bluuebunny/crossref_metadata_2025 huggingface dataset:
Echocardiographic Imaging of Right Ventricular Outflow Obstruction During Chemotherapy of Mediastinal Lymphoma
Authors: LAINE OUTI K. , GROUNDSTROEM KAJ W.E. , KOIVUNEN ELLI A.
Published: December 2007

Transthoracic echocardiography is a versatile method for imaging cardiac complications caused by mediastinal tumors. Especially, the response to therapeutic measures can be assessed promptly. We present echocardiographic imaging of the regression of right ventricular outflow tract obstruction by chemotherapy.
Advances in Exercise Echocardiography
Authors: MARWICK THOMAS H.
Published: December 2007

In the current literature, pharmacologic stress techniques are the focus of interest and excitement regarding new technologies and new indications such as the diagnosis of viable myocardium. In contrast, exercise echocardiography has evolved less and is less amenable to the introduction of new technologies. This article reviews the indications for exercise echocardiography (especially in contrast to pharmacologic stress), its accuracy relative to other testing, and application to clinical decision making. Exercise echocardiography remains to be well accepted as a diagnostic and risk‐assessment technique, and in some clinical situations it provides valuable data that are not available during pharmacologic stress testing.
Diagnostic and Prognostic Use of Stress Echocardiography and Radionuclide Scintigraphy
Authors: SMART STEVEN C. , SAGAR KIRAN B.
Published: December 2007

Stress echocardiography and radionuclide scintigraphy are effective diagnostic and prognostic techniques in patients with known or suspected coronary artery disease (CAD), myocardial infarction (MI), chronic left ventricular dysfunction (LVD), and those undergoing noncardiac surgery. Both are sensitive and specific for the detection and extent of CAD. Negative tests confer a high negative predictive value for cardiac events irrespective of clinical risk. Positive studies confer a high positive predictive value for ischemic events in patients with intermediate to high clinical risk. Both provide incremental diagnostic and prognostic information relative to clinical, resting echocardiographic, and angiographic data. Meta‐analysis studies have shown that the diagnostic and prognostic information provided by stress echocardiography is comparable with radionuclide scintigraphic stress tests. Stress echocardiography may be more specific for the detection and extent of CAD, whereas radionuclide scintigraphy may be more sensitive for single‐vessel disease. Sensitivities are similar for the detection and extent of disease in patients with multivessel CAD.
Interaction of Microbubbles with Ultrasound
Authors: VON BIBRA HELENE , VOIGT JENS‐UWE , FRÖMAN MATS , BONE DIANNA , WRANNE BENGT , JUHLIN‐DANNFELDT ANDERS
Published: December 2007

The clinical need for bedside myocardial perfusion studies is obvious in the present era of revascularization. Animal and first clinical studies suggest that microbubbles can be used as intravascular tracers of perfusion in conjunction with echocardiography as an imaging modality. In order to fully appreciate the potential and limitations of this approach, the complex interactions of microbubbles within an acoustic field need to be elucidated. Most importantly, there is a strong dependence of bubble effects on the acoustic pressure. At low pressures, linear backscatter yields low signal intensities; at medium range of pressures, bubble resonance causes the reflection of nonlinear signals with harmonic frequencies; and at high pressures, spontaneous acoustic emission with high signal intensity occurs as a final signal of the bubble in its process of disintegration. Thus, in order to allow sufficient replenishment of bubbles to the imaging plane, triggered imaging should be used with one frame every second to eighth cardiac cycle. Traditional gray scale echocardiography was not successful as an imaging modality because of the similarity of gray shades between the myocardium and the contrast effect. Subsequently, second harmonic imaging was developed and was fairly successful in contrast detection, although inherent problems persisted due to the overlap of fundamental and harmonic frequencies in the filtered signals. Harmonic power Doppler imaging turned out as the most sensitive acquisition method, however, with an early dropout at medium range attenuation. In theory, the new technique of pulse inversion may be most promising as this bubble specific imaging modality should combine high sensitivity of detection with great tolerance for attenuation effects in humans. First in vitro studies have confirmed its superiority over harmonic power Doppler in combination with stabilized microbubbles such as SonoVue™. Thus, we will have to accomplish a lot more work and comparative studies in humans before myocardial contrast echocardiography can emerge as a reproducible technique for evaluating myocardial perfusion with high diagnostic accuracy.
Role of Contrast Echocardiography for the Assessment of Left Ventricular Function
Authors: SENIOR ROXY
Published: December 2007

The endocardial border of the left ventricle is incompletely identified in at least 30% of patients at rest or during stress echocardiography during fundamental imaging. This may lead to inaccurate assessment of regional and global left ventricular function or may lead to further diagnostic imaging with another modality resulting in a higher cost of healthcare. The recent development of second generation ultrasound contrast agents has resulted in improved detection of endocardial border at rest and during stress fundamental echocardiography. This has been consistently shown in various clinical trials involving 702 patients using a new contrast agent, SonoVue™. Other studies with contrast agents have also shown improved accuracy for determining left ventricular ejection fraction and volumes. Although unenhanced tissue harmonic imaging itself improved the assessment of left ventricular function, contrast enhanced harmonic imaging has recently been shown to be more accurate; however, larger clinical studies are required to establish the value of harmonic contrast imaging for the assessment of left ventricular function.
Contrast‐Enhanced Transcranial and Extracranial Duplex Sonography
Authors: BOGDAHN ULRICH , HÖLSCHER THILO , ROSIN LUDGER , GÖTZ BIRGIT , SCHLACHETZKI FELIX
Published: December 2007

Transcranial sonography is an ultrasonographic application with real problems of insufficient signal to noise ratio, which make it a primary candidate for applying ultrasonographic contrast enhancing agents. Within an international randomized multicenter phase II/III study, we investigated ten patients with insufficient Doppler signal retrieval using transcranial and extracranial color‐coded duplex sonography to define safety, toxicity, optimal dosing, and the potential of the new ultrasound contrast agent SonoVue™.Patients were studied with standard color duplex systems. SonoVue™ was administered by IV bolus injection at four different doses. Efficacy parameters included the assessment of global quality of Doppler investigations, color Doppler (CD), and spectral Doppler (SD) evaluated by semiquantitative analysis using a four‐point scale from 0 to 3 (very poor to excellent) and the duration of clinically useful signal enhancement. In addition, CD enhancement, evaluated at best signal enhancement, was assessed using a five‐point scale, from no enhancement, slight, moderate, optimal to excessive (0‐4). All examinations were compared to “gold” standard imaging (magnetic resonance imaging, digital subtraction angiography) to evaluate diagnostic confidence at optimum dosage. No serious adverse events were observed. Mean signal increase over baseline in CD or SD was 2 out of 4 points. Mean time to appearance of contrast enhancement was 22.8 seconds (9‐52 sec) at the optimal dosage. The mean duration of enhancement was 281 seconds (20‐593 sec) at the optimal dosage, which was of 2.4 ml of SonoVue™ in nine patients. CD and SD signal enhancement (n = 20, CD + SD) was considered optimal in 12 of 20, excessive in 1 of 20, and moderate or insufficient in 5 of 20 and 2 of 20 cases, respectively. There was a tendency for superior improvement in CD signal enhancement. Diagnostic confidence was improved in 8 of 10 cases without false diagnostic conclusions. SonoVue™ has been demonstrated to be a powerful and safe echo signal enhancing agent, which significantly improves transcranial and extracranial ultrasound investigations and increases the confidence in diagnosis.
Influence of Heart Rate on Doppler Aortic Regurgitant Velocity Curve:
Authors: GOZZELINO GIOVANNI , MOLENDI VITTORIO , PIZZETTI FABRIZIO , ALETTO CARLO , IVALDI MARIO
Published: December 2007

Because it was recently suggested that pressure half‐time (PHT) of aortic regurgitant velocity curve is influenced by heart rate (HR), we retrospectively analyzed 76 patients with aortic regurgitation (AR) to determine whether PHT independently correlates with HR and whether HR correction of PHT can be clinically useful. PHT correlated significantly (P < 0.001) with color Doppler relative regurgitant jet height (r = ‐0.62), with angiographic grading (r = ‐0.65), and with HR (r = ‐0.54); such correlations were confirmed by multivariate analysis. Tachycardia influences aortic velocity curve more than bradycardia, and this effect is more evident in patients with milder regurgitation. Two methods of HR correction of PHT were tested: relative PHT (PHT/diastolic time x 100) and corrected PHT (PHT/√RR): only corrected PHT was independently related to both relative regurgitant jet height and angiographic grading (P < 0.001). HR correction of PHT by corrected PHT was of limited clinical usefulness: in fact, in the entire study population, the accuracy of the usual cutoff (< 300 msec) in detecting relevant AR was not improved by corrected PHT. However, in patients with higher HR (≥ 85 beats/min), in whom the effect of HR on aortic velocity curve appeared to be greater, corrected PHT was superior to PHT because the cutoff value of < 300 msec showed a good specificity (100%), a moderate sensitivity (66%), and a good accuracy (80%) in detecting relevant AR. Corrected PHT can be useful to confirm AR severity when a short PHT is observed in tachycardic patients.
Contribution of Velocity Profiles at the Left Ventricular Outflow Tract to Calculations of Stroke Volume
Authors: FUJIMOTO SHINICHI , MIZUNO REIKO , HASHIMOTO TOSHIO , DOHI KAZUHIRO , HIRAI ATSUSHI , NAKANISHI SHIRO , NAKANO HIROSHI
Published: December 2007

Objective: The goal of the study was to determine whether the central velocity of the left ventricular outflow tract represents the mean velocity of the total outflow area. Methods: Thirteen healthy men (mean age, 30 ± 6 years) and nine patients with aortic valve disease (seven with aortic regurgitation and two with aortic valve stenosis) were examined. Cine gradient echo images were obtained in the left ventricular outflow long axis. Cine images with velocity mapping were obtained in the short axis of the outflow tract. Values for peak velocity were obtained on the right‐left axis and on the anteroposterior axis. Distances were measured along the axes from the right and anterior edges of the outflow tract at the point of peak velocity. Percentages of the distances for outflow diameter were calculated. Peak velocity at the left ventricular outflow tract using pulsed‐Doppler method were also measured. Results: In normal subjects and in patients, on the right‐left axis, the peak velocity was 87 ± 16 and 72 ± 11 cm/sec, respectively, and the distance from the right edge of outflow tract corresponded to 19%± 8% and 21%± 7%, respectively. On the anteroposterior axis, the peak velocity was 86 ± 16 and 60 ± 9 cm/sec, and the corresponding distance from the anterior edge was 30%± 13% and 41%± 12% for normal subjects and patients, respectively. The central velocity of the outflow tract was 74 ± 15 cm/sec, whereas the mean of the total outflow tract was 74 ± 13 cm/sec. Central and mean velocities of the outflow tracts as revealed by magnetic resonance imaging showed a close and highly significant correlation in both groups. Velocity obtained by pulsed‐Doppler method and mean velocity of the outflow tract by magnetic resonance imaging also showed significant correlation in both groups. Conclusions: Central velocity at the left ventricular outflow tract represented the mean of the total outflow tract both in normal subjects and in patients with aortic valve disease. The stroke volume measured by pulsed Doppler is therefore considered reliable if the sampling point is placed exactly at the center of the outflow.
Effects of Low‐Dose Dobutamine on Displacement of the Atrioventricular Plane and Assessment of Myocardial Viability in Patients with Acute Myocardial Infarction Treated with Thrombolysis
Authors: SAMAD BASSEM A , ALAM MAHBUBUL
Published: December 2007

Previous echocardiographic studies have highlighted the usefulness of atrioventricular (AV) plane displacement (the mitral annular motion) in assessing left ventricular function at rest. However, the effects of low‐dose dobutamine on AV plane displacement in thrombolyzed patients with acute myocardial infarction (AMI) are unknown. Thirty‐four patients with AMI treated with a thrombolytic agent and having rest wall motion abnormalities at the infarct site were studied with rest and low‐dose dobutamine echocardiography before discharge. Thirty‐one patients were followed up 18 months later with rest echocardiography. The systolic descent of the AV plane toward the apex at four different left ventricular sites (i.e., at the septal, anterior, lateral, and inferior walls) was recorded to assess left ventricular function. Compared with age‐matched healthy subjects, the AV plane displacement was significantly reduced, especially at the infarct sites, in AMI patients at rest. During low‐dose dobutamine, the AV plane displacement was increased at infarct sites (P < 0.001) in patients with signs of viability. A cutoff point of an increase in AV plane displacement of ≥ 2 mm at the infarct sites during low‐dose dobutamine stress had a sensitivity of 89% and a specificity of 87% in assessing myocardial viability. Using the same cutoff point of a spontaneous increase in the AV plane displacement of ≥ 2 mm during the follow‐up rest echocardiography, 87% of the patients with initial signs of viability and only 25% without signs of viability showed a spontaneous late recovery of initially stunned myocardium. Thus, the study shows that changes in the amplitude of the AV plane displacement during low‐dose dobutamine stress echocardiography can easily be used to detect myocardial viability at an early stage with late potential spontaneous recovery.
Transesophageal Echocardiography with Pathological Correlation in Severe Valvular Disease Associated with Fenfluramine‐Phentermine
Authors: MANGION JUDY R. , HABBOUB AHMAD A. , KAMAT BRINDA R. , TAM STANLEY K. C.
Published: December 2007

We describe the case of severe diffuse multivalvular disease associated with fenfluramine‐phentermine (Fen‐Phen) in a 52‐year‐old patient who presented to the echocardiography laboratory for evaluation of a new heart murmur and ultimately required isolated aortic valve replacement. The patient was known to have a transthoracic echocardiogram 1 year before starting the diet pill combination that showed no significant valvular disease. Pathological evaluation of the excised aortic valve was consistent with that described with Fen‐Phen use. Transesophageal echocardiography played an important role in defining unique features associated with the valvular disease and in intraoperative management of the patient.
Lambl's Excrescences Involving the Pulmonary Valve Detected by Transesophageal Echocardiography
Authors: VOROS SZILARD , NANDA NAVIN C. , THAKUR ABHASH C. , NARAYAN VIRENJAN K. , SAMAL ADITYA K.
Published: December 2007

We report the first case of echocardiographically detected Lambl's excrescences on the pulmonary valve in a 72‐year‐old man who was referred for transesophageal echocardiography as a part of an evaluation for ischemic stroke. A total of four excrescences were noted on the arterial aspect of the pulmonary valve; two of them were on the anterior cusp, one was on the left cusp, and one was on the right cusp. The excrescence on the left cusp was the largest, measuring 5 mm in length. These valvular strands (Lambl's excrescences) represented an incidental finding and were not associated with any disease process.
Evaluation of Left Ventricular Diastolic Performance Using Automated Border Detection
Authors: SPENCER KIRK T. , MOR‐AVI VICTOR , WEINERT LYNN , LANG ROBERTO M.
Published: December 2007

Acoustic quantification (AQ) is a noninvasive technique which provides online left ventricular (LV) area/volume waveforms. The filling portion of the AQ waveform can be used to assess LV diastolic properties. Analysis of signal‐averaged AQ curves enhances the waveforms and allows reliable, quantitative, and automated analysis. From signal‐averaged AQ LV waveforms, the phases of diastole can be easily detected and several parameters of diastolic performance calculated. Analysis of signal‐averaged LV waveforms is complementary to that of LV AQ analysis. AQ has been used to identify diastolic dysfunction in patients with LV hypertrophy and systemic hypertension. Normal values of these parameters are age dependent and reference values will soon be available.
Color Kinesis
Authors: MOR‐AVI VICTOR , GODOY IVAN E. , LANG ROBERTO M.
Published: December 2007

Color kinesis is a relatively new echocardiographic technique that allows color encoding of endocardial motion in real time. We briefly review the literature on the current clinical uses and limitations of this technique, as well as its potential future applications based on some of our results. The major advantage of this modality is that it provides the basis for objective and automated evaluation of regional systolic and diastolic function, which may have a direct impact on the diagnosis of various myocardial disease states and, in particular, coronary artery disease.
Evaluation of Global and Regional Right Ventricular Function Using Automated Border Detection Techniques
Authors: VIGNON PHILIPPE , SPENCER KIRK T. , MOR‐AVI VICTOR , WEINERT LYNN , LANG ROBERTO M.
Published: December 2007

Quantitative evaluation of right ventricular (RV) function remains challenging due to the complex geometry of this chamber, which precludes the use of simple geometric assumptions. Automated border detection (ABD) techniques, which provide online changes in cardiac chamber dimensions, have been predominantly used for quantitative assessment of global as well as regional left ventricular function. Recently, acoustic quantification has been validated for quantitative evaluation of global RV function, and color kinesis has been used to objectively assess systolic and diastolic regional RV function. In this article, the main studies validating ABD for the objective assessment of global RV function and the current clinical uses of this technique are reviewed. In addition, technical guidelines and limitations of ABD techniques are described, and potential applications of color kinesis for quantitative assessment of regional systolic and diastolic RV performance are detailed. ABD techniques provide new insights into right atrial and RV systolic and diastolic properties. The clinical value of these techniques in the diagnosis, prognosis, and potential guidance of therapeutic management of RV dysfunction remains to be determined.
Evaluation of the Left Atrial Performance Using Acoustic Quantification
Authors: STEFANADIS CHRISTODOULOS , DERNELLIS JOHN , TOUTOUZAS PAVLOS
Published: December 2007

In most clinical studies, evaluation of left atrial (LA) function evolved from estimation of LA size on chest radiograph, electrocardiographic P wave abnormalities, LA diameter determined at fluoroscopy or by echocardiography, LA pressure recordings, blood flow velocity with Doppler echocardiography, and measurements of LA volume based on echocardiographic, cineangiographic, radionuclide, and magnetic resonance imaging techniques. The recent development of real‐time two‐dimensional echocardiographic acoustic quantification (AQ) suggests that LA dimensions can be measured instantaneously to provide online assessment of its systolic and diastolic functions. By means of AQ echocardiography and simultaneous recordings of LA pressure, the LA pressure‐area relation can be obtained. LA pressure‐area relation consisted of two loops: the A loop, representing the LA pump function, and the V loop, representing LA reservoir and passive emptying functions. The importance of LA function has been demonstrated in congestive heart failure, atrial fibrillation, hypertension, and ischemic heart disease and during pacing or dobutamine infusion.
Echocardiographic Detection of Occult Cor Pulmonale During Exercise in Patients with Chronic Obstructive Pulmonary Disease
Authors: TAKAKURA MASAHIRO , HARADA TAKASHI , FUKUNO HIROSHI , OKUSHI HIDESATO , TANIGUCHI TETSUZO , SAWADA SEIZO , FUJINAGA HIROYUKI , WAKATSUKI TETSUZO , OKI TAKASHI
Published: December 2007

We tested the ability of cycle ergometer exercise echocardiography to detect cases of occult cor pulmonale among 25 patients with chronic obstructive pulmonary disease (COPD). The M‐mode echocardiographic ventricular septal motion, left ventricular shape determined by short‐axis two‐dimensional (2‐D) echocardiography, and right and left ventricular pressure curves were recorded at rest and during exercise and were compared between patients. The ventricular septal motion was normal at rest in all of the patients. In nine patients (dip group), there was marked downward ventricular septal motion in early diastole during exercise, indicating distortion of the left ventricular shape. There were no distinct changes in the remaining 16 patients (non‐dip group). At rest, the cardiac index was significantly lower, and right ventricular systolic and mean pulmonary artery pressures were significantly higher in the dip group than in the non‐dip group. However, no significant difference was noted in the right ventricular end‐diastolic pressure between the two groups at rest. The right ventricular systolic and end‐diastolic pressures were greater during exercise in the dip group than in the non‐dip group. In all of the patients in the dip group, the right ventricular pressure exceeded the left ventricular pressure only in early diastole, coinciding with the early diastolic dip of the ventricular septum, during exercise. In conclusion, occult cor pulmonale can be diagnosed accurately by the appearance of an early diastolic dip of the ventricular septum and distorted left ventricular shape during exercise in patients with COPD.
Impact of Age on the Safety and the Hemodynamic Response Pattern During High Dose Dobutamine Echocardiography
Authors: CHENZBRAUN ADRIAN , KHOURY ZAHI , GOTTLIEB SHMUEL , KEREN ANDRE
Published: December 2007

Background: The purpose of the present study was to assess the safety and hemodynamic response of high dose dobutamine echocardiography (DE) in different age groups. DE is frequently used in the diagnosis of coronary artery disease; its safety in very elderly patients is not established, and there are no standards for blood pressure and heart rate response. Methods and Results: The test was performed using up to 50 μg/kg/min in 400 patients: 164 middle‐aged (age < 65 years), 187 elderly (age, 65–79 years), and 49 very elderly (age ≥ 80 years). It was stopped because of side effects in 91 (23%) patients. Serious side effects occurred in 1.5% of the patients. There was a significant (60%± 35%) increase in heart rate, and a modest (10%± 19%) increase in the blood pressure (P <.001). The change in heart rate was similar in the three age groups, but there was a blunting of the blood pressure response with age. Hypotension was related to ischemia only in the very old. Conclusions: High‐dose dobutamine is safe in all age groups. Dobutamine induces mainly a chronotropic and less a hypertensive response. The chronotropic response of the very old is similar with that of younger patients, but the hypertensive response is blunted in this group.
A Case of Ball Valve Thrombus
Authors: THANIKACHALAM S. , SENGOTTUVEL G. , GEORGE SUSAN , KUMAR M. SAMPATH , SHIVAKUMAR R. V. , BALAKRISHNAN K. R. , MURTHY J. S. N.
Published: December 2007

Ball valve thrombus is a very rare cardiac pathological entity; most case reports are postmortem. It is always associated with a very tight rheumatic mitral stenosis. The antemortem diagnosis of ball valve thrombus has become easy with the advent of echocardiography and even easier with biplane or multiplane transesophageal echocardiography, including the three‐dimensional acquisition of images. We present the case of a patient with a ball valve thrombus diagnosed during routine echocardiographic examination as a prelude to surgery.
Aortopulmonary Window with Interrupted Aortic Arch and Pulmonary Artery Sling: Diagnosis by Echocardiography and Magnetic Resonance Imaging: Case Report and Literature Review
Authors: TEO EU‐LEONG H. J. , GOLDBERG CAREN S. , STROUSE PETER J. , VERMILION ROGER P. , BOVE EDWARD L.
Published: December 2007

We present the pediatric case of a patient who had aortopulmonary window with interrupted aortic arch, intact ventricular septum, and pulmonary artery sling that was imaged with echocardiography and magnetic resonance imaging. This case is unique because this combination of findings has not been previously reported. The diagnosis was made without the need for angiography, and the findings were confirmed at surgery. This case shows that complex congenital heart defects can be accurately imaged by noninvasive methods.
Esophageal Perforation After Transesophageal Echocardiogram
Authors: SHAPIRA MICHAEL Y. , HIRSHBERG BOAZ , AGID RONIT , ZUCKERMAN ELENA , CARACO YOSEPH
Published: December 2007

Esophageal rupture after transesophageal echocardiogram (TEE) is a rare but life‐threatening complication. Risk factors for perforation include spasm or hypertrophy of the cricopharyngeal sphincter, cervical arthritis, forward and left lateral bending of the distal esophagus, and esophageal disease such as inflammation or neoplasm. We present the case of a 80‐year‐old woman who developed perforation of her esophagus after TEE. Prior irradiation to the chest due to treatment for breast cancer and subsequent fibrosis probably contributed to this complication. Physicians referring patients for a TEE and physicians performing this procedure should be aware for the risk of perforation. The identification of risk factors and gentle maneuvering of the probe may prevent this severe, life‐threatening complication.
Transesophageal Echocardiographic Diagnosis of Proximal Coronary Artery Stenosis in Patients with Ischemic Stroke
Authors: THAKUR ABHASH C. , VOROS SZILARD , NANDA NAVIN C. , GOMEZ CAMILO R. , TERRY JOHN B. , TULYAPRONCHOTE ROEKCHAI , OCAK OZLEM
Published: December 2007

Atherosclerosis is the leading cause of death worldwide. It encompasses several clinical entities, including coronary artery disease and cerebrovascular disease. Because the underlying pathophysiological mechanism is the same, coronary artery disease and cerebrovascular disease frequently coexist. Transesophageal echocardiography (TEE) is routinely done in patients with ischemic stroke to exclude possible cardiac sources of cerebral embolism. Since the introduction of multiplane transesophageal transducers, it has become easier to visualize the proximal coronary arteries during transesophageal examinations. We report three cases in which routine TEE for ischemic stroke revealed significant coronary artery disease that was not previously suspected. In one patient, the stroke was so severe that further evaluation of the coronary artery disease was not deemed useful. The other two patients underwent coronary angiography based on the echocardiographic findings, confirming the lesions noted on the echocardiogram. Subsequently, both patients were successfully revascularized: one by percutaneous transluminal coronary angioplasty and the other by coronary artery bypass graft surgery. We conclude that the examination of coronary arteries during routine TEE for ischemic stroke may become a useful screening tool for the detection of coexisting, asymptomatic, significant proximal coronary artery disease.
Dobutamine Stress Tele‐Echocardiography as a Clinical Service in the Emergency Department to Evaluate Patients With Chest Pain
Authors: TRIPPI JAMES A. , LEE KAMTHORN S.
Published: December 2007

Patients presenting with chest pain to the emergency department should be efficiently triaged. During our previous research trial, the use of dobutamine stress tele‐echocardiography (DSTE) effectively and safely allowed the diagnosis of patients who could be released from the emergency department. To assess the usefulness of DSTE as a clinical service, the protocols, training, and implementation of our experience are reviewed from > 4 years of testing 734 patients in our emergency department. The patient demographics of those tested appeared to remain consistent during the study period. An average of 12.5% of patients who underwent DSTE yielded abnormal results. In addition to myocardial ischemia, numerous cardiac disorders were uncovered. Side effects from DSTE caused the testing to be prematurely discontinued in 3.1% of patients. Within ∼ 6 hours of arrival at the emergency department, 70% were discharged after their normal DSTE. DSTE appears to be safe, rapid, and useful in triaging nonstudy patients with chest pain who are of low to moderate risk for myocardial infarction or ischemia.
Use of Transesophageal Echocardiography for the Assessment of Traumatic Aortic Injuries
Authors: VIGNON PHILIPPE , LANG ROBERTO M.
Published: December 2007

Acute traumatic lesions of the thoracic aorta or its branches (TLA) constitute highly lethal yet treatable injuries that are increasingly diagnosed in surviving patients. Traumatic disruptions are limited to the region of the aortic isthmus in ∼ 90% of cases. Unlike aortography, usually referred as the gold standard diagnostic technique, transesophageal echocardiography (TEE) is a noninvasive imaging modality that can be rapidly performed at the patient bedside. Accordingly, TEE is being increasingly used as a first‐line screening test for the evaluation of patients with suspected TLA. The TEE signs associated with TLA depend on the anatomic type of aortic disruption. After a period of validation, multiplane TEE allows accurate diagnosis of traumatic disruptions of the aortic isthmus, with a sensitivity of 88% (range, 57%–100%) and a specificity of 96% (range, 84%–100%). False‐negative TEE results have been mainly attributed to lacerations of aortic branches. Accordingly, aortography must be routinely performed when a traumatic injury to brachiocephalic arteries is suspected. False‐positive TEE findings have been associated with the presence of ultrasound artifacts or atherosclerotic changes that mimic TLA. Accurate determination of the depth of aortic wall tears and diagnosis of blunt cardiac injuries during the TEE study are crucial to guide patient management. The presence of TEE signs associated with imminent risk of adventitial rupture should lead to prompt surgery. The use of TEE as a first‐line imaging modality simplifies the initial assessment of patients at high risk for TLA and helps guide acute management.
Effect of Programmed Atrioventricular Delay on the Patterns of Mitral and Pulmonary Vein Flow Profiles and Their Durations in Patients with Dual‐Chamber Pacemakers
Authors: PAI SUDHA M. , JACOBSON ALAN K. , PAI RAMDAS G.
Published: December 2007

Cardiac pacemakers are increasingly used in patients with dilated and hypertrophic cardiomyopathy. In these patients, unusually short atrioventricular (AV) delays are used. Changing the AV delay has been shown to affect the mitral E/A velocity ratio, but its effect on the duration of left ventricular (LV) isovolumic relaxation time, LV filling time, or pulmonary vein flow pattern has not been investigated. Twelve patients with dual‐chamber pacemakers were studied. The pacemaker was set at a rate of 70 beats/min, and the AV delay was programmed from 25 to 250 msec in 25‐msec increments. At each stage, mitral and pulmonary vein flow velocities were recorded using pulsed‐wave Doppler technique. Increasing AV delay resulted in a shortened LV diastolic filling period, a change in LV isovolumic relaxation time, a reduction in the E/A velocity ratio, and an increase in A – AR wave duration. These findings have implications not only in the optimization of LV filling but also in the interpretation of mitral and pulmonary vein flow profiles in the evaluation of LV diastolic function and filling pressures.
Transesophageal Echocardiographic Examination of Left Subclavian Artery Branches
Authors: NANDA NAVIN C. , THAKUR ABHASH C. , THAKUR DINESHKUMAR , NARAYAN VIRENJAN KUMAR , ESPINAL MIGUEL A. , SHOEB GAMAL , SAMAL ADITYA K. , VOROS SZILARD , AALURI SRINIVASA R. , OCAK OZLEM , JOHN ABRAHAM S. , PASIA ARNOLD T. , AIKENS MICHAEL
Published: December 2007

This preliminary study demonstrates the feasibility of examining the proximal segments of the branches of the left subclavian artery during probe withdrawal toward the end of a routine transesophageal echocardiographic study. The branches identified most commonly were the vertebral and the internal mammary arteries.
Echocardiographic Assessment of Complications Related to Left Ventricular Function in Acute Myocardial Infarction
Authors: KHALID M. ATIQ , BHATIA ATUL , GAL RAMI
Published: December 2007

Three complications of acute myocardial infarction without myocardial rupture are directly associated to the function of the myocardium: papillary muscle dysfunction, congestive heart failure, and cardiogenic shock. In this article, the pathophysiological mechanism of each complication is discussed, and the contribution of echocardiography to diagnosis and management is reviewed.
Right Ventricular Infarction: Contribution of Echocardiography to Diagnosis and Management
Authors: JUGDUTT BODH I.
Published: December 2007

Right ventricular infarction (RVI) is associated with nearly one third of patients who have inferior myocardial infarction (MI). The classic triad of hypotension, clear lung fields, and increased jugular venous pressure in the setting on inferior MI is highly suggestive of RVI. Direct visualization of the RV and left ventricular chambers on two‐dimensional echocardiography allows early diagnosis by demonstration of predominant RV asynergy (akinesis plus dyskinesis), RV dilation, and decreased RV ejection fraction. The extent of RV involvement varies widely and correlates with outcome. Serial two‐dimensional echocardiography and Doppler are also valuable in short‐ and long‐term management, to detect complications, and to assess outcome.
Role of Echocardiography in Complications Associated with Partial or Complete Rupture of the Myocardium in Acute Myocardial Infarction
Authors: BHATIA ATUL , KHALID M. ATIQ , GAL RAMI
Published: December 2007

In this report, we focus on the specific complications of acute myocardial infarction that are associated with rupture of the myocardium and for which two‐dimensional and Doppler color flow echocardiography expedites accurate diagnosis for prompt treatment, including surgical repair, which can be crucial to survival in such cases.
Relationship Between Echocardiographic Determinants of Left Atrial Spontaneous Echo Contrast and Thrombus Formation in Patients with Rheumatic Mitral Valve Disease
Authors: CINAR CAHIDE SOYDAS , GURGUN CEMIL , NALBANTGIL SANEM , CAN LEVENT , TURKOGLU CUNEYT
Published: December 2007

Spontaneous echo contrast (SEC) may be detected by ultrasonography in environments favoring blood stasis. It is most commonly seen through the use of transesophageal echocardiography in the left atrium of patients with rheumatic mitral valve disease especially in the presence of atrial fibrillation. We studied the predictors of SEC, such as cardiac rhythm, left atrium and left atrial appendage functions, and mitral and pulmonary vein flow parameters, in patients with rheumatic mitral valve disease. The relationship between these parameters and the severity of SEC and appearance of thrombus was evaluated.
Management of Nonobstructive Thrombosis of Prosthetic Mitral Valve in Asymptomatic Patients in the Early Postoperative Period: A Study in 20 Patients
Authors: BEMURAT LAURENT R. , LAFFORT PATRICK R. , DEVILLE CLAUDE J. , ROQUES XAVIER G. , BAUDET EUGENE M. , ROUDAUT RAYMOND P.
Published: December 2007

The purpose of the present study was to determine the optimal management of nonobstructive thrombi in the early postoperative period after mitral valve replacement. Twenty cases of early thrombi were revealed by systematic transesophageal echocardiography (TEE) performed 9 days after surgical implantation of 229 St. Jude prostheses. Patients were prospectively randomized into two groups: the first group received oral anticoagulants (fluindione), and the second group was treated with a combination of oral anticoagulants and aspirin. The impact of the different therapies on prosthetic thrombi was assessed by systematic TEE at 5 months. All thrombi were nonobstructive and disappeared without fibrinolytic agents or surgery. Seven large (≥ 5 mm) thrombi disappeared: in two patients after reintroduction of intravenous heparin and in five patients with an optimized oral treatment (anticoagulants alone in one patient, anticoagulants associated with aspirin in four patients). In the 13 small (< 5 mm) thrombi, 11 disappeared with an optimized oral treatment: anticoagulants alone in nine patients and anticoagulants associated with aspirin in two patients. The other two small thrombi treated with heparin alone initially persisted and finally disappeared with heparin associated with aspirin. In the group with large thrombi, we recorded a 43% rate of thromboembolic events, with more deaths and severe cerebral embolic events than in the patients with small thrombi. Embolic events were associated with mobile thrombi. An optimized oral anticoagulation therapy with correction of the parameters of Virchow et al. is effective in the treatment of small prosthetic thrombi. For large thrombi, the high rate of thromboembolic events would appear to require a more aggressive approach such as an association of heparin with aspirin and TEE follow‐up.
Comparison of Three Different Protocols for Dobutamine Stress Echocardiography
Authors: TAKEUCHI MASAAKI , MIURA YASUSHI , SONODA SHINJOU , KUROIWA AKIO
Published: December 2007

The addition of atropine during dobutamine stress echocardiography (DSE) is increasingly used for detecting coronary artery disease (CAD), but its safety and whether it has added diagnostic accuracy have not been well defined. The aim of this study was to retrospectively compare the complication rate and diagnostic accuracy of three different protocols in the same laboratory. DSE was performed in 1090 patients over a 5‐year period. The protocol had included (1) 5’stages up to 30 μg/kg/min of dobutamine in the first 184 patients, (2) 3’stages up to 40 μg/kg/min in the next 274 patients, and (3) 3’stages up to 40 μg/kg/min with atropine, when required in the last 632 patients. A large number of patients (n = 938) underwent coronary angiography within 2 weeks, and 524 patients had a significant coronary stenosis (> 50%). In the whole group of 1090 patients, serious complications developed in 5 patients (one acute myocardial infarction, one sustained ventricular tachycardia, and three prolonged ischemia). Although the incidence was low, there were no detectable differences between protocols. Hypotension, which was defined as a ≥ 20 mmHg decrease in systolic blood pressure from the baseline, was observed in 68 patients. Premature ventricular contraction was the most common arrhythmia. The complication rate was similar among three protocols. The diagnostic accuracy for detecting CAD was nearly the same among three protocols (30 μg, 86%; 40 μg, 84%; and 40 μg with atropine, 84%), but the prevalence of CAD was higher with the 30‐μg protocol (65%) than the 40‐μg protocol (55%) or 40‐μg‐with‐atropine protocol (53%, P < 0.01). In 469 patients without a previous myocardial infarction, the prevalence of CAD was the same (38–42%). Sensitivity increased with more aggressive protocols (71%, 76%, and 84%). However, it was associated with the loss of specificity (92%, 92%, and 85%). Thus, the diagnostic accuracy was similar among groups (84%, 85%, and 84%). In conclusion, the addition of atropine during DSE does not increase the rate of complication compared with previous conservative protocols and shows the same diagnostic accuracy with a small increase in sensitivity at the cost of a small and matched decrease in specificity.
Transesophageal Echocardiographic Evidence for Acute Right Atrial Dysfunction
Authors: VARGAS‐BARRÓN JESÚS , ROMERO‐CÁRDENAS ANGEL , ESPÍNOLA‐ZAVALETA NILDA , MOLLICK ABRAHIM B. , KEIRNS CANDACE
Published: December 2007

We describe the clinical course and echocardiographic findings of a 64‐year‐old man who was hospitalized with an infarction of the inferior myocardial wall of 5 days' evolution and extension to the right ventricle. Transesophageal echocardiography showed biventricular inferior dyssynergia and akinesis of the right atrial wall. One thrombus was visible in the right atrial appendage, and another crossed the foramen ovale and reached the mitral valve. After the patient received anticoagulant agents, transesophageal studies showed the disappearance of atrial thrombi, as well as recuperation of right atrial movement and active participation of atrial contraction in right ventricular filling. The findings of these serial echocardiograms support the existence of ischemic right atrial stunning manifested by wall akinesis that favored slow atrial flow and the formation of thrombi.
Double‐Chambered Left Ventricle: Unusual Presentation with an Apical Defect in a Thallium Scan in a Middle‐Aged, Asymptomatic Woman
Authors: RICKLI HANS , JOST CHRISTINE H. ATTENHOFER , LOCHER JOHANNES T. , JENNI ROLF
Published: December 2007

A left ventricular apical filling defect was found in a whole‐body thallium scan performed for routine follow‐up for surgically cured thyroid cancer in a 51‐year‐old woman. She had no cardiovascular symptoms, and her electrocardiogram at rest and during exercise was unremarkable. Transthoracic and transesophageal echocardiography revealed a double‐chambered left ventricle. A prominent fibromuscular ridge distal to the papillary muscles was seen dividing the left ventricular cavity into a small apical portion and a large basal portion. There was no significant intraventricular gradient. No treatment was necessary, and the patient has remained asymptomatic in a 4‐year follow‐up.
Characterization of an Unusual Right Atrial Mass by Echocardiography, Magnetic Resonance Imaging, Computed Tomography, and Angiography
Authors: BURRI HARAN , BLOCH ANTOINE , HAUSER HERMANN
Published: December 2007

A right atrial mass was discovered by echocardiography in a 53‐year‐old man. A work‐up consisting of magnetic resonance imaging and computed tomography studies established the diagnosis of atrial lipoma. The echocardiographic features are compared with the radiological findings, and the characteristics permitting differentiation of lipoma from other causes of cardiac masses are discussed. In this case, echocardiography not only permitted the initial identification of the mass but also proved to be useful in follow‐up of its evolution over time, thereby influencing the therapeutic management.
Palpable Cardiac Impulse Predicts Adequate Acoustic Windows
Authors: EICHELBERGER JAMES P. , PENTZ WILLIAM H.
Published: December 2007

In this study, we sought to determine the usefulness of palpating an apical cardiac impulse on physical examination in predicting adequate echocardiographic images for stress echocardiography. A variety of stress tests using either echocardiographic imaging or nuclear imaging are available to referring physicians. Deciding which test is best for a given patient is often dificult. In the case of stress echocardiography, the most significant limitation is poor image quality i n a small portion of patients. We enrolled 136 consecutive outpatients referred for echocardiography. The presence or absence of a palpable cardiac apex on physical examination was recorded by two independent and blinded examiners. Data, including age, sex, weight, prior chest surgery, and smoking, were also collected. Echocardiographic imaging of the left ventricle was scored according to the number of adequately visualized wall segments in a standard 16‐segment model. One hundred eleven patients (82%) had adequate visualization of at least 14 of 16 wall segments. Ninety‐eight patients (72%) had a palpable cardiac impulse, of whom 90 (92%) also had adequate acoustic image quality versus only 21 (55%) of the 38patients in whom an apex was not palpable (P < 0.0001). Other variables that were measured were not significantly related to image quality, with the exception of weight; patients with adequate images weighed a mean of 75 kg versus 91 kg i n those with inadequate images (P < 0.0006). However, multivariate analysis showed a palpable apex to be the only independent predictor after controlling for other variables. A physical examination assessment for a palpable apical impulse is useful to predict adequate echocardiographic image quality for stress echocardiography. When used in conjunction with other parameters, this may lead to more appropriate referral to augmented stress testing. (ECHOCARDIOGRAPm, Volume 17, January 2000)
Comparison of Indicator‐Dilution Curves Obtained from Dye Dilution and Echo Contrast Using Harmonic Power Doppler Imaging
Authors: TIEMANN KLAUS , SCHLOSSER THOMAS , POHL CHRISTOPH , BIMMEL DIETER , WIETASCH GÖTZ , HOEFT ANDREAS , LIKUNGU JAMES , VAHLHAUS CHRISTIAN , KUNTZ STEFANIE , NANDA NAVTN C. , BECHER HARALD , LÜDERITZ BERNDT
Published: December 2007

Background: Harmonic power Doppler imaging (H‐PDI) has been introduced into the field of contrast echocardiography as a contrast‐specific imaging modality. However, there has been considerable skepticism as to whether H‐PDI would be quantifiable, because it depends on the destruction of microbubbles and has more complex signal processing than gray scale imaging. The aim of the present study was to evaluate the relationship between the concentration of microbubbles and the resulting H‐PDI signals even under conditions where bubble destruction is most likely. Furthermore, we evaluated whether micro‐bubbles of Levovist freely pass the microcirculation, which is a prerequisite for the assessment of myocardial blood flow. Methods and Results: A strong positive correlation was found between the H‐PDI signals and the amount of microbubbles up to the onset of acoustic shadowing (r= 0.968, P < 0.001). Time‐intensity curves for H‐PDI of air‐filled microbubbles were compared with time‐concentration curves of indocyanine green (ICG) in both a flow phantom and a working heart setup. The mean transit times (MTTs) through the myocardium of both agents were compared after a bolus injection into the left coronary artery. A close correlation was observed between 1/MTT and flow in both setups (r> 0.98, P < 0.0001). However, at high flow rates, the MTTs of the microbubbles were slightly, albeit not significantly, faster than those of indocyanine green. Conclusions: We conclude that microbubbles fulfill the prerequisites of free flowing tracers through the myocardium. Furthermore, H‐PDI technology allows a reliable assessment of time‐concentration curves of air‐filled microbubbles up to the onset of acoustic shadowing. (ECHOCARDIOGRAPHY, Volume 17, January 2000)