The 60/60 sign in 2D transthoracic echocardiography (TTE)-a combination of pulmonary acceleration time (PAT) less than 60 milliseconds and tricuspid regurgitation (TR) jet gradient of less than 60 mmHg-has been found to be specific for the diagnosis of pulmonary embolism (PE). Materials and methods An observational prospective analysis was carried out on cases of suspected PE presenting to the emergency room (ER). TTE was performed on all cases with suspected PE prior to computed tomography pulmonary angiography (CTPA). Emphasis was placed on measurement of PAT and early systolic notching (ESN) on the pulsed wave (PW) Doppler of the pulmonary valve, TR jet gradient, right ventricle systolic excursion velocity (RV S') by tissue doppler imaging (TDI), tricuspid annular plane systolic excursion (TAPSE), and right ventricle to left ventricle end-diastolic dimension ratio (RV:LV EDD) in modified parasternal short-axis view. These signs were taken as screening tests and compared to CTPA as the standard test. Patients were followed up until hospital discharge or death. Observations Fifty-six cases of suspected PE were enrolled for the study. Of these, 24 cases of PE were confirmed by CTPA. Out of 24 cases of PE, 15 were high-risk PE, six were intermediate high-risk PE, and three were intermediate low-risk PE. The mean age was 53.07±9.79 years with a male-to-female ratio of 1.95:1. The 60/60 sign was present in 70.83% of cases of PE. RV:LV EDD in a modified short-axis view of more than 0.9 was present in 91.67% of cases of PE, and ESN on the PW Doppler of the pulmonary valve was present in 75% of cases of PE. The 60/60 sign, RV:LV EDD ratio more than 0.9, and ESN showed sensitivities of 70.83%, 91.67%, 75%, and specificities of 93.75%, 75%, and 100%, respectively for PE. For prediction of mortality, presence of the 60/60 sign (Odds Ratio=8.13, p-value=0.034) and ESN (Odds Ratio=17.50, p-value=0.02) were statistically significant. Conclusions 60/60 sign and ESN are specific for the diagnosis of PE but have poor sensitivity.

An unroofed coronary sinus is an uncommon congenital cardiac anomaly. It leads to a left to right shunt like an atrial septal defect (ASD) and comprises <1% of all ASDs. It can also additionally create a pathway for paradoxical embolization to the brain and other attendant complications. Here, we present the case of an asymptomatic 40-year-old-male with a history of prior surgical closure of an ostium secundum ASD who was referred for preoperative evaluation for non-cardiac surgery. An unroofed coronary sinus with persistent left superior vena cava (PLSVC) was suspected on transthoracic echocardiography and confirmed by transesophageal echocardiography.

An unroofed coronary sinus is a rare congenital anomaly in the roof of the coronary sinus causing a communication between the coronary sinus and the left atrium leading to a left to right shunt. It is often associated with a persistent left superior vena cava and other complex congenital lesions like anomalous pulmonary venous return and heterotaxy. Since it is a deep-seated defect, it is seldom diagnosed by transthoracic two-dimensional (2D) echocardiography and requires multimodal imaging for a diagnosis. Here, we present the case of a 27-year-old male in whom the defect was very apparent on standard 2D transthoracic echocardiography. Transthoracic 2D echocardiography revealed situs solitus, levocardia, and a dilated coronary sinus with unroofing which was most prominent in the standard parasternal long-axis view and the foreshortened apical four-chamber view. A color Doppler demonstrated a flow from the left atrium into the dilated coronary sinus. The right ventricle and atrium were dilated with mild pulmonary arterial hypertension. There was no right ventricular dysfunction. Examination with modified suprasternal views showed a left superior vena cava. All four pulmonary veins drained into the left atrium. Other chambers of the heart and great vessels were structurally normal without coarctation or patent ductus arteriosus. The interventricular septum was intact and atrioventricular and ventriculoatrial concordance was preserved. Detection of a dilated coronary sinus by transthoracic 2D echocardiography must be followed by multimodal imaging techniques like cardiac computed tomography and transesophageal echocardiography to detect and manage associated defects.

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Tricuspid atresia (TA) is a rare cyanotic congenital heart disease. A persistent left superior vena cava (LSVC) may be associated with TA. The presence of LSVC raises important considerations for eventual repair, in that it may lead to persistent arterial desaturation even after corrective surgery, if associated with an unroofed coronary sinus. Here, we present the case of a 4-month-old child who was diagnosed with TA type 1B, LSVC and a dilated coronary sinus by transthoracic echocardiography.