Ischemic stroke remains a major cause of morbidity and mortality. Cardiac sources of embolism account for almost up to 40% of all the ischemic strokes. Accordingly, echocardiography is an important investigation in the evaluation of clinically suspected cardioembolic stroke or cryptogenic stroke. Both transthoracic echocardiography and transesophageal echocardiography (TEE) are complementary to each other for this purpose. However, because of its superior resolution and the ability to image structures that are the most likely sources of cardioembolism (e.g., left atrial appendage), TEE is the preferred imaging modality in the cardiac evaluation of stroke. This document describes the systematic TEE evaluation of the patients referred with a clinical diagnosis of either cryptogenic stroke or cardioembolic stroke.

Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.

Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of prognostic importance in heart failure (HF) diseases. Recently, right ventricular (RV) function is being increasingly recognized as critical parameter in terms of mortality outcomes both in acute and chronic HF. We sought to determine the prognostic significance of PH and RV function in patients of acute and chronic HF from retrospective institutional data. Methodology: We studied 306 patients with HF presentation including acute decompensated HF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH as PASP >50 mmHg and tricuspid annular plane systolic excursion (TAPSE) <1.6 cm along with global RV fractional area change. The primary endpoint was all-cause mortality during 3-year follow-up. Results: PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV dysfunction had PH (58.1%). Patients with normal RV function and PH had an intermediate risk. However, patients with RV dysfunction without PH were not at increased risk for 3-year mortality. Conclusion: Critical echocardiography parameters in the evaluation of HF include PASP for pressure and volume overload status as well as RV function. The incremental prognosis is also determined by PH and RV function. The compounding effect of PH & RV dysfunction is detrimental in terms of high morbidity rates and mortality outcomes.

Physicians and sonographers performing echocardiographic scans place themselves at risk of developing work-related musculoskeletal disorders (WRMSDs) owing to faulty posture and repetitive hand and arm movements. Poor ultrasound ergonomics plays a pivotal role in the development of WRMSD and can result in injury and sickness absence, impacting efficiency and work productivity. The aim of this article is to draw the attention to common considerations and corrective measures to reduce the risk of WRMSD among professionals actively performing echocardiographic scans.

Hepatic vein (HV) flow pattern closely correlates with pressure changes in the right atrium. Normally, there are two forward flow waves – systolic and diastolic. Diastolic wave is slightly smaller than systolic wave. Three reversal waves can be seen – late systolic, mid-diastolic, and third during right atrial contraction. Normally, forward wave velocities increase during inspiration. Reversal waves are slightly more prominent during expiration. Systolic wave is diminished in atrial fibrillation, right ventricular systolic dysfunction, and tricuspid regurgitation. When these pathologies are severe or they coexist, systolic wave may reverse. Diastolic wave is diminished in tricuspid stenosis and impaired relaxation of the right ventricle as seen in right ventricular hypertrophy, right ventricular ischemia, or infarction. Diastolic flow reversal wave becomes prominent in restrictive cardiomyopathy and pericardial constriction. Reversal wave during right atrial contraction is absent in atrial fibrillation. It is diminished or absent when compliance of HVs is decreased due to diseases of liver parenchyma. This reversal wave is prominent in each cardiac cycle in tricuspid stenosis with sinus rhythm and in patients with right ventricular hypertrophy. It is intermittently prominent in the presence of ventricular ectopics and complete atrioventricular block.

Cardiac mass is defined as an abnormal structure within or immediately adjacent to the heart. The three basic types of cardiac masses are tumor, thrombus, or vegetation. Echocardiography is the main diagnostic tool for the detection of a cardiac mass. We present an infant with a mass in the left atrium in whom there was a diagnostic dilemma.

A 79-year-old man was admitted with diagnosis of septicemia. During his week-long stay in the hospital, he was treated with parenteral antibiotics and other supportive care with which he improved clinically and was to be discharged. However, he developed acute onset breathlessness followed by hemodynamic collapse and cardiorespiratory arrest. Cardio pulmonary resuscitation was initiated, and he was successfully resuscitated. Urgent bedside echocardiography revealed air in the left atrium (LA) and left ventricle. Color Doppler and contrast echocardiography failed to demonstrate any intracardiac or pulmonary arteriovenous shunt. Central venous (CV) line was removed just before discharge and the procedure was performed at siting posture probably with open hub of CV catheter. Hence, we assume large amount of air must have been entered into the venous circulation and passed across the pulmonary capillary bed into the left heart. Paradoxical air embolism to LA and ventricle is well known, where air enters into the venous circulation at a very rapid rate and exceeds the maximum volume of air that the pulmonary vasculature can filter.

A 44-year-old male patient presented with breathlessness on exertion but no compressive symptoms. Transthoracic two-dimensional echocardiography revealed a giant left atrium (LA) with severe mitral stenosis (MS) and mild mitral regurgitation (LA size 8.9 cm; LA volume 1133 ml). Giant LA has been variably described in literature, but there is no definition based on LA volume. A giant LA is rarely seen with MS.

Ventricular septal defect (VSD) is usually diagnosed in childhood. In adults, it is less often diagnosed due to spontaneous closure of some VSD's during the early years of childhood. Perimembranous VSD is a defect seen in the upper part of the septum and near the valves occurring in nearly 75% of patients. Although spontaneous closure has been reported in VSD, with about 30%–40% closing before 2 years of age and the remainder of cases closing by about 4 years of age, it is rare for VSD's to close after 8 years of age. Most of the small VSD's will remain asymptomatic, but one of the long-term complications of a small VSD is the development of infective endocarditis (IE). Most of the studies in adults with small VSD's and IE had many complications such as arrhythmias, subaortic and sub-pulmonic stenosis, and exercise intolerance. Here, we report a patient with small perimembranous VSD who was asymptomatic in childhood but suddenly become symptomatic due to development of IE. In this patient, the vegetations were large, multiple chunky linear vegetations partly sealing the VSD defect and also occluding the right ventricular outflow tract and pulmonary valve mimicking severe pulmonary stenosis, which was managed conservatively.

Prosthetic valve thrombosis (PVT) is a rare but dreadful complication of mechanical prosthetic valves. Even though mechanical valves in pulmonary position are rarely implanted, obstruction by thrombosis warrants rapid diagnostic assessment and treatment. Transthoracic echocardiography plays an important role than transesophageal echocardiography because of anterior location of pulmonary prosthetic valve. Thrombolytic therapy is the mainstay of the treatment for right-sided mechanical obstructive PVT. We are presenting a case of pulmonary mechanical PVT which was diagnosed and successfully thrombolysed with streptokinase.

An 18-year-old female presented with complaints of breathlessness on exertion for the past 6 months. Systemic examination was normal. Echocardiography showed a large hyperechoic well-defined right atrial mass occupying the entire right atrium and extending up to tricuspid valve. Mild pericardial effusion was noted. Visualized portions of pulmonary arteries were normal. Contrast-enhanced computed tomography (CT) chest demonstrated a lobulated heterodense mass occupying the anterior mediastinum which infiltrated superior vena cava and extended into right atrium up to the tricuspid valve. Histopathological examination through CT = guided biopsy and immunohistochemistry confirmed the mediastinal mass as B-cell lymphoma. The patient was started on chemotherapy as per medical oncologist opinion. Despite chemotherapy, the patient succumbed to unexplained sudden death.