation. These diagnostic techniques aid in evaluating the severity and location of the coarctation and guide treatment decisions.

Aortic dissection occurs when a tear forms in the inner lining of the aorta, exposing it to high pressures and causing the intima to separate from the aortic wall, creating a false lumen alongside the true one. This tear can propagate in various directions due to the elevated pressures. A re-entrant tear may allow blood to circulate through the false lumen. The hallmark sign of aortic dissection is the intimal flap, a mobile linear echo seen on imaging, separating the true and false lumens with flow on either side. Typically, the false lumen is significantly larger than the true lumen, and the flap moves throughout the cardiac cycle. Flow in the true lumen is usually greater than in the false lumen, predominantly antegrade during systole, with the flap moving toward the false lumen. Early detection and management of aortic dissection are crucial to prevent life-threatening complications.

Papillary fibroelastomas are commonly small tumors, typically measuring between 9 to 12 mm in diameter. When observed through echocardiography, these tumors often display a pedunculated and mobile appearance, characterized by a homogeneous speckled pattern with distinctive stippling along their edges. This stippling corresponds to the papillary projections found on the tumor's surface. This imaging pattern aids in the identification and diagnosis of papillary fibroelastomas, assisting healthcare professionals in providing appropriate management and treatment for patients with these cardiac tumors.

_{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676606/}

Quadricuspid aortic valve (QAV) is a congenital heart defect characterized by the presence of four cusps in the aortic valve, differing from the typical three-cusp structure. A common clinical presentation of QAV is aortic regurgitation (AR) without aortic stenosis, primarily caused by chronic aortic insufficiency (AI). Patients with QAV may remain asymptomatic until their sixth decade, with symptoms emerging later depending on the valve's function and any associated issues. Congestive heart failure often represents the most prevalent initial diagnosis. While some QAV cases are nonpathological, symptomatic degeneration is often linked to prolapsing and enlarged cusps, leading to poor coaptation due to smaller cusps.

_{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8827235/}

Read our comprehensive blog on aortic regurgitation here.

Read our comprehensive blog on aortic stenosis here.

Cardiac myxomas are biologically benign tumor but “functionally malignant”. They can cause life-threatening embolic events. The classical features of an atrial myxoma in echocardiography include polypoid or papillary mass attached to the interatrial septum through a stalk and moving out or into the cavity, sometimes protruding into the corresponding ventricular cavity across the atrioventricular valve.

LA thrombus (blood clot) is usually situated in the posterior portion of the atrium, has a preference for the atrial appendage, has a layered appearance and is most commonly seen in the presence of valvular mitral stenosis, atrial fibrillation and spontaneous echo contrast.

Left ventricular aneurysm is the discrete thinning of the ventricular wall (<5 mm) with akinetic or dyskinetic wall motion causing an out-pouching of the ventricle. True aneurysm, usually, calls for an elective surgery.

Left ventricular hypertrophy (LVH) is a condition in which there is an increase in left ventricular mass, either due to an increase in wall thickness or due to left ventricular cavity enlargement, or both. Most commonly, the left ventricular wall thickening occurs in response to pressure overload, and chamber dilatation occurs in response to the volume overload.

LV pseudoaneurysm is formed if cardiac rupture is contained by pericardium, organizing thrombus, and hematoma. This condition calls for urgent surgical repair.

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. The combination of blood stasis, endothelial injury and hypercoagulability, often referred to as Virchow's triad, is a prerequisite for in vivo thrombus formation

Papillary fibroelastomas are one of the most common types of primary cardiac tumors or benign neoplasms. They are increasingly recognized as the spatial resolution of imaging modalities improves. Also, they are a potential cause of transient ischemic attacks, strokes, myocardial infarction, and sudden death.

Double orifice mitral valve (DOMV) is an uncommon congenital defect affecting the mitral valve structure. It involves an additional fibrous tissue bridge, which divides the mitral valve into two openings, either partially or entirely. This condition was initially documented in 1876. The mitral valve's functionality can vary, potentially leading to normal operation or causing issues like mitral regurgitation (MR) or stenosis.

_{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331838/}

Mitral Leaflet Flail (MLF) occurs when there is a failure of leaflet coaptation, causing the affected leaflet to swiftly move into the left atrium during systole. This movement is typically caused by either ruptured chordae tendineae or papillary muscle dysfunction. MLF can result in acute, subacute, or chronic mitral regurgitation.

In this case, note the large anterior mitral leaflet that prolapses beyond the annular plan in this parasternal long axis view. A prolapsing anterior leaflet typically causes a posteriorly directed jet.

This case shows a large posterior leaflet, prolapsing beyond the anterior plane and creating an anteriorly directed jet.

Read our comprehensive blog on aortic regurgitation here.

Vegetation characterized on echocardiography by a mobile echodense masses implanted in a valve or mural endocardium in the trajectory of a regurgitant jet or implanted in prosthetic material with no alternative anatomical explanation

Systolic anterior motion of the mitral valve caused by the Venturi (drag) effect. 

Pulmonary stenosis, alternatively known as pulmonic stenosis, occurs when the pulmonary valve, situated between the right ventricle and the pulmonary artery, is abnormally constricted, either due to size reduction, narrowing, or stiffening. This condition impedes the flow of blood from the heart's right ventricle to the pulmonary artery, disrupting normal circulation patterns and potentially leading to various cardiac complications.

Apical hypertrophic cardiomyopathy (AHCM) represents a less common manifestation of hypertrophic cardiomyopathy (HCM), typically affecting the apex of the left ventricle. In rare instances, it may also extend to involve the apex of the right ventricle or both ventricular apices.

Dilated cardiomyopathy (DCM) is characterized by the enlargement (dilation) of the left ventricle, the primary pumping chamber of the heart. This dilation often accompanies eccentric hypertrophy of the left ventricle, where the wall thickness remains normal or only slightly increased, while the overall mass of the left ventricle increases due to dilation. As the chamber expands, its muscular wall stretches, resulting in thinning and weakening. DCM typically presents with diffuse hypokinesis, though regional abnormalities in wall motion, such as akinesis or dyskinesis, may occur, particularly affecting the left ventricular septum or apex. Conversely, better contractility is commonly observed in the posterior and lateral walls of the left ventricle.

Hypertrophic cardiomyopathy (HCM) is diagnosed clinically when there is enlargement of the left ventricle (LV) without the presence of hypertension or valve disease. In the general population, LV enlargement unrelated to cardiovascular issues occurs in about 1 in 500 individuals. This statistic encompasses various types of enlargement, not exclusively HCM, which is a hereditary condition characterized by a dominant inheritance pattern and caused by mutations in genes responsible for sarcomeric proteins.

Cardiac amyloidosis (CA) is an infiltrative disease caused by the extracellular deposition of defective proteins. There is biventricular wall thickening with normal cavity size, and bi-atrial enlargement. The atria are immobile, best noted on the apical 4-chamber view. Despite the normal left ventricular ejection fraction, longitudinal function is significantly impaired, as noted on the tissue Doppler and on the color map of longitudinal strain.

Takotsubo cardiomyopathy is also known as also known as stress-induced cardiomyopathy, broken-heart syndrome or apical-ballooning syndrome. Patients present with akinesia of the apical and mid-ventricular segment while the basal segments are hypercontractile. The apex appears dilated (ballooning). 

Transthoracic echocardiography can easily identify the secundum ASDs and also differentiate secundum ASDs from other kinds of ASDs, such as ostium primum ASD, sinus venosus ASD and coronary sinus ASD, as well as patent foramen ovale.

Cor triatriatum is a rare congenital heart condition where a child is born with a thin membrane dividing either the left or right atrium into three chambers. The most common form is cor triatriatum sinister, where the left atrium is divided into an upper chamber receiving blood from the pulmonary veins and a lower chamber connected to the left atrial appendage. This structure obstructs the mitral valve orifice, causing a significant blockage of blood flow into the left ventricle. This condition is differentiated from supravalvular mitral stenosis by the presence of the left atrial appendage.

_{https://doi.org/10.5083/ejcm.20424884.21}

Double inlet left ventricle (DILV) refers to hearts where both atrioventricular (AV) valves are positioned and connected to a single ventricular chamber of left ventricular morphology. In some cases, one of the AV valves may extend across the ventricular septum by more than 50%. 

Marfan syndrome is an autosomal dominant disorder involving multiple systems. It features skeletal abnormalities including long bone overgrowth and ocular lens dislocation, along with pneumothorax, decreased skeletal muscle mass, and mitral valve prolapse. Aortic root dilatation and regurgitation are common cardiac manifestations, potentially leading to aortic dissection and rupture. These symptoms are caused by mutations in the FBN1 gene, which encodes fibrillin-1, an extracellular matrix protein.

Patent foramen ovale (PFO) is a common congenital heart anomaly resulting from incomplete fusion of the septum primum and septum secundum. It affects about 25% of the general population and is associated with several conditions such as decompression sickness, platypnea-orthodeoxia syndrome, and migraines. PFO is implicated in allowing thrombi to pass directly from the right heart chambers into the arterial circulation, potentially leading to cryptogenic stroke, especially in individuals with deep venous thrombosis and additional structural abnormalities like atrial septal aneurysms, Chiari network, and Eustachian tube dysfunction.

_{https://doi.org/10.11909/j.issn.1671-5411.2021.09.009}

Tricuspid atresia is a type of congenital heart defect characterized by the absence of the tricuspid valve, leading to no direct connection between the right atrium and ventricle. Consequently, the right ventricle is underdeveloped (hypoplastic). Nearly all patients with tricuspid atresia also present with an atrial septal defect, causing systemic venous blood to bypass the atretic tricuspid valve through a right-to-left shunt. Furthermore, abnormal arterial connections may also be observed in these cases.

Ventricular septal defect (VSD) is a common congenital heart condition where there's an abnormal opening in the wall between the heart's lower chambers (ventricles). Types include: Perimembranous VSD: Most common, near the membrane of the septum. Muscular VSD: In the muscular part of the septum. Mal-aligned VSD: Similar to perimembranous VSD. Inlet VSD: Near the tricuspid valve between the right atrium and ventricle. Subpulmonic VSD: Near the pulmonary valve, affecting blood flow to the lungs.

Barlow's disease is a degenerative condition affecting the mitral valve, where the infiltration of myxoid material leads to the valve's appearance resembling myxomatous tissue, notably with excessive thickening of the leaflets. This condition is characterized by significant dilatation of the annulus, prolapse of both leaflets, and the presence of thick, spongy leaflets caused by an abundance of myxomatous tissue proliferation.

Infective endocarditis (IE) is primarily associated with risk factors such as prosthetic valve replacement, hemodialysis, venous catheters, immunosuppression, intravenous drug use, and cardiac implantable electronic devices. The leading causative agents, accounting for majority of cases, are Gram-positive cocci  (e.g. Staphylococcus, Streptococcus species). Echocardiography plays a crucial role in diagnosing IE by identifying key features like vegetations, abscesses, and prosthetic valve dehiscence. It evaluates the size, number, shape, location, echogenicity, and mobility of vegetations, providing valuable information for predicting the risk of embolism.

Pleural effusion (PE) is identified as an echo-free space behind the heart when a patient is in the supine or left lateral position. In our echocardiographic practice, we differentiate between pleural and pericardial fluid based on specific criteria. Fluid found exclusively behind the left atrium is more indicative of pleural effusion rather than pericardial effusion. One reliable distinction is the location of the fluid relative to the descending thoracic aorta: fluid situated posterior to the descending aorta is likely pleural, whereas fluid anterior to the aorta is typically pericardial.

Mitral stenosis (MS) results in obstruction of blood flow from the left atrium to the left ventricle. This leads to increased pressures in the left atrium, pulmonary vasculature, and the right side of the heart, while the left ventricle remains unaffected in isolated MS. The primary cause of MS is typically rheumatic heart disease, characterized by mitral commissural fusion, thickened valve leaflets with restricted motion at the tips, and thickening, shortening, fusion, and calcification of the chordae tendineae. In resource-limited settings, patients with rheumatic heart disease may present with pure MS, pure mitral regurgitation, or a combination of both conditions.

Simpson's biplane rule (SBR) is widely regarded as the gold standard for quantifying left ventricle (LV) volume using echocardiography. It employs a summation-of-disks method, which assumes specific orientations and cross-sectional shapes of the LV. The recommended echocardiographic views for tracing the LV include the apical four-chamber (A4C) and two-chamber (A2C) views longitudinally.


_{https://doi.org/10.1016/j.ultrasmedbio.2022.07.013}

Constrictive pericarditis (CP) is a chronic condition that can develop following various pericardial diseases. It is characterized by the loss of normal pericardial elasticity, leading to exaggerated interventricular dependence and discordance between intracardiac and intrathoracic pressures during breathing. Echocardiographic criteria used to distinguish CP from restrictive cardiomyopathy include observing a respiration-related ventricular shift (septal bounce), variations in mitral inflow velocity with respiration, and prominent diastolic flow reversal in the hepatic veins during expiration.

Echocardiographic Assessment of Aortic Stenosis - St. Michael's Hospital, Toronto.

Objectives covered in this video: Assessment of aortic valve morphology, standard transthoracic echocardiographic measurements for assessment of aortic stenosis and common caveats to echo parameters of aortic stenosis