Micro-nodulation, a manifestation of pulmonary stasis in the presence of mitral disease

Abstract Background Rheumatic heart disease has become rare in developed countries and physicians have grown unfamiliar with the disease and its clinical course. The mitral valve is most commonly affected leading to mitral regurgitation and/or stenosis. The chronic volume and/or pressure overload leads to atrial remodelling and enlargement, driving the development of atrial fibrillation and thromboembolic events. Case Summary A 87-year-old patient with a history of rheumatic mitral stenosis and mitral valve replacement was admitted to the neurology department for vertigo. A stroke was suspected and she underwent a transoesophageal echocardiogram which was complicated by dysphagia. Oesophageal manometry and CT revealed oesophagogastric junction outflow obstruction due to extrinsic compression by a giant left atrium. Discussion Dysphagia due to a giant left atrium is rare. Various diagnostic criteria exist and the prevalence thus depends on which criterium is used. It is mostly encountered in rheumatic mitral disease, although there are reports of non-rheumatic etiology. When the left atrium assumes giant proportions it can compress adjacent intrathoracic structures. Compression of the oesophagus can lead to dysphagia, as in our case. A transoesophageal echocardiogram in these cases is relatively contraindicated and should only be performed if there is considerable reason to believe that it may change patient management.

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Atrial fibrillation

The ESC Handbook on Cardiovascular Pharmacotherapy ◽

10.1093/med/9780198759935.003.0011 ◽

2019 ◽

pp. 185-208

Author(s):

Gheorghe-Andrei Dan ◽

Jan Steffel

Keyword(s):

Quality Of Life ◽

Atrial Fibrillation ◽

Management Strategies ◽

Healthcare Providers ◽

Mechanical Valve ◽

Vitamin K Antagonist ◽

Antiarrhythmic Drug Therapy ◽

Mitral Disease ◽

Valve Prostheses

Atrial fibrillation (AF) is the commonest cardiac arrhythmia in hopspitalized patients, with an increasing incidence with age and an epidemic increase projected for the next 10 years. Therapy of AF has several goals: to decrease mortality (mainly due to cardiovascular diseases), stroke rate, ventricular deterioration and heart failure, cognitive impairment, and dementia, as well as to increase quality of life. The recent European AF guidelines specify the management strategies for each of the above-mentioned goals. For stroke prevention, treatment with a non-vitamin K antagonist oral anticoagulant (NOAC) has emerged as the therapy of choice for the majority of patients with AF in the absence of rheumatic mitral disease and mechanical valve prostheses. However, in daily use of these drugs, many challenges remain that healthcare providers need to be aware of. Regarding treatment of the arrhythmia itself, it remains a therapy addressing the quality of life. Catheter ablation has emerged as a valid alternative for a variety of patients. Nevertheless, pharmacological antiarrhythmic drug therapy remains an important pillar for the majority of patients, and effective and safe use implies an important skill for every cardiologist.

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Transoesophageal echocardiography, sonoanatomy, and standard views

Focused Intensive Care Ultrasound ◽

10.1093/med/9780198749080.003.0006 ◽

2019 ◽

pp. 47-54

Author(s):

Nick Fletcher

Keyword(s):

Aortic Dissection ◽

Right Ventricular ◽

Transthoracic Echocardiography ◽

Left Atrial ◽

Transoesophageal Echocardiography ◽

Clinical Applications ◽

Right Ventricular Failure ◽

Atrial Appendage ◽

Critically Ill Patient ◽

Mitral Disease

This chapter will describe the omniplane probe (with its scan planes) and indications, contraindications, and complications of transoesophageal echocardiography (TOE), before defining a scheme for focused TOE assessment in a critically ill patient. It will highlight the cardiac structures that are best imaged using either transthoracic echocardiography or TOE, and outline specific clinical applications (including suspected aortic dissection, left atrial appendage thrombus, mitral disease, and right ventricular failure) that lend themselves to TOE assessment.

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