Tricks, Mimics, and Diagnostic Treats: October’s CASE Reports

The latest issue of CASE is now available with intriguing reports, including “The Hidden Danger of Aortic Stenosis—Exercise-Induced Cardiac Arrest in a Young Man with Bicuspid Aortic Valve,” by Rassmussen et al. CASE Editor-in-Chief, Vincent Sorrell, MD, FASE, remarked, “”I was happy to read the report by Rasmussen et al. who described a cautionary tale of work up and evaluation of an athletic young man with congenital bicuspid aortic valve (BAoV) and variable reported symptoms. He was followed closely in the ambulatory setting with clinical examinations and echocardiography, and the authors included a table with details from their findings across more than 2 years consistent with non-severe AS. A normal stress test was also obtained during this serial evaluation.

Later, at 19 years of age, during a football (soccer) match, the patient had sudden cardiac arrest and was successfully resuscitated. During this index clinical presentation, the authors commented upon the use of highly experienced sonographers and multiple windows, but once again reported that the maximal aortic valve velocity remained < 4.0 m/s. Since the clinical examination was suspicious for severe AS and was discrepant from the echo findings, a cardiovascular magnetic resonance and invasive heart cath was obtained. These additional studies confirmed severe AS.

The authors discussed the potential value of a dedicated small dual-crystal (non-imaging) CWD transducer which was not employed in their patient. They suggest that the most plausible mechanism for underestimation of the AS, despite their careful serial evaluation, was that the BAoV jet was directed away from conventional continuous wave Doppler cursor alignment. They conclude by reminding readers that the underestimation of severe AS can have fatal consequences.”

This month’s CASE reports offer a fascinating reminder of the breadth of clinical insights echocardiography can provide, and the importance of looking beyond the expected. Garg et al. present an outstanding series of echocardiographic findings in an iatrogenic complication following congenital heart disease repair during the first year of life. Baqal et al. introduce yet another mimicker of apical-variant hypertrophic cardiomyopathy (aHCM). Hajiali et al. combine radiography, CT, and echocardiography to uncover a highly unexpected source of chest pain in a young man with psychiatric illness, while Haastrup et al. highlight another potential underlying diagnosis to consider when echocardiography is performed in the evaluation of stroke. In a compelling clinical story featuring a 35-year-old man with stroke and multiple serial echocardiographic examinations, Lipat et al. reinforce a critical lesson: the search for an embolic source demands a comprehensive approach. Sammaan et al. turn our attention to myocardial work (MW), an important yet underutilized diagnostic tool that remains unavailable on all ultrasound platforms. Finally, Holman et al. explore diastolic mitral and tricuspid regurgitation associated with underlying cardiac conduction disease. Together, these cases underscore the value of echocardiography not only in recognizing familiar patterns, but also in questioning assumptions, uncovering unexpected diagnoses, and refining our understanding of complex clinical presentations.

Readers can look forward to Dr. Sorrell’s editorial, “The Cover of (The Rolling Stone) CASE.”

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