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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
A RWMA a Dancing Wu Li Master Could Love
Case#: 3
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
Presentation:
81 y.o. male with history of SOB, DOE, chest pain, moderate COPD, renal isufficiency, remote history of colon cancer, OCD, and atrial fibrillation. Cath results show a 95% mRCA, 95% mLAD, 90% D1, 99% Cx, and a 30% LMCA stenosis. The patient is on lasix, dignoxin, atenolol, KCL, lovastatin and lexapro. Coumadin was stopped 7 days ago. A preop echo shows severe MR, moderate-severe TR and a LVEF of 40-50%.

A 2D and 3D scan of the anterior wall was performed on a patient (Loop1 and 2). Please explain the findings.
Discuss the findings of the MR and if the valve is repairable.
 
Loops:


Case Discussion/CME Questions
 
The 2D RWMA of the anterior wall is either normokinetic or slightly hypokinetic. On the 3D view the wall appears much worse - severely hypokinetic or akinetic. Which is the correct call?

One study showed that during a stress test, 2D and 3D scans of the walls were in agreement (concordance rate 90%), although 3D scans took longer to analyze. 2D will image more walls (99%) compared to 3D (94%) but when the wall is imaged, there is high agreement between the modalities (99%). In DSE, 3D offered advantages over 2D in that 3D was faster and was more senstive for CAD than 2D. The main advantage was the ability to do one scan rather than multiple scans. Also, when slicing the 3D scan, it was more anatomically correct than a 2D scan.

The main advantage of 3D versus 2D wall motion interpretation is with 2D mode, translational and rotational effects are not easily accounted for when performing wall motion interpretation. With 3D, the translational and rotational effects are easily accounted for in the interpretation.  Tethering can also be more readily seen on 3D, especially if the tethering is occurring outside of the plane of the 2D scan but is affecting the wall motion. Irrespective of these advantages, 2D is still the gold standard and highly accurate, whereas 3D may offer some advantages.

Note: The Dancing Wu Li Masters is a book about quantum physics where if you looked at the basic quantum object as a particle (having mass) it did have mass and behaved like a particle or if you looked at the basic quantum object as a wave it didn't have mass and behaved like a wave. In other words, it all depended upon how you looked at it determined its behavior. Similarly, like the wall motion - if you looked at it in 2D it looked different than in 3D.

The mitral valve has several mechanisms occurring. While we didn't show many of the color flow Doppler views, there were 2 main jets. A central jet that extended throughout the whole valve and another jet that was eccentrically and anteriorly directed. A flail chordae can be seen. This chordae was consistent with the P3 flail scallop. The scallops were redundant and prolapsing in various degrees throughout the valve. The annulus was dilated. The annulus was heavily calcified. To repair this valve would require decalcification of the annulus, and some chordal replacement and resection of the redundant tissue. A skilled surgeon might have been able to repair this valve, but, given that the patient was 81 years old, had a depressed ejection fraction, had atrial fibrillation, and the valve was very complex, replacing the valve might be a better option for an improved outcome.
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