Case-of-the-Week

Case of the Week

Home->COTW
AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.

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).

You can change the size and the format of the image or video loops by using the links below the image or video loop.

= Windows Media Video	= MP4 Video
= QuickTime	= WebM Video
= Flash	= Ogg Video
= JPG Image	= GIF Image
Video Sizes
1X = 200x150 pixels 2X = 400x300 pixels	3X = 600x450 pixels 4X = 800x600 pixels

Loop Text Key
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

Post MVR AV High Velocity Jet

Case#: 4

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:
41 y.o. male with history of an ASD repair 16 years ago ow presents with increasing SOB and DOE. He has a history of hypertension and mild renal insufficiency. The preoperative echocardiography exam showed severe MR and mild TR with a LVEF of 40%. The patient was scheduled for a minimally invasive mitral valve repair. Discuss the findings of the intraoperative echo and the post repair echo of the LVOT/AV. A high velocity jet was present after the repair that was not present on the preoperative echocardiography exam. What are the possible etiologies of the high velocity jet.

Loops:

Case Discussion/CME Questions

The MV leaflets are thickened, especially at the leaflet edges. The MR is severe and is centrally located. No evidence of leaflet restriction or prolapse/flail could be found. The annulus is dilated. Therefore, the etiology of the MR was annular dilation.

The causes of post MVR high velocity jet in the LVOT or AV are the following:

SAM
IHSS
AS
MR
TR
Subaortic Membrane
Intraventricular Gradient

SAM (Systolic Anterior Motion) of the anterior leaflet which partially occludes the LVOT is the most common cause of a high velocity jet. Much less commonly, the posterior mitral valve leaflet can cause SAM.

The CWD scan line could be interrogating an MR or TR jet and misinterpretation of the location of the high velocity jet could occur.

IHSS could be present preoperatively but, because of the increased LV volume, IHSS is not diagnosed preoperatively. Postoperatively, the LV volume is decreased after the MVR and IHSS is uncovered.

In both SAM and IHSS the CWD profile is typically dagger shaped. The CWD in this case was not dagger shaped. Also, with a huge cleft in the anterior mitral valve leaflet, it would take both anterior leaflets to exhibit SAM to cause a significant gradient at the LVOT. The PISA formation at the origin of the LVOT did not show any SAM.

AS gradients are flow related so increased flow through the AV after a MVR would increase the gradient. However, the echo showed an AV that almost fully opened but the leaflets appeared to be caught in a turbulent wave. Also, a very nice PISA formation was present at the origin of the LVOT.

Given the PISA formation at the LVOT, the turbulent pattern in the LVOT, and the CWD profile indicating a static stenosis/obstruction, and the AV leaflets fluttering in a turbulent jet, and no evidence of SAM, we felt that the increased jet velocity was due to increased flow resulting in a high velocity jet. The PISA formation image shows that the LVOT diameter to be around 1 cm. The differential diagnosis would be a subaortic valve membrane but the preop CWD of the AV didn't show a turbulent pattern or a subaortic valvular gradient. An intraventricular gradient would also be unlikely given the location of the PISA formation and a non-daggar-shaped CWD profile.

On week later, a repeat echocardiographic exam showed no gradient or high velocity jet through the LVOT/AV apparatus.

Please answer the following questions correctly to obtain your CME.

Web Links/References

Instution Info

User Info

CME Info

Help

User License

HIPAA

References

Calcs

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of University of Nebraska Medical Center, Center for Continuing Education and JLS Interactive, LLC.

The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is approved by the American Society of Radiologic Technologists (ASRT) as sonography-related continuing education (CE). Credit(s) issued for successful completion of ASRT-approved CE activities are accepted by the American Registry of Diagnostic Medical Sonography, American Registry of Radiological Technologists, Cardiovascular Credentialing International and Canadian Association of Registered Diagnostic Ultrasound Professionals. Contact the applicable registry for additional information / restrictions on their acceptance of ASRT CE credit.