SHA24/015003

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