DK2985_C000 1..28 - AlSharqia Echo Club

458 Transesophageal EchocardiographyTEE, especially in febrile patients soon after deviceimplantation (,12 weeks) (29). Almost all patients withproven or strongly suspected endocarditis on permanentpacemaker or defibrillator wires must have these surgicallyremoved (25,26,29). The imaging specialist in theoperating room is in a privileged position to confirm thediagnosis and rule out the presence of TV and right heartinjury following the pacemaker lead extraction.B. AbscessesAn abscess is an encapsulated collection of necrotic andinfected debris. The most common site of a cardiacabscess is the aortic root in association with an AoV infection(30,31). Left and especially right AV groove abscessesare uncommon, insidious and associated with fistuloustracts and false aneurysm. They are more common indrug addiction-related endocarditis (31). A cardiac abscessappears typically as an oval or circular lesion containingdifferent echo densities, reflecting solid, fluid, andgaseous necrotic contents. Transesophageal echocardiographyhas been shown to be superior to TTE in disclosingperivalvular abscess (31). One should bear in mind that theright coronary artery is surrounded by adipose tissue in theright AV groove and may appear as a small echo free space.This should not be mistaken for an abscess or tumor.Adipose tissue appears more homogeneous, echo-dense,and speckled, while a tricuspid abscess is usually associatedwith significant tricuspid leaflet infection, with a right ventricularto right atrial flow seen within an annular perforationby color flow imaging. The presence of a pulmonaryroot abscess is usually associated with a prosthetic valveor conduit and is extremely rare. The diagnosis is generallydifficult to establish by TEE because of the anterior locationof the pulmonary trunk in the far field from the esophagus.Often, CT or magnetic resonance imaging (MRI) isrequired to confirm the diagnosis.IV.RHEUMATIC VALVE DISEASEOver the last 30 years, cases of rheumatic fever have beenon the decline, as a result of aggressive antibiotic treatmentof streptococcal infections, however, rheumaticdisease is still prevalent in regions of poor socio-economicstatus. Rheumatic tricuspid valvulitis seldom accounts fortricuspid involvement in rheumatic disease in Westerncountries (32). Most commonly, functional TR occursdue to right ventricular pressure overload and tricuspidannular dilatation as a result of pulmonary hypertensionfrom rheumatic mitral stenosis (MS). Severe TR substantiallyreduces surgical following mitral valvuloplasty orreplacement (33).When rheumatic tricuspid valvulitis occurs, the mostcommon result is leaflet retraction and thickening withchordal fusion and shortening causing TR. Less frequently,rheumatic valvulitis leads to commissural fusionin the closed position with diffuse fibrosis, causing tricuspidstenosis (TS) (9). The frequency of TS differs betweenreports, ranging between 5% and 38% of patients withrheumatic heart disease (4).Two-dimensional diagnosis of TS rests on echocardiographicvisualization of tricuspid leaflet thickening andrestricted motion. Doppler echocardiography providesinsight into TS severity with the typical flattening of thetricuspid E-wave slope and prolongation of the tricuspiddeceleration slope. Mild to moderate TS produces meangradients of 3–9 mmHg while severe TS is generallypresent with mean gradients .10 mmHg. The naturalhistory of mild to moderate TS is generally benign anddoes not appear to benefit from surgery (1).A. Other Inflammatory ValvulopathiesAnother form of characteristically right-sided inflammatoryvalve disease is carcinoid heart disease. Carcinoidvalvulitis is more commonly seen with small bowel carcinoidcomplicated by liver metastases, which producehigh levels of circulating serotonin and systemic symptoms(e.g. flushing, bronchospasm and diarrhea).Serotonin stimulates plaque development on the TV andPV, leading to leaflet thickening and rigidity (9). Tricuspidregurgitation occurs in .90% of cases. Less commonly,20–30% of carcinoid heart disease cases are associatedto TS, PV regurgitation, and stenosis. Unless an intracardiacright-to-left shunt is present, it is unusual for theleft heart to be involved in carcinoid disease as serotoninand its metabolites are inactivated in the lung. The shorttermprognosis of this disease was formerly quite grimbut as a result of disease control by chemotherapy andwith medium-term survival increasingly achieved, patientswith significant right heart failure symptoms are occasionallyreferred for valve surgery.Connolly et al. (34) reported a nonrandomized series of26 patients operated on for carcinoid valve disease. All hadsevere TR and significant mixed PV disease with: (1)severe right heart failure symptoms; (2) controlled systemicdisease; and (3) no concurrent severe medical problems.All patients underwent TV replacement, most hadpulmonic valvectomy and in five, removal of endomyocardialmetastases was carried out. The perioperative mortalitywas 35%, with a substantial number of deathsoccurring as a result of right heart failure or uncontrolledpostoperative bleeding. Survival of surgically treatedpatients was 40% at two years compared with 8% formedically treated patients. Furthermore, when PV diseasewas present, data from the same institution supports theuse of PV replacement over simple valvectomy in reducingright ventricular dilatation (35). However, it is possiblethat carcinoid disease may accelerate bioprosthetic