key: cord-0018512-kgkmjb1b
authors: Zimmerman, Karen G.; Leonardo Rodriguez, L.
title: Expect the Unexpected!
date: 2021-06-21
journal: CASE (Phila)
DOI: 10.1016/j.case.2021.04.003
sha: 01f6859fe31c54f773c435d972c14c49cc8395c1
doc_id: 18512
cord_uid: kgkmjb1b

nan

Lots of clich es are appropriate for this issue of CASE. Two of the most important concepts to remember in echo are that there are no such things as ''never '' or ''always.'' Even as new technologies and uses for echo continue to evolve, the old tried and true tricks remain. New technologies allow us to implement novel ways to guide therapy and intervention. Juggling treatment strategies and techniques with ECMO for COVID-19, are shared by Julio C. Sauza-Sosa, MD and team from Mexico City, Mexico in the report ''Acute Cor Pulmonale in a Critically Ill Patient with COVID-19 Resolved with Venoarteriovenous Extracorporeal Membrane Oxygenation.''

In the case of ''Unusual Cause of Left Ventricular Outflow Tract Obstruction Following Transcatheter Mitral Valve-in-Ring Replacement'' sent to us by Aiden Sharkey, MD and team from Boston, Massachusetts, we see the importance of procedural planning and image guidance. Even with plans to avoid LVOT obstruction following TMVR, there can still be trouble. Papillary muscles became displaced following deployment. This case required new plans and additional guidance through multiple procedures to correct the outflow obstruction. The options available to interventional teams are incredible, and they can result in complex management algorithms. Alcohol septal ablation and laceration of the anterior mitral leaflet are a few such options.

In another papillary muscle related case, good old-fashioned M-mode continues to provide precise and reliable insight for cardiac timing and function, as seen in ''A Case Report of Asymmetry of Systolic Anterior Motion of the Mitral Valve, A Not Widely Well-Known but Practically Important Echocardiographic Presentation in Hypertrophic Cardiomyopathy.'' This case shows us the importance of M-mode, and pulsed-wave Doppler, to avoid underestimating LVOT pressure gradient with asymmetric SAM.

We have an interesting case to test your knowledge of coronary artery blood supply to the papillary muscles. Why is blood supply anatomy important? And when could an infarct rupture most likely occur? Some things just don't go away, creating problems down the road. We have a few congenital cases which will emphasize the importance of familiarity with embryology when imaging adults. Blood cysts are relatively common up to about six months of age but are something to be wary of in adulthood. Other consequences of abnormal heart development may involve the Eustachian valve and interatrial septum. And there are acquired problems that just can't be explained, such as stenosis of all four valves in a Boxer with no definitive histopathologic findings.

Probably the wildest, most unfortunate case report is sent to us from Mansi Gaitonde, MD, sonographer Joseph Kreeger, ACS, RCCS, RDCS, and their team in Atlanta, Georgia. It is hard to imagine the complexity of figuring out which parts belong where in these conjoined twins. And what does ''Omphaloischopagus'' even mean! Specialized fetal imaging teams and referral centers provide great insight into prenatal imaging and management strategies for twins with complex cardiac interdependence like none other. Our hats are off to these teams. To our knowledge, this is the first reported case of its kind, another first for CASE.

Again, we hope you will enjoy and learn from this issue of CASE. It just goes to show, (two final clich es) .''the more you know, the more you know'' and ''never say never!''

Copyright 2021 Published by Elsevier Inc. on behalf of the American Society of Echocardiography. This is an open access article under the CC BY-NC-ND license