A 68-year-old elderly individual presented with takotsubo cardiomyopathy, and echocardiography revealed left ventricular outflow tract obstruction with a substantial gradient, particularly exacerbated by the Valsalva maneuver. Resolution occurred within a few days through meticulous fluid management and beta-blocker administration, concurrent with an improvement in ejection fraction.

A50-year-old female patient presented with a posterior cerebellar stroke which was proved by magnetic resonance imaging brain as bilateral cerebellar infarctions, mainly involving the left cerebellar hemisphere. Magnetic resonance angiography brain showed a significant proximal left vertebral artery stenosis with near-total occlusion of its distal part as well. The risk factors include mild hypercholesteremia with a history of two miscarriages. Referred for transesophageal echocardiography (TEE) to rule out cardiac sources of thrombi. The TEE showed multiple fresh thrombi in the aorta mainly at the arch and at the origin of the left subclavian artery [Figure 1a-c].Figure 1: (a and b) TEE short-axis and long-axis views of the aortic arch showing two highly mobile pedunculated fresh thrombi (yellow arrows). (c) Modified short-axis TEE view of the aortic arch (40°) showing the origin of the LSA (blue arrow) with one fresh thrombus (yellow arrow) seen just at the orifice of the LSA. TEE: Transesophageal echocardiography, LSA: Left subclavian arteryThe patient was started on heparin and warfarin for 2 weeks and a follow-up TEE showed complete clearance of the thrombi [Figure 2a and b].Figure 2: (a and b) TEE short-axis and long-axis views of the aortic arch showing clearance of previously mentioned thrombi after 2 weeks of anticoagulation. TEE: Transesophageal echocardiographyThe patient was further investigated for hypercoagulable state and thrombophilia defects. Her Protein C, Protein S, and antithrombin III were normal. Serum fibrinogen was mildly elevated, and the antiphospholipid antibody turned out to be positive. Approximately 20% of people younger than 50 who have a stroke have antiphospholipid syndrome, and approximately 10%–15% of individuals who experience recurrent miscarriages have antiphospholipid syndrome. Aortic arch atheroma (AAA) is a frequent finding in patients with ischemic stroke.[1] TEE is considered a gold standard for its detection. The prevalence of AAA increases with age. In patients aged 25–34 years, it is 4.9%; in 35–44 years is 12.1%; in between 45 and 54 years (our patient) is 22.5%; and in those with 55–64 years, up to 33%.[2] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Background/Aims The COVID-19 pandemic challenged not only global healthcare systems, but also educational systems, with many large, in-person training programmes being suspended. Instead, virtual learning platforms have been used, with promising results. This study explored the effectiveness of a virtual quality improvement training programme in a healthcare setting. Methods A 6-week interprofessional virtual quality improvement training programme was developed and delivered to a total of 137 participants across three cohorts. Pre- and post-programme surveys were administered to assess knowledge gained from training. Focus groups were also conducted for more in-depth feedback about the sessions. Information was then collected regarding any quality improvement projects participants had undertaken after completing the training. Results Mean scores were higher in the post-programme than the pre-programme survey across all knowledge domains (P<0.001, Cohens d=6.63). Over 80% of participants reported that the training improved their understanding of and confidence in undertaking a quality improvement project, and that they would recommend the training to their colleagues. Participants went on to either lead or contribute to a variety of quality improvement projects across a wide range of specialisms. Conclusions The virtual quality improvement training programme is an effective method of teaching, leading to participants being able to demonstrate competency in quality improvement. This approach to training delivery represents an efficient alternative to in-person training for building capability in frontline healthcare staff.

A 56-year-old male patient was diagnosed 6 years ago with left eye choroidal melanoma presented with progressive visual loss. Left eye enucleation was done. He is known for coronary artery disease and had pacemaker implantation for a complete heart block. The patient has pelvic and right orbital metastasis and is currently on dual immunotherapy. He was sent for echocardiography for routine follow-up. Transthoracic echocardiography with intravenous contrast showed multiple homogenous myocardial masses on the interventricular septum, apex, and proximal interatrial septum. Left ventricular systolic function was mildly impaired. No valvular lesions were noted [Figure 1].Figure 1: Transthoracic echocardiography apical four-chamber view (a) and apical two-chamber views (b). Images (c) and (d) are the corresponding images with left ventricular contrast. The multiple well-circumscribed masses are marked by blue arrowsThe patient was sent for cardiac magnetic resonance which also revealed well-defined iso-to-hypointense (melanin-containing) homogenous masses in the left, right ventricular myocardium, and interatrial septum. T1 postgadolinium showed intense enhancement of myocardial lesions [Figure 2].Figure 2: Cardiac magnetic resonance imaging long-axis four-chamber views: (a) Single cut from four-chamber CINE bright blood SSFP showing well-defined iso-to-hyperintense (melanin containing) homogenous masses (yellow arrows) in the LV and RV myocardium as well as the interatrial septum (yellow arrows). b) Four-chamber T1 postgadolinium administration showing intense enhancement of the myocardial lesions (yellow arrows). LV: Left ventricle, RV: Right ventricle, LA: Left atrium, SSFP: Steady-state free precessionPositron emission tomography (PET) and computed tomography showed an intense radiotracer uptake in the aforementioned myocardial masses [Figure 3].Figure 3: Positron emission tomography/computed tomography axial images: (a) Pre-FDG administration axial computed tomography chest level, showing ill-defined hyperdense lesions (yellow arrows) scattered in the myocardium. (b) Corresponding post-FDG axial image at the same level showing intense radiotracer uptake in the aforementioned myocardial masses (yellow arrows). LV: Left ventricle, RV: Right ventricle, FDG: FluorodeoxyglucoseThese findings are very suggestive of the hyperenhancing malignant melanoma metastasis with the rich capillary network. Ocular melanoma is diagnosed in approximately 6 million people annually.[1] However, ocular melanoma metastasizes less frequently than cutaneous melanoma (75% vs. 96%, respectively). When it does metastasize, it is invariably fatal. Liver metastasis is the most frequent (90%). Later reports suggested that cardiac metastases are extremely uncommon and clinically underdiagnosed.[1] Later autopsy reviews estimated that cardiac metastasis from ocular melanoma was found in approximately one-fifth of patients who die of this tumor. It mainly involves the myocardium (98%) and also the epicardium and the endocardium (78% and 73%, respectively).[2,3] PET is particularly helpful for staging of melanoma and assessing the response to treatment. In the literature, cardiac metastasis leading to arrhythmia is very rare. Our case has had complete heart block and needed pacemaker insertion.[4] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

A 74-year-old man presented to the emergency department for retrosternal chest pain and heaviness radiating to the left arm with progressive shortness of breath and orthopnea for the last 7 h before admission. The patient had a past medical history of smoking, diabetes mellitus, hypertension, and hyperlipidemia. He had serial electrocardiograms (ECGs) in the past 7 years which showed right bundle branch block and a previous transthoracic echocardiography 5 years ago which was normal. On initial assessment, he was conscious, alert, in pain, and on semi-sitting position, his temperature was 37.1°C, H.R 94/min, respiratory rate 25/min, and his blood pressure 80/50 mmHg. An oxygen saturation is 94% at room air. His initial laboratory investigations revealed elevated troponin-T HS: Chest X-ray showed interstitial and alveolar opacities in a butterfly pattern consistent with cardiogenic pulmonary edema. His ECG showed sinus tachycardia with upsloping ST segment depression in Leads II, AVF, V2-V3, and the posterior precordial leads were normal. An urgent transthoracic echocardiography was done which revealed hyperdynamic left ventricle, flail anterior mitral leaflet with attached highly mobile bell-like mass suggestive of ruptured chordae and possible head of papillary muscle rupture, severe posteriorly directed torrential mitral regurgitation, and severe pulmonary HTN (70 mmHg). The cardiac chambers dimension was normal. Urgent transesophageal echocardiography (TEE) was needed to clarify the mechanism of mitral regurgitation. In the Cath lab TEE was done which revealed ruptured head of anterolateral papillary muscle [Figure 1], flail anterior mitral leaflet, hyperdynamic left ventricle, torrential posteriorly directed mitral regurgitation swirling to the roof of the left atrium [Figure 2a, b and Supplementary Video 1https://links.lww.com/HV/A129], systolic flow reversal in left pulmonary veins, and normal other cardiac valves.Figure 1: Transgastric long axis TEE view showing the ruptured anterolateral papillary muscle which is marked with green arrows. TEE: Transesophageal echocardiographyFigure 2: (a) Transgastric long axis TEE view (left) showing the head of the papillary muscle floating in the left atrium (green arrow) and (b) showing the torrential MR swirling to the roof of the left atrium (white arrow). TEE: Transesophageal echocardiography. MR: Mitral regurgitationCoronary angiography revealed 30% proximal left anterior descending (LAD), 70% proximal D2, 30% proximal left circumflex artery (LCX), and 60% mid right coronary artery (RCA) lesions [Figure 3]. An intra-aortic balloon pump was inserted. These nonsignificant obstructive coronary lesions did not require percutaneous coronary interventions and after discussion with cardiothoracic surgery team, the patient was immediately shifted to the operating room.Figure 3: Coronary angiography revealed 30% proximal LAD, 70% proximal D2, 30% proximal LCX, and 60% Mid RCA lesions. LAD: Left anterior descending, LCX: Left circumflex artery, RCA: Right coronary arteryIn the operating room, the excision of the original valve was done and was replaced by a tissue valve size 31. The patient went off-pump and intraoperative TEE was done to assess the prosthesis. TEE showed moderate-to-severe central mitral regurgitation due to tethering and marked restriction of posterior leaflet mobility of MV Bio-prosthesis [Figure 4a, b and Supplementary Video 2https://links.lww.com/HV/A130]. The patient went on the pump again and there was a stitch looped around the strut and the tethered leaflet causing its damage. The 31-size tissue valve was replaced with another tissue valve [Supplementary Video 3https://links.lww.com/HV/A131]. No coronary artery bypass grafting was done.Figure 4: (a) Transgastric 5-chamber TEE view showed tethering and marked restriction of posterior leaflet mobility of mitral bioprosthetic valve and (b) showed moderate-to-severe mitral regurgitation. TEE: Transesophageal echocardiographyThe estimated incidence of papillary muscle rupture (PMR) is 0.5%–5% of myocardial infarction (MI) patients. PMR typically occurs 5–7 days after the onset of MI and is a rare complication of MI. It has poor prognosis (90% mortality) which depends on the extent of rupture.[1] A high index of suspicion is warranted for early recognition and timely management of this catastrophic condition. Urgent echocardiography is the gold standard in the early diagnosis of this lethal condition and in guiding the management, which saves lives.[2,3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Abstract Background Ruptured sinus of Valsalva aneurysm (RSOVA) is rare, and it is more common in Asians. Typically, the patient presents with acute/subacute shortness of breath (SOB) and chest pain. Echocardiography is the gold standard for diagnosis in most of these cases. Surgery has remained the first line of management. Case summary We present two cases of RSOVA in which the patients presented to the emergency department with SOB. Their preoperative echocardiography results showed RSOVA into the right ventricle. During surgical repair, ventricular septal defect (VSD) was also found. Discussion RSOVA is frequently associated with other congenital anomalies, and most often with VSD. In our cases, we believe that VSDs were missed preoperatively because either the large aneurysmal sacs covered the VSD or there was overlap between the two shunts. Additionally, in the first case, right ventricular pressure was high approaching systemic pressure, which probably reduced the shunt across the VSD. Early intervention is recommended to prevent endocarditis or enlargement of the ruptured aneurysm; long-term results were excellent after surgical repair. Most patients undergo surgery between 20 and 40 years of age, and the reported survival rate is 95% at 20 years. If left untreated, patients typically die of heart failure or endocarditis within 1 year after onset of symptoms.

Conflicting data exist about the relationship between cardiac resynchronization therapy (CRT) and diastolic function. Aims of the study are to assess diastolic patterns in patients undergoing CRT according to the 2016 recommendations of the American Society of Echocardiography/European Association of Cardiovascular Imaging and to evaluate the prognostic value of diastolic dysfunction (DD) in CRT candidates. Methods and results: One-hundred ninety-three patients (age: 67 +/- 11 years, QRS width: 167 +/- 21 ms) were included in this multicentre prospective study. Mitral filling pattern, mitral tissue Doppler velocity, tricuspid regurgitation velocity, and indexed left atrial volume were used to classify DD from grade Ito III. CRT-response, defined as a reduction of left ventricular (LV) end-systolic volume > 15% at 6-month follow-up (FU), occurred in 132 (68%) patients. The primary endpoint was a composite of heart transplantation, LV assisted device implantation. or all-cause death during FU and occurred in 29 (15%) patients. CRT was associated with a degradation of DD in non-responders. Al multivariable analysis corrected for clinical variables, QRS duration, mitral regurgitation. CRT-response and LV dyssynchrony, grade 1 DD was associated with a better outcome (HR 0.37,95% CI: 0.14-0.96). Non-responders with grade II-III DD had the worse prognosis (HR 4.36, 95%a 2.10-9.06). Conclusions: The evaluation of DD in CRT candidates allows the prognostic stratification of patients, independently from CRT-response. (C) 2021 Elsevier B.V. All rights reserved.

Background: Despite all having systolic heart failure and broad QRS intervals, patients screened for cardiac resynchronization therapy (CRT) are highly heterogeneous, and it remains extremely challenging to predict the impact of CRT devices on left ventricular function and outcomes. The aim of this study was to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular remodeling and prognosis of CRT candidates by the application of machine learning approaches. Methods: One hundred ninety-three patients with systolic heart failure receiving CRT according to current recommendations were prospectively included in this multicenter study. A combination of the Boruta algorithm and random forest methods was used to identify features predicting both CRT volumetric response and prognosis. Model performance was tested using the area under the receiver operating characteristic curve. The k-medoid method was also applied to identify clusters of phenotypically similar patients. Results: From 28 clinical, electrocardiographic, and echocardiographic variables, 16 features were predictive of CRT response, and 11 features were predictive of prognosis. Among the predictors of CRT response, eight variables (50%) pertained to right ventricular size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with particularly good prediction of both CRT response (area under the curve, 0.81; 95% CI, 0.74-0.87) and outcomes (area under the curve, 0.84; 95% CI, 0.75-0.93). An unsupervised machine learning approach allowed the identification of two phenogroups of patients who differed significantly in clinical variables and parameters of biventricular size and right ventricular function. The two phenogroups had significantly different prognosis (hazard ratio, 4.70; 95% CI, 2.1-10.0; P < .0001; log-rank P < .0001). Conclusions: Machine learning can reliably identify clinical and echocardiographic features associated with CRT response and prognosis. The evaluation of both right ventricular size and functional parameters has pivotal importance for the risk stratification of CRT candidates and should be systematically performed in patients undergoing CRT. (J Am Soc Echocardiogr 2021;34:494-502.)

The relationship between diastolic dysfunction (DD) and outcome after CRT is debated. Purpose of this study was to evaluate the role of DD in predicting all-cause mortality in heart failure patients undergoing CRT. One-hundred ninety-three patients (age: 67±11 years, QRS width: 167±21 ms, LVEF 28±8%) were included in this multicentre prospective study. Mitral filling pattern, mitral tissue Doppler velocity, tricuspid regurgitation velocity, and indexed left atrial volume were used to classify DD from grade I to III according to the 2016 recommendations of the American Society of Echocardiography/European Association of Cardiovascular Imaging. A reduction of LV end-systolic volume >15% at 6-month follow-up (FU) identified CRT-responders and was observed in 132 (68%) patients. During a median 35 months FU, 29 (15%) patients died. Through multivariable analysis, coronary artery disease, NYHA functional class and grade I DD were shown to be independent predictors of prognosis (Table 1). Grade I DD was associated with a longer survival rate in both responders and non responders (Figure 1). Non responders with grade II-III DD had the worse outcome (HR 12.5 [3.56–44.04], p<0.0001). Better diastolic function at baseline is associated with an improved survival after CRT implantation, independently of CRT-response. Type of funding source: None

We present 2 cases presented to the emergency department with shortness of breath (SOB). Their preoperative echocardiographies showed ruptured right sinus of Valsalva (RSOV) into the right ventricle (RV). Ventricular septal defect (VSD) was diagnosed only intraoperatively.

Pietro Longhi (1702 or November 5, 1701 – May 8, 1785) was a Venetian painter of contemporary genre scenes of life. Longhi’s genre pictures provide a varied and detailed documentation of contemporary Venetian life and events. “The Apothecary” is a oil on canvas painting, is a scene of a apothecary’s shop where he is examining a young lady, possibly a courtesan. Others are waiting their turns while an young man is heating perhaps a herbal concoction and another is writing out a possible prescription. The potted plant has been described by some commentators as “aloes”. However, according to Bentham and Hooker’s renowned British Flora, the true aloes of botanists are in fact liliaceous plants .This is clearly an agave plant, This was a recognized symbol of healing at the time and used to ward off plague. According to Sharif Kaf al-Ghazal, and S. Hadzovic, apothecary shops existed during the Middle Ages in Baghdad, operated by Islamic pharmacists in 754 during the Abbasid Caliphate, or Islamic Golden Age. Apothecaries were also active in Islamic Spain by the 11th century. From the 15th century to the 16th century, the apothecary gained the status of a skilled practitioner. In this painting the Apothecary is clearly involved in examining the patient as well as recommending and preparing medicine. The dual roles are nicely depicted in this work.

We describe the case of a 32-year-old man with history of patent ductus arteriosus (PDA) closed with an Amplatzer device 12 years earlier. Imaging investigations revealed a persistent large PDA and the device migrated in the right pulmonary artery. A new transcatheter PDA occlusion was attempted with optimal post-procedural results. (Level of Difficulty: Advanced.)

Background: Few studies have demonstrated the utility of a teaching program for evaluation of left ventricular ejection fraction (LVEF) of echocardiographic images acquired with high-end machines. No study to date explored the value of similar programs when a handheld ultrasound device is used. The aim of this study was to determine whether a teaching intervention could improve the accuracy and the reliability of LVEF visual assessment of echocardiographic images acquired with HUD. Materials and Methods: Twenty echocardiograms acquired with a hand-held ultrasound device with a spectrum of LVEF were presented to 26 participants with varying experience in echocardiography (range 2–12 years) for single-point LVEF visual estimates. After this baseline assessment, participants underwent three training sessions which included analysis of the individual baseline results and review and interpretation of additional 60 cases from the same platform. After 2 months, 20 new echocardiograms were presented to the same 26 participants for visual LVEF assessment. For each participant, the visual LVEF for each case was compared with the reference LVEF (quantitative measurements by experts), and a difference of > ±5% was considered a misclassification. Results: The misclassification rate was 61% preintervention and decreased to 41% after intervention (P < 0.0001). The mean absolute differences in LVEF between visual estimates and reference before and after intervention for all readers were −7.9 ± 9.6 and −1.2 ± 7.8, respectively (P < 0.0001). Inter-rater repeatability analysis was performed using the intraclass correlation coefficient. The intraclass correlation coefficient for inter-rater reliability was fair preintervention (0.65, 95% confidence interval [CI] 0.59 0.71) and good after intervention (0.80, 95% CI 0.73 0.87), and there were no differences when categorized according to the level of experience. Conclusions: A teaching intervention can improve the accuracy and the reliability in the visual LVEF assessment of images acquired with handheld ultrasound device.

A 32-year-old man was referred for evaluation of exertional dyspnoea. Transthoracic echocardiography showed an ostium secundum atrial septal defect (ASD). O 2 saturation in room air was 98%. A transoesophageal echocardiogram was performed for better delineation of the pathology, which confirmed the presence of the ASD with left-to-right shunt (Supplementary data online, Video S1 ). Agitated saline injection through the left antecubital vein resulted in opacification (asterisks) of the left upper pulmonary vein (LUPV) before entering the left atrium (LA) ( Panel A ; Supplementary data online, Video S2 ). Chest computed tomography (CT) confirmed the presence of a persistent left superior vena cava (PLSVC) draining into the LUPV ( Panels B and C ). Cropping of the acquired 3D dataset identified three left pulmonary veins (upper-LUPV, accessory-LAPV, and lower-LLPV) draining into the LA ( Panels D–F ), which were nicely appreciated by volume rendered display ( Panel G ; Supplementary data online, Video S3 ). Finally, virtual intracardiac navigation with endocardial view showed the joining of the PLSVC within the LUPV ( Panel H ) and the three pulmonary vein orifices opening into the left side of the LA ( Panel I ; Supplementary data online, Video S4 ). The patient refused further investigations and treatment.

Powering up a typical house in Medina, Kingdom of Saudi Arabia (KSA) using hybrid solar and hydrogen fuel-cell energy systems is investigated. The return on investment (ROI) of the proposed hybrid system has been estimated as well. It is found that the payback period for the proposed system is about 3.5 years based on a price of $0.06 for each kW h sold to the grid. The price of kW h sold to the grid is assumed because currently there are no rules that regulate renewable energy production in the Kingdom. After the payback period, a yearly profit of about $7754 is achieved for the proposed system. The price of electricity in Saudi Arabia is too low compared to non-oil producing neighboring countries like Jordan, in which the monthly price for over than 500 kW h is $0.16. As it is known, the government of Saudi Arabia subsidizes prices of oil and electricity.

Background: Ischemic Heart Disease (IHD) is a major and increasing health care issue in Bangladesh.Since the first human percutaneous transluminal coronary angioplasty (PTCA) procedure was performed in 1977, the use of this procedure has increased dramatically, becoming one of the most common medical interventions performed.The technique, originally developed in Switzerland by Andreas Gruentzig, has transformed the practice of revascularization for coronary artery disease (CAD).Initially used in the treatment of patients with stable angina and discrete lesions in a single coronary artery, coronary angioplasty has multiple indications today, including unstable angina, acute myocardial infarction (MI), and multivessel CAD.With the combination of sophisticated equipment, experienced operators, and modern drug therapy, coronary angioplasty has evolved into an effective nonsurgical modality for treating patients with CAD.