Ahmad Omran MD, FACC, FESC, FASE Head, Non-Invasive Cardiology Lab King Abdulaziz Cardiac Center Kingdom of Saudi Arabia
Interactive Case Discussion (1) 10th Gulf Heart Association Conference joined with SHA 24 February 13-16, 2013 Riyadh, Kingdom of Saudi Arabia
Case 1 The boy whom I do not want to see again!!
Case 1 10-year-old boy with one month history of fever, anemia and SOB was referred to our pediatric cardiology clinic in 2003
Question: What is your diagnosis? • A- VSD • B- Perforation of aortic valve • C- Perforation of mitral valve • D- Perforation of MV and AOV
Patient was taken to the OR 5 days after medical treatment
Patient had AVR with subcoronary implantation of a Medtronic free-style root. AMVL perforation was repaired by a fresh autologous pericardial patch.
Medtronic free-style root is a porcine (xenograft) aortic root for AVR and root replacement
Follow up TTE in 2005
Presented again with SOB in 2011
What is your next step? • A- Medical treatment and watchful follow up • B- Redo AVR and MVR with mechanical valves • C- Redo AVR with mechanical but repair the MV • D- Only mechanical MVR
Patient underwent redo AVR with mechanical valve and mitral valve repair with an annuloplasty ring. Post op TEE in the OR‌..
Follow up echo 4 month later‌
What is the diagnosis? • A- Endocarditis of mitral valve • B- Mitral ring dehiscence • C- Perforation of anterior mitral leaflet • D- Mitral annular dilatation and MR
TEE
LV side
Systole
Diastole
Patient was taken to the OR on Jan 2013
Dr Najim, KACC, 08-Jan-2013
Case 2 32-year-old Syrian male with 2-3 month history of fatigue, SOB, peripheral edema and ascites
What is your diagnosis? • A- Dilated cardiomyopathy • B- restrictive cardiomyopathy • C- Posterior wall infarction • D- None of the above
Inspiratory shift of the septum
Pericardial thickness= 0.6 cm
RVSP= 18 +10= 28 mmHg
TAPSE = 1.36 cm
Doppler respiratory variation of tricuspid inflow, inspiratory increase
Doppler respiratory variation of mitral inflow, Expiratory increase
E
A
Mitral inflow Doppler :E= 60.8 cm/sec, A= 48.7 cm/sec
Color M-mode velocity propagation (Vp) Vp= 40.3 cm/sec (arrow)
IVRT= 71 sec
S
D
RUPV flow
Tissue Doppler Imaging (TDI), velocity of mitral annulus motion showing supper normal velocity at lateral and septal annulus
TDI= 15-18 cm/sec
IVC plethora and lack of collapsibility, hepatic venous flow reversal
End-diastolic hepatic venous flow reversal augmented in expiration (arrows)
End-diastolic hepatic venous flow reversal augmented in expiration (arrows)
End-diastolic hepatic venous flow reversal, augmented in expiration (arrows)
Dr AlKhaldi, KACC, 30-Oct-2012
F/U echo 3 month after pericardiectomy
Case 3 39-year-old male presented with SOB
Where is the attachment of the mass?
• A- LA roof
• B- Interatrial septum • C- Anterior mitral valve leaflet • D- coronary sinus
Dr A.Ghamdi, KACC, 05-Feb-2013
Case 4 36-year-old diabetic female with history of MI in another hospital referred to echo lab for SOB
What is the pathology? • A- Endocarditis of the aortic valve • B- Stent in RCA injuring AOV • C- Stent in LMCA injuring AOV • D- Stents are in right position, AI is due to prolapse of aortic cusps
Dr Najim, KACC, 17-05-2012