Transesophageal echocardiography (TEE) has unique advantages over conventional transthoracic echocardiography (TTE). Compared with TTE, TEE generally provides excellent quality images, especially of the posteriorly situated cardiac structures, such as atria, pulmonary veins, mitral valve, and left atrial appendage. TEE also offers a useful alternative to TTE in patients in whom transthoracic acoustic windows are suboptimal. Furthermore, TEE is the most suited imaging modality for use in the operating rooms and cardiac catheterization labs for guiding cardiac surgical or interventional procedures. However, specific training and competence are required for performing TEE successfully, smoothly, safely and with minimum patient discomfort. This document describes the basic principles of TEE examination, including patient selection and preparation, periprocedural monitoring, and probe handling and maneuvers. Commonly recommended views and the techniques to obtain these views are described in detail, followed by evaluation of specific cardiac structures. Finally, the role of TEE in certain specific clinical settings, such as during advanced circulatory support, is also discussed.

Context: Study of the prevalence of echocardiographic abnormalities and there relation to disease progression in chronic kidney disease (CKD). Aims: Study correlation of echocardiographic changes and CKD progression. Settings and Design: A prospective, cross-sectional, observational, analytical study, where we performed complete echocardiographic evaluation of patients with CKD stage II–V. We compared various echocardiographic parameters to predict the progression of CKD. Subjects and Methods: Ninety CKD patients stage II–V presenting to our hospital from November 2016 to December 2017 were included in the study. A complete echocardiographic evaluation was done. Left ventricular hypertrophy (LVH), systolic and diastolic dysfunction using Doppler indices at mitral inflow, left atrial volume, speckle tracking, and global longitudinal strain (GLS) were studied. Results: Patients were age and sex matched in all the groups with a male preponderance. Forty-one patients (45.56%) were diabetic and 74 (82.22%) were hypertensive. The prevalence of hypertension increased from 66.67% to 89.29% as CKD stage progressed from stage II to stage V. There were significant echocardiographic abnormalities seen in CKD patients. The severity increased with worsening of the stages of CKD. LVH and early diastolic mitral inflow to annular velocity ratio progression was statistically significant when stage V was compared to stage II. Left atrial volume, mitral early diastolic to late diastolic velocity ratio, maximum tricuspid regurgitation (TR_max) velocity, and diastolic dysfunction prevalence were significantly raised in stage IV and stage V compared to stage II. Only GLS showed statistical significance between stage II to stage III, stage IV and stage V and thus predicting progression of CKD. Conclusions: LVH, dilated left atrium, abnormal GLS, TR_max, diastolic dysfunction, and related tissue Doppler imaging parameters correlate with worsening renal function. GLS was the only parameter showing significant difference between stage II and stage III. This can be used as a novel modality for detection of subclinical cardiac dysfunction in CKD.

Background: The association between vitamin D and heart failure, especially left ventricular (LV) function, is still not clear. Objectives: We aimed to study the correlation between 25-hydroxy vitamin D levels and parameters of cardiac systolic and diastolic functions in patients with LV systolic heart failure. Materials and Methods: Ninety patients of heart failure coming to our hospital with systolic heart failure (LV ejection fraction <40%) were included. Venous sample were taken for measurement of 25-hyrdoxy vitamin D levels. Transthoracic echocardiography was done for all patients, and parameters of LV systolic and diastolic functions were taken. Results: Compared to patients having vitamin D <20 ng/ml, patients having vitamin D levels ≥20 ng/ml had higher early diastolic mitral annular velocity (e'), significantly lower ratio of early diastolic mitral inflow velocity (E) to e' (E/e'), significantly shorter isovolumetric relaxation time (IVRT) suggestive of better diastolic function. Furthermore, patients having vitamin D <20 ng/ml had higher LV end-systolic volume, LV end-systolic diameter, larger LV end-diastolic diameter, higher interventricular septum thickness, higher LV wall thickness, and higher LV mass. Conclusion: Reduced vitamin D (<20 ng/ml) was associated with worse systolic function in terms of systolic volume and diameter, diastolic function in terms of lower e′, higher E/e′, and longer IVRT.

Background: Patients with large perimembranous ventricular septal defects (pm-VSDs) undergo surgical repair with prosthetic material during infancy. However, the effect of the presence of akinetic patch in the ventricular septum on the left ventricular (LV) mechanical synchrony and ventricular function has not been studied. In our study, we assessed LV function in postoperative pm-VSD closure patients on two-dimensional (2D) echocardiography (echo) after 1 year of surgery using biplane Simspon's method, fractional shortening (FS), and global longitudinal strain (GLS) to assess the regional strain pattern. Methods: This was a a single-institution observational study. Patients following up 1 year after surgical ventricular septal defect closure at our institute were enrolled. On follow-up, detailed 2D echo was done with special emphasis on left atrial size, LV size (by M-mode), and presence of any residual shunt. LV function was assessed using biplane Simpson's method and longitudinal strain on 2D echo. GLS was measured in three standard apical views. Results: Of the 121 patients enrolled, 101 patients fulfilling the inclusion and exclusion criteria were analyzed. Of these 101 patients, 75.2% were males. The median age at follow-up after surgery was 3.67 ± 2.7 years. About 92.1% of patients did not have residual VSD lesion. No patient had pulmonary arterial hypertension. All except one patient had normal ventricular function. Patients with ventricular dysfunction had LV ejection fraction (LVEF) of 47%, GLS –17.4%, and FS −20.5%. The mean values of FS, LVEF, and GLS were 32.0 ± 5.28%, 62.2% ± 4.2%, and −26.53 ± 2.93%, respectively, in pm-VSD closure patients. Regional strain pattern analysis showed significantly lower strain values in basal anteroseptal segment with a mean of −21.4 ± 2.7%. FS and GLS were noted to have significant correlation with each other (P = 0.01) and LVEF by biplane Simpson's method and GLS had significant correlation with each other (P = 0.0001). Conclusions: GLS has strong correlation with LVEF by Simson's method and FS. Basal anteroseptal segment in pm-VSD patients had significantly lower strain values compared to other segments. There is no significant correlation between age at surgery and GLS in pm-VSD closure patients who were operated within 1 year of age. The type of VSD closure does not have significant influence on GLS.

Background: Although coronavirus disease-2019 (COVID-19) is predominantly a respiratory disease, cardiac involvement occurs commonly, especially in those with more severe illness. Echocardiography is the preferred imaging modality for diagnosing cardiac involvement in COVID-19. However, there are currently no data to describe echocardiographic abnormalities in Indian patients with COVID-19. Methodology: A cross-sectional observational analysis was performed among adult patients admitted to a tertiary care center between May 2020 and August 2020. Patients were included if they underwent transthoracic echocardiography during the hospitalization after a positive reverse transcriptase–polymerase chain reaction diagnosis for COVID-19 pneumonia. Demographic and clinical data were obtained and analyzed along with echocardiographic data. Results: During the study period, consecutive 245 patients were evaluated with echocardiography, of whom 11 were excluded due to nondiagnostic images. The remaining 234 (mean age 57 ± 16 years, 71.7% of men) were included in this analysis. All patients were admitted to intensive care unit or high-dependency unit. Right ventricular (RV) dilatation and/or dysfunction (37%) was the most common finding, followed by left ventricular (LV) systolic and diastolic dysfunction (27.7% and 23.1%, respectively). Pericardial effusion was present in 12% of cases. A total of 49 (20.9%) patients had preexisting LV systolic dysfunction (LVSD). After excluding them, the LVSD and LV diastolic dysfunction were observed in 8.6% and 2.7% of patients, respectively. Conclusions: This study demonstrates that RV dilatation/dysfunction is the most common echocardiographic abnormality in hospitalized patients with severe COVID-19. Further, larger, multicentric studies with systematic data collection and comparison with non-COVID patients are needed to determine the true incidence of echocardiographic abnormalities in COVID-19.

Background: Long-term effects of coronavirus disease-2019 (COVID-19) causing pulmonary fibrosis are a well-established fact. Whether similar changes persist in myocardium remains a cause of concern. Cardiac magnetic resonance imaging (MRI), although logistically limited during the acute phase of illness, is an excellent modality for evaluating persisting myocardial involvement in patients recovering from COVID-19. No previous study has described cardiac MRI in Indian patients with COVID-19. Materials and Methods: We summarize cardiac MRI findings in 43 patients (29 males) who underwent cardiac MRI at our center for various clinical indications after recovering from their COVID-19 episodes. All cardiac MRI examinations were performed on Siemens Verio 3 Tesla Scanner System with 70 cm bore. Necessary precautions and safety measures were taken as per the Society for Cardiovascular Magnetic Resonance recommendations and standard imaging protocols were followed. Results: Half of all patients (22, 51.2%) had presented after 6 weeks of their initial COVID-19, whereas most of the remaining patients (19, 44.2%) underwent MRI during 3–6 weeks after recovering from COVID-19. Exercise intolerance was the most common clinical presentation observed in 22 (51.2%) patients, followed by fatigue or generalized weakness (15 patients), fast heart rate (12 patients), and breathlessness (12 patients). The most common cardiac MRI finding was elevated T1 and T2 mapping values (14 patients, 32.6%). The other common findings were late gadolinium enhancement in 12 (27.9%) patients, pericardial effusion ± enhancement in 12 (27.9%) patients, and impaired left ventricular systolic function in 9 (20.9%) patients. Eleven (25.6%) patients had normal cardiac MRI. Conclusions: Our findings summarize common cardiac abnormalities detected by cardiac MRI in patients with recent COVID-19. Although these results cannot be postulated to estimate the overall burden of cardiac involvement in COVID-19, they provide valuable insight into clinical spectrum of these patients in Indian scenario.

Balloon mitral valvuloplasty (BMV) is an accepted treatment for certain subsets of patients of mitral stenosis. Prior to BMV, a full clinical and echocardiographic evaluation is done. This 36-years old lady of severe mitral stenosis had two BMV's including a three-dimensional transesophageal echocardiography at leading cardiac centers. However, an important echocardiographic finding was missed which would have altered the course of management. These details are discussed.

We describe an unusual case of a large aortopulmonary window which was not very symptomatic and presented as Eisenmenger syndrome at the age of 20 years in a male patient. We take this opportunity to highlight some of the basic investigations like chest X-ray and contrast echocardiography which can delineate the level of the shunt. Attention should be given to the subtle bedside clinical signs which can give clues to the diagnosis. We did a cardiac computed tomography scan for confirmation of the diagnosis.

Coronary artery aneurysm following percutaneous coronary angioplasty (PTCA) is rare in interventional cardiology. Several factors may contribute to the development of such complication following PTCA that include stent size, improper apposition, nature of vascular disease, and operative technique. Here, we report a case of giant right coronary artery in-stent restenosis and aneurysm following PTCA stenting within 1-month duration. The operative technique, underlying diseased segment of coronary artery, and associated comorbidities are contributing factors for such complications. Bedside echocardiography may detect aneurysm and expedite the process of treatment.

One of the major causes of reversible left ventricular (LV) systolic dysfunction is takotsubo cardiomyopathy. It is characterized by angina, dyspnea, electrocardiogram changes (ST segment elevation and T wave changes on chest leads of electrocardiogram), echocardiographic changes (LV dysfunction with predominant apical involvement), elevation of troponin and brain natriuretic peptide, usually mimicking acute coronary syndrome. Coronary angiogram in such cases is either normal or shows only insignificant coronary disease. Although LV apical involvement is the commonest manifestation, about one-fifth of cases of takotsubo cardiomyopathy have normal apical contractility but severe systolic dysfunction of the basal segments of the left ventricle. We report a case of reverse takotsubo cardiomyopathy developed in a relatively young patient following hip surgery and how three-dimensional and strain echocardiography clearly demonstrated the abnormality and aided the recovery of the patient.

Left ventricular (LV) thrombosis is caused by multiple etiological factors. Acute anterior wall myocardial infarction tops the list. Acute inferior wall infarction is not commonly associated with LV thrombus formation. A rare case of LV thrombus formation at LV apex due to acute inferior wall myocardial infarction is described in a young adult with successful resolution on medical therapy. Appropriate cardiac imaging is the key in correct diagnosis and treatment.

Hemodynamically significant large pulmonary embolism causes right ventricular dysfunction that stretches open the foramen ovale in the atrial septum. Paradoxical embolism is common in patients with right ventricular dysfunction. While anticoagulation and thrombolysis are considered the treatment of choice in pulmonary embolism, a large thrombus in transit across the patent foramen ovale carries a serious risk of systemic thromboembolism and warrants urgent surgery. The recent coronavirus disease 2019 (COVID-19) pandemic has led to a significant increase in the incidence of thromboembolic illnesses. A patient acutely presented with deep vein thrombosis, pulmonary embolism, large thrombus in transit across the foramen ovale along with elevation of multiple inflammatory biomarkers that were suggestive of a possible post-COVID sequelae. Images and management strategies are discussed in this report.