Let's do some echo:

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This is the ME 4 chamber for a patient with non-ischemic CM, coming for Heartmate 3 LVAD...


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...And this is the identical picture post-bypass, with the VAD now set to 5300RPM.

Anyone want to venture a guess as to what that thing is that we’re now seeing in the left atrium? Are we worried? Is there anything we could do to fix it?
 
Hork Bajir said:
View attachment 334021
This is the ME 4 chamber for a patient with non-ischemic CM, coming for Heartmate 3 LVAD...


View attachment 334024
...And this is the identical picture post-bypass, with the VAD now set to 5300RPM.

Anyone want to venture a guess as to what that thing is that we’re now seeing in the left atrium? Are we worried? Is there anything we could do to fix it?
Click to expand...
Left atrial dissection?

*I’ll admit I’m throwing a Hail Mary*
 
Looks like an LA hematoma. (Or pericardial posterior to th LA) If that's what it is, it's expanded pretty rapidly so leaving it alone not a great option?
 
Sorry, should have clarified- this was actually a PFO closure device (gone terribly wrong). Forgive my delirium, I desperately need some sleep...

I was more just trying to comment on the risks of all these catheter-based interventions... in this case the tricuspid valve got pretty chewed up before they were able to retrieve the device (maximally invasive at that point).
 

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Is that an amplatzer? what did the anterior space look like? Was there a good biting ridge? We have aborted this procedure due to device/tissue issues. Echo... is super important here.
 
Hork Bajir said:
Sorry, should have clarified- this was actually a PFO closure device (gone terribly wrong). Forgive my delirium, I desperately need some sleep...

I was more just trying to comment on the risks of all these catheter-based interventions... in this case the tricuspid valve got pretty chewed up before they were able to retrieve the device (maximally invasive at that point).
Click to expand...

Hopefully you won’t be fired for taking a photo.
 
What size was it?
These devices are definitely not small.
 
sevoflurane said:
No identifiers.

Thanks for posting @Hork Bajir
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I was referencing posts like this. Personally I think it’s silly.

agolden1 said:
Previous hospital’s opinion take on this, not mine:

Even without any identifiers, the patient did not provide permission for you to take this picture and post it and discuss their health on an online forum. If somehow you were doxed or a colleague reported it, you would be terminated without a second thought.

Easiest course of action when in doubt? Every hospital has a HIPAA person or office. If you have questions, quietly reach out and clarify. They’re happy to chat security often follow case outcomes across the country and can do tell you legal outcomes far better than our anecdotal stories.

Having very nearly been burned by this myself at one point in my career, it’s something I take as seriously as possible.
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I’ve put in some of the biggest sized ones. Gives me a little bit of reservation, but echo/fluoro is key.
 
abolt18 said:
I have no idea what I'm looking at. Heartworms? (joking) I don't know though. Thrombus hanging off the end of a CVC? Looking forward to your description of this one.
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This is thrombus in transit through the right side of the heart. Judging by the position of the inter-atrial septum and the size of the IVC, some of the thrombus has already found a new home in the lungs. Hopefully for this patient’s sake there was no PFO (and hopefully these pictures were taken right before a surgical thrombectomy)
 
Quick question. If you want to submit a case report do you need permission from the patient? I have a potential case which quite honestly probably would get rejected and I’m not sure how much support I’m going to get being in private practice but I’m just curious
 
Hork Bajir said:
Surgeons are frantically prepping to crack the chest, and I’m like “hold up can you guys stop touching the patient for a sec, it’s messing up my 6 beat acquisitions”
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I remember in fellowship a CV surgeon called me out because during an emergency pericardial window from cath lab I was doing pulse wave measurements on the pulmonary veins
 
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sevoflurane said:
Is that an amplatzer? what did the anterior space look like? Was there a good biting ridge? We have aborted this procedure due to device/tissue issues. Echo... is super important here.
Click to expand...
Delayed answer to your question: this was a Cardioform septal occluder (Gore). The anterior rim was virtually non-existent, so I had my doubts as to whether this procedure was ever going to be successful... The cardiologists told me they chose this device (as opposed to an Amplatzer) because it is a little bit more flexible in terms of its ability to “splay out” over the aortic root in the case of a deficient anterior rim. Interestingly, they were right (initially): the device was successfully placed and looked to be in good, stable position. Then 20 minutes later as they were closing up the groin, the patient started coughing and having lots of ectopy- guess what we found next...
 
This patient had an AVR and ascending aortic replacement about 6 months prior (done for BAV stenosis and ascending aneurysm, native root left alone during the index surgery). He now presents with a couple of blue toes, and you obtain these echo images. It’s 5pm on a Friday... Anyone want to describe the abnormal findings here? Are we going to the operating room? If so, can it wait until Monday? (Look closely...)

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Big ol paravalvular there eh on the posterior aspect. Looks like what would be the non or the lefts gotta strand... Ominous enough... Probably gotta move on that

Valves rocking. Might be an abscess
 
If you look closely at the 1st clip in systole you can clearly see a goober on the bioprosthetic leaflet where the native LCC would be, in the region of the LCC/RCC commisure.

Also, it does look like the valve is rocking but sometimes it can have that appearance with a sized down valve in a root sparing procedure and be normal. But in this case I would bet on partial dehiscence. High risk for stroke. Go to OR.
 
Nice. Anything else catch your eye? Anything unusual about this “paravalvular leak”? What kind of operation do you anticipate this patient is going to need?
 
So the first thing to notice is that the aortic root measures about 5.5cm- this patient had an AVR/ascending about 6 months prior, and they wouldn’t have left the route alone if it looked the same at that point in time (which it didn’t). Additionally, note that the anterior wall of the aortic root in SAX looks very thin and irregular... something is seriously wrong with that tissue, and it is disintegrating fast.

As @vector2 and @Newtwo pointed out, the valve is rocking, and a vegetation can be seen. All of this points towards partial dehiscence. What’s cool here is that this isn’t the usual kind of paravalvular leak: it seems to happen mostly in systole, rather than diastole. The valve is lifting up off of the aortic anulus with each beat, and then during diastole it falls back into place and closes off the “hole”.

Based on what we have seen so far, dude needs a redo AVR and root replacement. This next image is from the same patient- anything additional that you want to tell the surgeon?

1618612791363.gif
 
Hork Bajir said:
So the first thing to notice is that the aortic root measures about 5.5cm- this patient had an AVR/ascending about 6 months prior, and they wouldn’t have left the route alone if it looked the same at that point in time (which it didn’t). Additionally, note that the anterior wall of the aortic root in SAX looks very thin and irregular... something is seriously wrong with that tissue, and it is disintegrating fast.

As @vector2 and @Newtwo pointed out, the valve is rocking, and a vegetation can be seen. All of this points towards partial dehiscence. What’s cool here is that this isn’t the usual kind of paravalvular leak: it seems to happen mostly in systole, rather than diastole. The valve is lifting up off of the aortic anulus with each beat, and then during diastole it falls back into place and closes off the “hole”.

Based on what we have seen so far, dude needs a redo AVR and root replacement. This next image is from the same patient- anything additional that you want to tell the surgeon?

View attachment 335077
Click to expand...
I could be creating problems but it looks like he needs his mitral fixed as well. Anterior leaflet looks like it has a little something growing on it and i would bet there's some degree of MR. Redo AVR, Root, add an MVR?
 
@Twiggidy you’re spot on- he had a satellite “kissing lesion” on the ventricular surface of the AMVL. Fortunately there was only trace MR, and the surgeon was able to debride the leaflet and otherwise leave the native mitral valve alone

@Newtwo you’re overly pessimistic... Maybe you need to work with better surgeons? Certainly this is a bad problem to have, but dude is doing ok so far and recovering from the surgery as expected
 
great work!!

We got 2 world class surgeons, the rest have their days where they can be good or terrible. Some rarely have good days unfort
 
Ok, different case- this one was from today. CABG/MVR/TVr. Come off pump and start to assess the valves, and you see these images. What is it, and can we give protamine or is there more work to do?

(And for bonus points, take a look at the third image- what pathology do we see, and does it have any implications as to whether the ischemic MR would have been repairable?)

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I don’t see how this is even possible right after cpb, but in addition to an anterior pvl it looks like you have a thrombus on the subvalvular apparatus. Acute thrombosis is rare and usually occurs days after MVR. Also possibly something (torn suture?) on the anterior aspect of the MV on the LA side (could just be normal suture line tho).

Nice cases everybody.
 
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