Posts Tagged ‘tee’


A 50-year-old man was referred for dizziness, bradycardia and dysphagia .He was very clear in describing his symptoms and  landed up in Gastro- enterology  OPD , from there was referred to my clinic for cardiac work up . His ECG showed a sinus bradycardia HR of 48 /mt.


Echocardiogram revealed a structurally normal heart as we expected , but was surprised to spot suspicious shadow in para-sternal long axis view , beneath left atrium.

A well demarcated large mass compressing left atrium.  Trans Thoracic Echocardiography  may not be looking at the heart alone ,(Its technically Thoracic Ultrasound though we may refer it as Echocardiogram   )

  • Aortic aneurysm ?
  • Mediastinal teratoma?
  • Bronchial adenoma ?
  • Esophageal mass ?

The Answer is none of the above

As I was wondering what it was, the staff nurse in charge threw a heavy folder with well worked up gastro Investigations.

That moment , diagnosis became obvious , without a need for further scrutiny to my medical acumen.

Note: The barium swallow of the Esophagus reveals the Intimate relationship between the food tube and the heart as it descends vertically downwards posteriorly  . Realise , how the proximity of these two structures could  confuse a physician when symptoms spill over on either way. (I would have expected a lateral view to show the compressive effect of Esophagus on the left atrium the radiologists felt its not important !)

Yes , it is Achalasia of the cardia , dilating the lower end of esophagus with fluid /mass effect  , compressing the posterior surface of Left atrium.He underwent a myomectomy surgery.

Why bradycardia  ?

There is well described esophago-vagal reflex reproducible by stressful swallow or balloon inflation in the lower end of esophagus at D7 level.(Ki Hoon Kang,Korean J Intern Med. 2005 Mar; 20(1): 68–71.)

Achalasia cardia is known to be associated with symptomatic bradycardia, dizziness, and rarely swallow syncope,though this patient didn’t have a classical syncope.The bradycardia is probably due to high vagotonia, (Hugging effect on posterior surface of heart known for rich innervation of vagus.) . Complete reversal  of bradycardia after esophago -gastric surgery is expected.

Implication for cardiologists

There has been instances of patients with esophageal syncope and reflex bradycardia getting permanent pacemaker therapy. I think , clinical or sub clinical esophageal disorders should be included in the work bradycardia before labelling them as intrinsic sinus node dysfunction .(Ref 1,4)

Final message 

The field of Cardiology  is often referred to as a super specialty atleast in India . I disagree with it strongly. Cardiologists are neither super(eme) nor special .We need to be reminded  its afterall a sub-specialty of Internal medicine and each specialist should undergo retro-training in medicine periodically .This patient is a typical example of a gastric problem entering the domain of cardiac Imaging.Strong foundations in symptom analysis and some degree of medical  curiosity will enable an occasional cardiologist to make a correct diagnosis belonging to a remote foreign specialty.


1. Palmer ED. The abnormal upper gastrointestinal vagovagal reflexes that affect the heart. Am J Gastroenterol. 1976;66:513–522. [PubMed]

2.Armstrong PW, McMillan DG, Simon JB. Swallow syncope. Can Med Assoc J. 1985;132:1281–1284. [PMC free article] [PubMed]

3.Turan I, Ersoz GBor S..Swallow-induced syncope in a patient with achalasia
4.Dysphagia. 2005 Summer;20(3):238-40  4.Basker MR, Cooper DK. Oesophageal syncope. Ann R Coll Surg Engl. 2000;82:249–253.

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Mitral valve can be termed as  the most important valve of heart . The reason  for this  : It is the only valve that is dependent on the  Left ventricular function (The  parameter  which   determines the  ultimate outcome in any form CAD ! )

So , indirectly mitral valve function will invariably be affected by some degree  at least in  most  patients with LV dysfunction. (After all LV free wall , is a component of mitral valve apparatus.)

While , we have numerous modalities to assess mitral valve function  ,  the one that has fascinated the surgeons during  mitral  valve surgery is the intra operative TEE.

Many believe TEE provides live  images  of mitral valve   which are not possible  even under  direct vision ! The eye of the  TEE sees the mitral valve  from a  posterior location , (of -course It can see at any angle !)   while surgeon can see in one angle . The  types of repair , the adequacy  of repair, the annulus status,  even a trial mitral run ,  can be done with the help of TEE.

The TEE probe silently does  this job sitting inside the esophagus   , without  obstructing the surgeon’s operative field .

The success of TEE as an investigative tool did not come easy.Decades of  observation , innovation and learning( Especially from  department of cardiac science  Mayo clinic USA , where they standardized the views. )  are involved .

Now we have omni plane, real time 3D TEE probes .

The books  which are  considered the best for  TEE aspects of mitral valve  and it’s  repair are

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Internet is  a  wonderful gift for  for mankind   but  only  occasionally we find great resources .

Hats off to Dr .Pybus from Australia for his efforts

A must read for  all cardiologists rather  everyone involved with echocardiography

Click on the Image to reach the site


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Logic would suggest  any two structures  in close proximity can have  some sort of anatomical , physiological or sometimes pathological relationship .Esophagus and heart  share a strategic  anatomical  space within the mediastinum  . The left atrial wall  is abetting the esophagus with only few millimeters separating the two. Trans esophageal  echocardiography has utilised this proximity for it’s  advantage . With the probe in esophagus we can get a  100%  interior view of left atrium . Both these structures can mutually compress one another at times of pathology . ( LA compression on esophagus in mitral stenosis , Esophageal compression of LA in hiatus hernia or esophageal growths) . Now ,  we also  realise , esophagus  a   functionally unrelated structure  to  cardiovascular system  can have a impact on cardiac functioning.

Hiatus hernia of gastroesophageal junction can mechanically compress the posterior aspect of heart and result in atrial  arrhythmias and pericarditis  ?


1 Duygu H, Ozerkan F, Saygi S, et al. Persistent atrial fibrillation associated with
gastroesophageal refl ux accompanied by hiatal hernia. Anadolu Kardiyol Derg
2008; 8(2):164-165.

A case report from South africa


Read further for esophagus- heart  stories.

  • Esophageal ulcers , spasm can trigger electrical activity that can mimic cardiac event  or rarely precipitate a real angina  , what is often referred to as  linked angina .
  • A rare case of pneumopericardium due to rupture of esophagus into pericardial space
  • ST elevation in ECG due to esophageal spasm


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Prosthetic valve obstruction is an important complication of artificial valves.The incidence of prosthetic valve obstruction  is  estimated  to  be  4% per year.

  • Pure thrombus 75%*
  • Pure pannus 10%
  • Combination of pannus and thrombus 12%

Data from Deviri (J Am Coll Cardiol, 1998; 32:1410-1417 )


*Note statistically you are going to be right 3 times out of 4 if you diagnose thrombus over pannus

Pannus  literally means a hanging flap of tissue. It is is a membrane of granulation tissue as an response to healing.It can  occur anywhere in the body. When it occurs in the prosthetic valve tissue interface it has important consequences.It  is  same  as excessive scarring , ( something similar to keloid formation ) .


How do they clinically present ?

Prosthetic valve thrombosis is usually a acute or sub acute event as thrombus formation rapidly deteriorates the clinical situation.Pannus brings a patient with the complaints of chronic progressive dyspnea.(This rule is very subjective  but . . .)

What are the determinants of pannus growth ?

Time is the major determinant. minimum period required is 12  months. It is a avascular mass.It should be noted  a  injured pannus can predispose  a thrombotic process and a chronic thrombus  can trigger intravascular   growth factors  that promotes pannus growth.

What is the direction of growth of pannus in prosthetic valve ?

The pannus grows , usually in the tissue valve interface.It tracks and creeps along the suture lines .Generally this does not encroach the valve orifice or chamber sapce  , but occasionally the hanging edges can hit upon a leaflet.This is more common with tilting disc on the side of minor orifice. When excessive it can make a valve leaflet almost standstill.

How common is pannus formation in starr edwards valve?

Is relatively uncommon as the dynamic ball periodically interrupts the process of pannus in growth within the orifice.

Final message

Why is recognition of pannus important ?

Prosthetic valve thrombois is amenable to thrombolysis and it should be proptly differentiated for pannus.This is many times a difficult excercise, but the above observation will be helpful.

Further reading


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