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The WATCHMAN™ atrial appendage closure device is designed to reduce the risk of stroke in patients with nonvalvular atrial fibrillation who are not suitable candidates for long-term oral anticoagulation therapy. However, the device also carries small risks, including procedural complications such as device migration, embolization, or pericardial effusion. We describe a case of WATCHMAN device migration requiring surgical retrieval.

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A 39-year-old woman with intermittent palpitations, psoriasis, and a family history of sudden death presented with dilated right heart chambers and an enlarged coronary sinus. Despite a normal bubble study, further evaluation with transesophageal echocardiography revealed an abnormal pulmonary venous return: the left pulmonary veins drained into the coronary sinus. Cardiac computed tomography confirmed this finding, suggesting a partial abnormal pulmonary venous return as the underlying issue. Cardiac catheterization indicated increased pulmonary artery flow with normal pulmonary vascular resistance. The patient was referred for surgery. In this pathway involving the differential diagnosis of right heart dilatation, despite a confusing history and conflicting findings, echocardiographic clues led to the diagnosis.

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BACKGROUND: Ball thrombus is rare and life-threatening. The correct diagnosis and timely management are key to improving patient prognosis. Here, we present a case report and literature review of ball thrombus. CASE PRESENTATION: A 75-year-old woman presented to our outpatient clinic because of palpitations and chest distress for 8 months. She was diagnosed mitral stenosis, and transthoracic echocardiography (TTE) showed a round mass attached to the left atrial (LA) wall. Before anesthesia induction, TTE found that the mass has dropped from the LA wall, and was spinning in the LA causing intermittent obstruction of the valve. Anesthesia induction was then carried out under TTE monitoring, and transesophageal echocardiograph found another mass in the LA appendage after intubation. She underwent LA mass removal and mitral valve replacement, and was discharged uneventfully. Histopathology confirmed the diagnosis of thrombus. Our literature review identified 19 cases of ball thrombus between 2015 and 2024. The average age was 54.8 (range 3-88) years. Heart failure was present as the initial symptom in 11 cases, and most patients had mitral valve disease or concomitant with atrial fibrillation. 12 cases received surgery, and 7 received medical treatment only. 2 deaths occurred, one due to the obstruction of left ventricular inflow tract and the other due to the worsening of heart failure. CONCLUSION: Ball thrombus is rare in clinical settings. Urgent thrombectomy should be performed as soon as possible, and echocardiography can be used for real-time monitoring during surgery.

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OBJECTIVE: This study aims to assess the efficacy and safety of tricuspid valve (TV) transcatheter edge-to-edge repair (TEER) procedures using the MitraClip or TriClip device in high-risk patients with severe secondary tricuspid regurgitation (TR) and provide Turkish-specific data on procedural outcomes and clinical follow-up. METHODS: This study enrolled 42 high-risk patients with severe secondary TR who underwent transcatheter edge-to-edge repair using either the MitraClip or TriClip device. Patient selection criteria included severe TR, high surgical risk (EuroScore ≥ 8 and Tricuspid Regurgitation Impact Severity Score (TRI-SCORE) ≥ 6), symptomatic despite medical therapy, and anatomical suitability for TriClip. Patients underwent rigorous evaluation by a specialized cardiac team before the procedure, including 2D/3D transesophageal echocardiography to assess eligibility. RESULTS: The study achieved a 100% procedural success rate, defined as successful implantation and at least one-degree reduction in TR severity. Post-procedure assessments revealed that 88.1% of patients had mild to moderate TR, indicating significant improvement, while only 11.9% retained severe TR. During the median follow-up of 11.5 months, rehospitalization occurred in 23.8% of patients, and mortality was observed in 7.1% of patients, demonstrating a favorable safety profile. Comparative analysis between TriClip and MitraClip devices showed similar efficacy and safety outcomes, with no significant differences in procedural durations or complication rates. CONCLUSION: The study demonstrates the effectiveness and safety of TV TEER using TriClip or MitraClip devices in managing severe secondary TR in high-risk patients. Procedure success, improved TR severity, and favorable clinical outcomes were observed, supporting the role of transcatheter techniques in TR management.

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BACKGROUND: To date, the relationship between the Transesophageal Echocardiography (TEE) monitoring indicator tricuspid annular plane systolic excursion (TAPSE) and the incidence of postoperative acute kidney injury (AKI) in Coronary Artery Bypass Grafting(CABG) patients remains unknown. The main objective of this study was to explore the relationship between the TAPSE and the incidence of AKI in CABG patients. METHODS: This was a multicenter prospective cohort study was conducted between September 2021 and July 2022. Among 266 patients aged at least 18 years who underwent elective CABG, 140 were included. RESULTS: We measured TAPSE via M-mode TEE via the mid-esophageal (ME) right ventricle(RV) inflow-outflow view (60°). All echocardiographic measurements were performed three separate times at each time point: T0 (before the start of CABG), T2 (approximately 5 ∼ 10 min after neutralization of protamine) and T3 (before leaving the operating room), and then averaged. Serum creatinine was measured 1 day before and within 7 days after CABG. There was no statistically significant association between the TEE-monitoring indicator TAPSE and the incidence of postoperative AKI in patients who underwent CABG. CONCLUSIONS: The TAPSE was not significantly correlated with postoperative AKI incidence and could not predict the early occurrence of postoperative AKI in CABG patients. TEE needs more evaluation for clinical efficacy of predicting the early occurrence of postoperative AKI in isolated CABG.

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BACKGROUND: The patent foramen ovale (PFO) and interatrial block (IAB) are associated with cryptogenic stroke (CS). However, the role of the interaction between PFO and IAB in CS remains unclear. METHODS: This case-control study enrolled 256 patients with CS and 156 individuals without a history of stroke or transient ischemic attack. IAB was defined as P wave duration > 120 ms. PFO was evaluated by contrast transesophageal echocardiography, and classified as no-PFO, low-risk PFO and high-risk PFO. Multiplicative and additive interaction analysis were used to assess the interaction between PFO and IAB in CS. RESULTS: Multiplicative interaction analysis unveiled a significant interaction between IAB and low-risk PFO in CS (OR for interaction = 3.653, 95% CI, 1.115-12.506; P = 0.037). Additive interaction analysis indicated that 68.4% (95% CI, 0.333-1.050; P < 0.001) of the increased risk of CS related to low-risk PFO was attributed to the interaction with IAB. The results were robust in multivariate analysis. However, but no significant multiplicative or additive interaction was observed between IAB and high-risk PFO. When stratified by IAB, high-risk PFO was associated with CS in both patients with IAB (OR, 4.186; 95% CI, 1.617-10.839; P = 0.003) and without IAB (OR, 3.476; 95% CI, 1.790-6.750; P < 0.001). However, low-risk PFO was only associated with CS in patients with IAB (OR, 2.684; 95% CI, 1.007-7.149; P = 0.048) but not in those without IAB (OR, 0.753; 95% CI, 0.343-1.651; P = 0.479). CONCLUSION: The interaction between IAB and PFO might play an important role in CS, particularly in cases with low-risk PFO.

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OBJECTIVES: The purpose of this study was to demonstrate the discriminating predictive indicators in peripheral blood and left atrium blood for predicting the risk of left atrial spontaneous echo contrast (LASEC) in atrial fibrillation patients underwent catheter ablation. METHODS: A total of 108 consecutive AF patients treated with radiofrequency ablation between July 2022 and July 2023 were enrolled and divided into two groups based on preprocedural transesophageal echocardiography: the non LASEC group (n = 71) and the LASEC group (n = 37). Circulating platelet and endothelial- derived MPs (PMPs and EMPs) in peripheral blood and left atrial blood were detected. Plasma soluble P-selectin (sP-selectin) and von Willebrand factor (vWF) were observed. Diagnostic efficiency was measured using receiver operating characteristic (ROC) curve. RESULTS: Peripheral sP-selectin, vWF and EMPs expressions elevated in all subjects when compared to those in left atrium blood. Levels of sP-selectin and vWF were significantly higher in peripheral blood of LASEC group than those of non LASEC group (p = 0.0018,p = 0.0271). Significant accumulations of peripheral PMPs and EMPs were documented in LASEC group by comparison with non LASEC group (p = 0.0395,p = 0.018). The area under curve(AUC) of combined PMPs and sP-selectin in predicting LASEC was 0.769 (95%CI: 0.678-0.845, sensitivity: 86.49%, specificity: 59.15%), significantly larger than PMPs or sP-selectin alone. CONCLUSIONS: Expressions of PMPs, sP-selectin, EMPs and vWF Increased in NVAF patients with LASEC and that might be potential biomarkers for LASEC prediction.

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RATIONALE: Alcoholic cardiomyopathy (ACM) is associated with various cardiac complications, but the development of isolated right atrial (RA) thrombus without deep vein thrombosis is rare and presents diagnostic challenges. PATIENT CONCERNS: A 53-year-old Hispanic male presented with shortness of breath, chills, cough, bilateral lower extremity edema, and distended abdomen. DIAGNOSES: The patient was diagnosed with ACM, liver cirrhosis, and a large RA thrombus. Initial transthoracic echocardiography showed severe left ventricular systolic dysfunction but failed to detect the RA mass. Subsequent computed tomography scan and transesophageal echocardiography revealed a large oval mass in the RA, measuring 40 mm × 22 mm × 18 mm. INTERVENTIONS: The patient received guideline-directed medical therapy for heart failure and anticoagulation with enoxaparin. He underwent cardiac catheterization for mechanical thrombectomy, which was minimally successful. OUTCOMES: The patient's condition was managed with the prescribed interventions. Regular follow-up was planned to assess thrombolysis. LESSONS: RA thrombosis is an uncommon complication of ACM. A multimodal imaging approach, with a low threshold for transesophageal echocardiography, is crucial in evaluating patients with ACM who present with cardiac complications. This approach enables accurate diagnosis and management of rare conditions like isolated RA thrombosis.

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Transesophageal echocardiography (TEE) plays an important role for real-time procedural guidance during surgical smyectomy (SM) for hypertrophic obstructive cardiomyopathy (HOCM). We aimed to compare (1) interventricular septum (IVS) thickness using 2- (2D) and 3-dimensional (3D) intraoperative TEE and preoperative cardiac magnetic resonance (CMR) and (2) mitral valve (MV) leaflet length using 2D, 3D TEE, automatic quantification of mitral valve (AMVQ) and preoperative CMR. We prospectively studied 50 patients with HOCM (age 59 ± 12 years, 44% men) who underwent SM during 2018 to 2019. The maximal basal, mid, and distal anteroseptum (AS) and inferoseptum (IS) were measured by multiplanar 3D reconstruction on TEE and by short-axis imaging on preoperative CMR and classified as mild (≤18 mm), moderate (18 to 25 mm), or severe (≥25 mm) groups based on AS and IS thickness on CMR. MV leaflet lengths were evaluated by preoperative CMR and intraprocedural 2D TEE, zoom 3D TEE, and AMVQ (EchoPAC, General Electric, Wisconsin). There was a moderate correlation between AS and IS thickness on 3D TEE and CMR (R2 = 0.46, p <0.01 and R2 = 0.41, p <0.01, respectively), with 3D TEE showing an average overestimation of 3.8 and 4.7 mm versus CMR. The 3D TEE overestimated 14 patients (56%) with mild thickness as moderate and 5 patients (22%) with moderate thickness as severe. Assuming 3D TEE as the gold standard, the closest correlation for anterior mitral leaflet length was with CMR (average overestimation by CMR of 0.5 mm [root mean square deviation (RMSE%) 17]), intermediate correlation with 2D TEE (average deviation of 0.6 mm [RMSE% 21]) and no correlation with AMVQ (average deviation of 0.7 mm [RMSE% 24]). In conclusion, 3D TEE overestimates IVS thickness versus CMR in patients with HOCM who underwent SM, with greater discrepancy in those with thinner IVS. There are significant differences in MV lengths measured using different imaging techniques.

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OBJECTIVE: This study aims to evaluate the application value of contrast-enhanced transthoracic echocardiography (cTEE) in the diagnosis of patent foramen ovale (PFO) under different states of stimulation, with the goal of enhancing the accuracy and efficiency of PFO diagnosis. METHODS: This research consecutively enrolled patients suspected of having PFO from October 2022 to February 2024, presenting primary clinical symptoms such as unexplained syncope, headache, dizziness, and stroke. Patients underwent standard transthoracic echocardiography (TTE) and cTEE under three different states of stimulation (resting state, coughing, and Valsalva maneuver). Based on the presence of microbubbles in the left heart and their initial appearance time, patients were classified into PFO and control groups, with further diagnostic confirmation via transesophageal echocardiography (TEE) or foramen ovale closure procedures. RESULTS: The study results revealed significant differences between the PFO and control groups regarding age (p = 0.034) and headache symptoms (p = 0.001). In the PFO group, TTE showed a higher positivity rate both at rest and during coughing, highlighting the association between PFO and specific clinical symptoms. The number of microbubbles observed during TTE increased significantly under various stimulation states, particularly during the Valsalva maneuver (p < 0.05). This increase became more pronounced as the duration of the maneuver was extended, underscoring the differential response of PFO patients under varied physiological testing conditions, especially during prolonged Valsalva maneuvers. CONCLUSION: The study confirms the significant value of cTEE in diagnosing PFO under different stimulation states, particularly emphasizing the application of the Valsalva maneuver to significantly improve the sensitivity and specificity of PFO detection. Thus, incorporating cTEE examinations under various stimulation states holds significant clinical importance for enhancing the accuracy and efficiency of PFO diagnosis.

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Marantic endocarditis is defined as a sterile endocarditis that is rarely encountered in clinical practice. This case series illustrates five cases of marantic endocarditis. All cases were diagnosed on trans thoracic echocardiography and verified on transesophageal echocardiography. The first three cases occur in the setting of antiphospholipid syndrome; the last two occur in the setting of advanced malignancy. Two cases were treated successfully with anticoagulation, while two others required valvular surgery. One case resulted in mortality. The treatment course of these five patients mirrors certain patterns described in the literature.

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BACKGROUND: Cleft in the mitral valve leaflet is a primary cause of congenital mitral regurgitation, stemming from developmental anomalies in the mitral valve and frequently associated with other congenital heart defects. Concurrent presence of cleft in mitral valve leaflet with atrial septal defect and ventricular septal defect is relatively rare. Echocardiography, especially transesophageal echocardiography, is essential in diagnosing cleft mitral valve leaflet and related congenital heart defects, providing critical, detailed imagery for accurate assessment. This study presents a young female patient whose anterior mitral cleft, along with atrial septal defect and ventricular septal defect, was revealed through three-dimensional transesophageal echocardiography. CASE PRESENTATION: A 25-year-old Iranian female, experiencing progressive dyspnea and diminished physical capacity over 3 months, was referred to our hospital. Initial examination and transthoracic echocardiography indicated severe mitral regurgitation. Further evaluation with transesophageal echocardiography corroborated these findings and identified a cleft in the anterior mitral valve leaflet, coupled with mild left ventricular enlargement and significant left atrial enlargement. The complexity of the patient's condition was heightened by the diagnosis of cleft mitral valve leaflet in conjunction with atrial septal defect and ventricular septal defect, showing the complex nature of congenital defects. CONCLUSION: This case emphasizes the critical role of transthoracic echocardiography in diagnosing cleft of mitral valve leaflet and associated cardiac anomalies, showcasing its superiority over transthoracic echocardiography for detailed visualization of cardiac structures. The identification of multiple congenital defects highlights the necessity for a comprehensive diagnostic approach to manage and treat patients with complex congenital heart diseases effectively. Future research should aim to refine diagnostic methodologies to enhance patient outcomes for cleft of mitral valve leaflets and related congenital conditions.

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Mitral valve repair techniques in ventricular functional mitral regurgitation are controversial due to ongoing debates about long-term repair durability in the setting of left ventricular remodelling. To address the limitations of conventional annuloplasty, subannular techniques, such as papillary muscle relocation, have been developed. However, the limited reproducibility of these techniques has hindered their widespread adoption. In this context, we introduce a simplified and reproducible method for papillary muscle relocation. This method utilizes transoesophageal echocardiographic guidance and premeasured polytetrafluoroethylene loops to streamline the procedure.

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OBJECTIVES: Ventricular septal defect (VSD) is a prevalent congenital cardiac anomaly. By enhancing the occluder design and optimizing procedural approaches, the indications for VSD closure can be broadened while minimizing associated complications. The utilization of fully biodegradable occluder holds promising potential in resolving conduction block issues encountered during VSD closure. This study aims to compare the results of the fully biodegradable occluder with the metal occluder in transoesophageal echocardiography-guided VSD closure via lower sternal level minor incision at the interim follow-up, and to find risk factors for the occurrence of electrocardiographic and valvular abnormalities postoperatively. METHODS: We reviewed the postoperative and 3-year follow-up data of all patients who underwent the randomized controlled study of VSD closure from January 1 to November 7, 2019 in the Second Xiangya Hospital of Central South University. The safety and efficacy of the procedure were assessed and compared between the 2 groups by electrocardiogram and echocardiography results, and the risk factors for the occurrence of postoperative electrocardiogram and valve abnormalities were studied with Logistic regression analysis. RESULTS: Twelve and fifteen patients underwent VSD closure with the metallic occluder and the fully biodegradable occluder, respectively. All patients survived during the follow-up period without major complications such as atrioventricular block, significant residual shunt, too rapid absorption of the occluder, and significant valvular regurgitation. There were no significant differences in the results of electrocardiograph and color Doppler ultrasonography the metal occluder group and the fully biodegradable occluder group 1, 2, and 3 years after operation (all P>0.05). The size of the occluder were risk factors for tricuspid regurgitation at 2 and 3 years postoperatively, and the difference between the occluder size and the VSD defect size were risk factors for tricuspid regurgitation at 2 years postoperatively (P<0.05). CONCLUSIONS: This study adequately demonstrates the safety and efficacy of fully biodegradable occluders in small VSD closure and shows the same postoperative effects as conventional nitinol occluders.

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BACKGROUND: Young patients suffering from cryptogenic stroke alongside a patent foramen ovale (PFO) are often considered for percutaneous device closure to reduce the risk of stroke recurrence. Residual right-to-left shunt after device closure may persist in approximately a quarter of the patients at 6 months, and some may close at a later time point. This study aimed to assess the prevalence and persistence of residual right-to-left shunt after percutaneous PFO closure. METHODS: Consecutive patients undergoing transoesophageal echocardiography-guided PFO closure for cryptogenic stroke between 2006 and 2021, with echocardiographic follow-up including contrast bubble study and Valsalva manoeuvre, were enrolled. Follow-up transthoracic echocardiography was performed at 6 months and repeated at 12 months in case of residual right-to-left shunt. Primary outcomes included the prevalence and grade of residual right-to-left shunt at 6 and 12 months after percutaneous PFO closure. RESULTS: 227 patients were included with a mean age of 43±11 years and 50.2% were women. At 6-month follow-up, 72.7% had no residual right-to-left shunt, 12.3% small residual right-to-left shunt, 6.6% moderate residual right-to-left shunt and 8.4% large residual right-to-left shunt. At 12-month follow-up, the presence of residual right-to-left shunt in all patients was 12.3%, of whom 6.6% had small residual right-to-left shunt, 2.6% had moderate residual right-to-left shunt and 3.1% had large residual right-to-left shunt. CONCLUSIONS: Residual right-to-left shunts are common at 6 months after percutaneous closure of PFO. However, the majority are small and two-thirds of residual right-to-left shunts achieve complete closure between 6 and 12 months.

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