Echo-of-the-Day

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AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.

Echo-of-the-Day Information

The Echo-of-the-Day is a presentation of 1 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
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
	= Legacy/Old Video Formats

Echo of the Day Information Table

IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE

Pel and Wilhelm did not have a feverish fight over this diagnosis

Case#: 289

AMA CME Units: 0.25 Units
Estimated Time: 15 minutes.

Presentation:
A patient presented with WPW and these echo loops:

Loop(s):

Case Discussion

The diagnosis is Epstein's Anomaly (EA).

The echocardiographic signs of EA are

TV Annulus in normal position
Apical Insertion of the Tricuspid Valve
Atrialization of the Right ventricle
Enlarged Right Atrium
Enlarged TV Anterior Leaflet
Small TV Septal and Posterior Leaflet
RV Dilation

The symptoms occur from the TR, other associated congenital anomalies and conduction abnormalities that may be present. EA is associated with the following congenital anomalies:

ASD/PFO
Bicuspid Aortic Valve (BAV)
Atretic AV
Pulmonary Atresia
Hypoplastic PA
Subaortic Stenosis
Coarctation
MV Prolapse
LV Moderator Bands
VSD
Pulmonary Stenosis (PS)
LV Noncompaction

50% of patients with EA will have WPW. Other conduction abnormalities are large P waves, 1st degree AV block, RBBB, inferior Q waves and anterior T wave inversion. Patients will typically present with

Cyanosis
SOB/DOE
Palpitations/Arrhythmias
Sudden Death
TIA/CVA
Right Sided Heart Failure

The treatment for EA, given the high mortality rate in neonates, is surgical repair or replacement. Most medical management focuses on arrhythmima prevention and management of the right sided heart failure.

Dr. Wilhelm Epstein discovered this condition and it was named after him (Epstein's Anomaly). Dr. Epstein also founded another condition where patients with Hodgkin's disease had cyclic fevers that increase and then decrease over one or two weeks. The cyclic phonomena was also discovered by Dr. P.K. Pel (who published the condition just before Epstein). Therefore, the condition was called Epstein-Pel fever (interesting that it wasn't called Pel-Epstein fever). They apparently argued over the etiology of the condition. Epstein-Pel fever only occurs in 5-10% of Hodgkin's patients. Dr. Richard Asher of the Medical Society of London, in 1959, felt that this condition only exists because it has a name.

CME Section

Please answer the following questions correctly to obtain your CME.

Web Links/References

Pel-Ebstein fever
Wilhelm Ebstein
Ebsteins Anomaly

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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.