Sunil Mankad, MD, FACC, FCCP, FASE

Sunil Mankad, MD, FACC, FCCP, FASE Director, Transesophageal Echocardiography Associate Director, Cardiology Fellowship Associate Professor of Medicine Mayo Clinic, Rochester, MN [email protected] @MDMankad Disclosures

Relevant Financial Relationship(s) Advisory Council: Siemens Healthcare, Ultrasound Division

Off Label Usage None Rules:

1. First team to light control will have chance to answer; if incorrect, next team to light control will have chance 2. One round 3. Anyone who answers before acknowledged by the host will forfeit turn and may give answer to other team 5. Two Daily Doubles 6. Final Arbitrator: Dr. William Freeman 7. Official Scorer: Dr. Rekha Mankad Jeopardy!: All trademarks, service marks and trade names are proprietary to Columbia TriStar Interactive, Columbia Pictures Inc. TriStar Pictures, Inc., Sony Pictures Entertainment, Inc. and Hill-top New Media, Inc.

Alex Trebek Sunil Mankad (Alex Imposter) Ready?? Let’s Play! ECHO JEOPARDY Dermatology It’s Echo Terror in The 3rd For the Complicated Potpourri Tucson Heart Dimension 100 100 100 100 100

200 200 200 200 200

300 300 300 300 300 400 400 400 400 400

500 500 500 500 500

B S S R A C Final Jeopardy It’s Complicated 100 This complication occurred as a result of Aortic Valve endocarditis This complication occurred as a result of Aortic Valve endocarditis It’s Complicated 100 • What is aneurysm of the AV intervalvular fibrosa? It’s Complicated 200

The Post MI Complication Shown The Post MI Complication Shown It’s Complicated 200 •What is myocardial rupture (with coagula tamponade)? Myocardial Free Wall Rupture

•Occurs in approximately 1% of MI’s • Accounts for up to 8-17% of deaths •More common in women, hypertensive and older patients •Single CAD •Usually no clinical warning signs • Sudden death Case •78 year old female •Presented with chest pain and evidence of “NSTEMI” by biomarkers •EKG - nonspecific •Echocardiogram: Preserved EF, lateral HK •Cath: occluded diagonal, 70% RCA and LCx  planned medical tx •Worsening dyspnea and atypical chest pain 48 hours after admission Stat Echo in Post NSTEMI patient (occluded diagonal)

LV RV

Taken Emergently to OR Myocardial Rupture

30-40% of patients may have “subacute” free wall rupture -Hypotension -Nausea/emesis -Pericardial chest pain 58 year old male 3 days post-MI Perioperative TEE More Typical Scenario for Myocardial Rupture •65 year old male •Inf Lat MI, PCI with DES, EF 45% 2 days later

•Patient in bathroom, syncope •Stat Echo during code •Echo reveals rupture with coagulum Myocardial Rupture  Tamponade  Death

Image Courtesy of William Edwards, MD Its Complicated 300 This complication led to heart failure in a patient with endocarditis This complication led to heart failure in a patient with endocarditis It’s Complicated 300 • What is mitral leaflet (anterior leaflet, A3 location) perforation? It’s Complciated 400

The most likely cause of acute dyspnea in this patient The most likely cause of acute dyspnea in this patient It’s Complicated 400 • What is an acute pulmonary embolus? Dilated IVC “Caught in the Act” DVT in Transit caught in PFO Pulmonary Embolus Daily Double!!! It’s Complicated 500

The specific cause of back pain in this patient with HTN is shown by TEE The specific cause of back pain in this patient with HTN is shown by TEE It’s Complicated 500

•What is intramural hematoma? • Localized thickening of aortic wall • Crescentic or circular • Intimal displacement of calcium It’s Complicated 500 •Intramural Hematoma Aortic Pathology

Coady MA et al. Cardiol Clin 1999;17:637 Berger F et al. Radiology Assistant Online 2006 Echo Potpourri 100

The specific congenital abnormality shown The specific congenital abnormality shown Echo Potpourri 100 What is an Unicuspid Aortic Valve? Often fatal aortic stenosis in children under 1 year Rare in adults ~0.02% Uni- or acommissural Causes aortic stenosis Associated with aorta dilatation

J Heart Valve Dis 2003 Nov;12(6):674-8 Echo Potpourri 200

The most likely diagnosis shown Echo Potpourri 200

The most likely diagnosis shown 2D TEE of Liver 3D TTE Echo Potpourri 200

•What is Carcinoid Heart Disease (Carcinoid Tumor Mets in the Liver)? 39 year old male with diarrhea, flushing and weight loss Carcinoid: Echo Features

Tricuspid valve • Thickened leaflets • Retracted leaflets • Fixed semi-open position Pulmonary valve • Thickened cusps • Retracted and rigid Pulmonary Valve Involvement Pulmonary Valve Involvement

Adapted from Mayo Image Data Base, William Edwards, MD Severe (Torrential) Tricuspid Regurgitation Systolic RV  RA pressure equalization

TR CW Doppler

Courtesy of Dr. WK Freeman Carcinoid Syndrome: 3D TTE En Face View of TV

Courtesy of Denisa Muraru, MD, PhD Padua, Italy

Eur Heart J Cardiovasc Imaging 2012 Courtesy of Dr. Heidi Connolly Carcinoid Tumor: 3D TTE En Face Liver Metastases View of TV Echo Potpourri 300

The Specific Congenital Abnormality Shown Echo Potpourri 300 The Specific Abnormality Shown Echo Potpourri 300

•What is a Sinus Venosus VSD with anomalous pulmonary venous return? Sinus Venosus ASD with anomalous pulmonary venous drainage (RUPV) Echo Potpourri 400

The specific diagnosis in this 20 year old with Down’s Syndrome The Specific Diagnosis Shown Echo Potpourri 400

What is an Endocardial Cushion (AV Canal) Defect? 20 year old female with Down’s Syndrome

RA LA

RA LA RV LV

RV LV

Echo Potpourri 500

The most likely diagnosis in this asymptomatic male athlete with LVH on EKG The most likely diagnosis in this asymptomatic male athlete with LVH on EKG What is Congenital LV Outpouching or aneurysm (accessory LV chamber)? Terror in Tucson 100

This diagnosis was made easier with contrast echocardiography and strain imaging This diagnosis was made easier with contrast echocardiography and strain imaging Terror in Tucson 100 What is Apical HCM? Terror in Tucson 200

The specific name for the secondary murmur that would be auscultated in the following patient The specific name for the secondary murmur that would be auscultated in the following patient Terror in Tucson 200

What is an Austin Flint Murmur? What is an Austin Flint Murmur?

Holodiastolic rumble S1

SEM Terror in Tucson 300 The most likely diagnosis of the mass shown by TEE The most likely diagnosis of the mass shown by TEE Answer 300 Lipoma or lipomatous mass in the transverse sinus Terror in Tucson 400

The specific diagnosis in this patient with an abnormal blood test The specific diagnosis in this patient with an abnormal blood test Terror in Tucson 400 What is Eosinophilic Myocarditis? Eosinophilic Heart Disease 4 Stages: Allergic reaction Autoimmune disease Parasitic or Malignancy Idiopathic 1) Acute inflammatory Protozoal infections myocarditis Overproduction of cytotoxic eosinophils 2) Eosinophil rich thrombus Infiltration of myocardium by eosinophils deposition Degranulation of eosinophilic granules - Mediated by injured Tissue damage endothelium Necrotic phase 3) Endocardial thickening Acute pericarditis, myocarditis, or endocarditis - Valve involvement Thrombotic phase Formation of intramural thrombi 4) Fibrosis Adjacent to injured endocardium Fibrotic phase Hirota Y: In Abelmann WH, Braunwald E [eds]: Atlas of Heart Diseases. Vol 2. 1995 Localized or extensive replacement fibrosis Natural History Hypereosinophilic Syndrome

RA LA

RV VS LV Clot Scar

Myocarditis  Thrombus  Fibrosis Basal LV Fibrosis with Mitral Posterior Leaflet Tethering

- Courtesy of Dr. N. Pandian Eosinophilic Heart Disease: Contrast Echo Hypereosinophilic Syndrome Treatment •Medical therapy •Corticosteroids •Hydroxyurea •Interferon •CHF Meds •Surgical Therapy •Palliative Our Case: TTE after 2 months of anticoagulation and 1 month of prednisone therapy Terror in Tucson 500

The cause of hypertension in this 24 year old male Terror in Tucson 500 The cause of hypertension in this 24 year old male Terror in Tucson 500 Answer: What is Aortic Coarctation? Aortic Coarctation Aortic Coarctation

CT Angio Bicuspid Aortic Valve

•Prevalence of 1-2% of the population (male > female) •From fusion of two cusps Bicuspid AV and Aortic Coarctation Warnes CA Heart 2003;89:965 Bruce CJ, Breen JF NEJM 2000

• 10% of Bicuspid Valves Associated with Coarctation • 40-50% of Coarctation Patients Have a Bicuspid AV Dermatology for the Heart 100 The diagnosis shown in this patient The diagnosis shown in this patient Dermatology for the Heart 100 •What is Cardiac Tamponade? Dermatology for the Heart 200 The most likely diagnosis in this patient following pericardiocentesis Dermatology for the Heart 200 Diagnosis after pericardiocentesis What is Effusive Constrictive Pericarditis? Effusive Constrictive Pericarditis •After pericardiocentesis, there is persistent modest elevation of right atrial pressure and the development of the classic “constrictive” waveform Dermatology for the Heart 300 The most likely diagnosis in this asymptomatic patient The most likely diagnosis in this asymptomatic patient

* * Deermatology for the Heart 300

What is Effusive Constrictive Pericarditisa Pericardial Cyst?

* * Dermatology for the Heart 400 The most likely diagnosis in this patient with an abnormal chest x-ray Dermatology for the Heart 400 The most likely diagnosis in this patient with an abnormal chest x-ray

LV Dermatology for the Heart 400

What is congenital absence of the pericardium?

LV Congenital Absence of the Pericardium Dermatology for the Heart 500 The specific diagnosis shown is the cause of hypotension and the reason the echocardiogram could not visualize the heart The specific diagnosis shown is the cause of hypotension and the reason the echocardiogram could not visualize the heart Dermatology for the Heart 500 What is Pneumopericardium Tamponade? Tension Pneumopericardium in Hodgkin’s Disease

by Frank M.P. van Haren, Aernout Borstlap, and Norbert Foudraine

Circulation Volume 114(5):e77-e79 August 1, 2006

Frank M.P. van Haren et al. Circulation. 2006;114:e77-e79

Copyright © American Heart Association, Inc. All rights reserved. Figure 2. ECG showing sinus tachycardia at 140 bpm with small voltage deflections in the precordial leads and inferior and anterolateral inverted T waves, suggestive of pericardial effusion.

Frank M.P. van Haren et al. Circulation. 2006;114:e77-e79

•The diagnosis shown by 3D TEE in this patient with bacteremia The diagnosis shown by 3D TEE in this patient with bacteremia The 3rd Dimension 100

•What is pacemaker lead vegetation (endocarditis)? The 3rd Dimension 200

•The specific abnormality revealed by TEE The specific abnormality revealed by TEE The 3rd Dimension 200

•What is a flail P1 (causing severe mitral regurgitation)? Transesophageal 3D Echocardiography

• Allows visualization of mitral valve leaflets, orifice, and submitral apparatus in a manner that is not possible using conventional 2D echo • “En face” views of the MV from atrial and ventricular perspective •Fully sampled volume, not mechanically rotated Mitral Valve Anatomy: View from the Left Atrium

Carpentier Nomenclature

A3 A1 A2 P3 P1 P2 Mitral Valve Scallops Commissural view at 60 degrees Flail MV Scallops P1 P2 P3 The 3rd Dimension 300

•The cause of CVA in this afebrile 33 year old female is shown by TEE Cause of CVA in 33 y.o. female (300) The Third Dimension 300 What is a papillary fibroelastoma on the AV? J Am Coll Cardiol 1997;30:785

American Heart Journal 2003;146:404

Ann Thorac Surg 2005;80:1712-8 Echo Features of PFE • Round, oval, or irregular • Well-demarcated border • Homogenous appearance • “Speckled” appearance • “Stippling” around the perimeter • Multiple fronds Third Dimension 400 The specific mitral intervention shown by 3D TEE The specific mitral intervention shown by 3D TEE

Pre-procedure Intra-procedure Third Dimension 400

•What is mitral valve-in-valve placement (for severe prosthetic valve stenosis)? Case

• 86 y/o with class IV CHF • S/P AVR→Core-Valve (Germany) • S/P MVR with a CE valve (2000) • Severe mitral prosthesis stenosis

MG = 13 mmHg Melody Valve • Bovine jugular venous valve segment • Platinum-Iridium stent Mitral Valve-in-Valve Therapy Transapical Approach Echo Guided Procedure Melody in Mitral Valve-in-Valve

Mean Gradient 5 mmHg Daily Double!!! The 3rd Dimension 500

•The specific prosthetic valve complication shown? Specific prosthetic valve complication shown Baseline After 1 month of warfarin

Mean gr = 3 mmHg (HR 66) Mean gr = 8 mmHg (HR 67) The 3rd Dimension 500

•What is bioprosthetic valve thrombosis? Mitral Prosthesis

• Diastolic mean gradient: 8 mmHg (HR: 69 BPM) • Blood cultures negative

Bioprosthetic Valve Thrombosis: Diagnosis

•Challenging •TTE: no set criteria • Increased gradients • Thickened cusps, thrombus •TEE • Soft echodensity in cusps •CT Misconceptions in BPVT

Peak incidence second year Longest interval: 6.5 years EJCTS 2014 Misconceptions in BPVT

EJCTS 2014 VKA as effective as surgery / lytics

Egbe et al. JACC 2015 Proposed Echo Criteria for BPVT 1. Increased gradient > 50% over baseline, especially within first 5 years post-implant 2. Thickened, non-calcified leaflets 3. Restricted leaflet mobility All 3 parameters: 72% sensitivity, 90% specificity for BPVT

Egbe et al. JACC 2015 Our patient: One Month VKA

Diastolic mean gradient: 3 mmHg (HR 66 BPM) Sensei: Dr. Jae K. Oh The “Switch” Seatbelts Save Lives! You think that you are having a bad day? The Great Actor! The Importance of Good Communication! Final Jeopardy “Echolocation” Final Jeopardy Which animal does not utilize echolocation? Shark Bat Narwhal

Dolphin. Shrew Swiftlet Defintion: Echolocation •Echolocation, also called bio sonar, is the biological sonar used by several kinds of animals. •Echolocating animals emit calls out to the environment and listen to the echoes of those calls that return from various objects near them. •They use these echoes to locate and identify the objects. •Echolocation is used for navigation and for foraging (or hunting) in various environments. Does Not Use Echolocation

Shark Champions Thank you!