No abstract

bicuspid aortic valve; transesophageal echocardiography, transnasal, monoplane probeBicuspid aortic valve is a common congenital heart disease whose incidence is 0.4-2.25%, 1 often associated with aortic coarctation. Complications of this valve disease are regurgitation since pediatric age, while valvular stenosis, ascending aorta dilatation, 2 and dissection 3 may occur after 40 years. Transthoracic echocardiography (TTE) successfully identifies this valvular anomaly in infant and children, whilst transesophageal echocardiography (TEE) is often required in adults.We report a case of bicuspid aortic valve diagnosed by a transesophageal echocardiography through nasal way (TEENW). A 54-yearold hypertensive man was referred for dyspnea and throbbing. On physical examination heart rate was 66 beats/min, arterial blood pressure was 145/90 mmHg and an apical pandiastolic murmur was present. ECG showed anterior fascicular block. TTE with color-Doppler revealed mild left ventricular hypertrophy (interventricular septum and posterior wall = 13 mm), thickened and reduced excursions of aortic cusps with suspect of bicuspid valve, moderate aortic regurgitation with a mild stenosis (transvalvular peak = 41 mmHg, average gradient = 23 mmHg), and ascending aorta dilatation (46 mm). In order to reach a definitive diagnosis, agreement from the patient was obtained to perform a TEENW, using a 10F, multifrequency (5.5-10 MHz), monoplane probe developed for intracardiac ultrasounds (AcuNav, Somerset, WI; Acuson Corporation, Mountain View, CA, U.S.A.). This probe was previously used for transesophageal examina-

Percutaneous device closure of patent foramen ovale (PFO) has become an effective and safe alternative to medical or surgery treatment. Transesophageal echocardiography (TEE), as commonly used to guide this procedure, has the limitation to require general anesthesia. Recently, intracardiac echocardiography (ICE) with AcuNav probe was used to guide percutaneous PFO closure. We report a 42 year-old man with two previous cryptogenetic strokes in whom both diagnosis and guidance of PFO closure were performed by means of TEE using the AcuNav catheter introduced through nasal way (TEENW). This technique, that does not require general anesthesia, provided adequate and complete view of the Amplatzer procedure. TEENW might offer a feasible and equivalent echocardiographic alternative either to standard TEE or ICE as a guide to percutaneous PFO closure.

A 44-year-old hypertensive woman with fever for 1 week and a history of apical myocardial infarction (1 month before) was transferred to our institution with chest pain and dyspnea. On physical examination, her heart rate was 115 bpm, her arterial blood pressure was 85/50 mm Hg, and peripheral cyanosis was present. The ECG showed sinus tachycardia and Q waves in the V 1 to V 2 leads. The serum concentrations of creatine phosphokinase-MB, troponin I, and myoglobin were within normal limits. A chest x-ray revealed an enlarged heart and a mild left pleural effusion. Two-dimensional transthoracic echocardiography (TTE) showed a large apical ventricular discontinuity (widest diameter 2.82 cm; Figure 1a) in communication with an echo-free space, suggestive of a huge pseudoaneurysm with a partially stratified thrombus (Figure 1b). A minimal pericardial effusion was present. The maximum internal end-systolic pseudoaneurysmal diameters were 11.27ϫ10.45 cm ( Figure 2a) with a ratio of orifice to cavity diameter of 0.25. Color Doppler showed flow passage from the left ventricle into the pseudoaneurysm (Figure 2b) and pulsed Doppler demonstrated systodiastolic flow through the false aneurysmal mouth (Figure 3a). Coronary angiography revealed a midportion occlusion of the left anterior descending artery; ventricular angiography was not performed because of the high risk of pseudoaneurysmal rupture. Surgery confirmed the diagnosis (Figure 3b), and the myocardial hole was repaired via endoventricular circular patch plasty. The postoperative course was uneventful.

Paraprosthetic leaks are a postoperatively complication recurring with a frequency from 15 to 30%, and mostly in the mitral than in the aortic position. Transthoracic echocardiography can suspect prosthesis valve dysfunction, but for both diagnosis and evaluation of the paraprosthetic dysfunction severity, transesophageal study is required. In this report a mitral paraprosthetic dehiscence was diagnosed using a miniaturized, 10 F, monoplane probe inserted through nasal way. This technique, that do not require topical and general anesthesia, appears to be well tolerated providing an accurate and more comfortable examination.