bluuebunny/crossref_metadata_2025 huggingface dataset:
Intraoperative Epicardial Echocardiography: Technique and Imaging Planes
Authors: KLEIN ALLAN L. , STEWART WILLIAM C. , COSGROVE DELOS M. , SALCEDO ERNESTO E.
Published: August 2007

With the recent innovations in cardiac surgical techniques, there is need for an immediate and reliable way to assess results in the operating room. Intraoperative epicardial echocardiography with Doppler color flow mapping provides an accurate and rapid imaging modality to assess the anatomical and functional results of cardiac surgery. This gives the surgeon a way to determine whether the hemodynamic abnormality has been successfully eliminated, prior to closure of the chest. After enclosure in a sterile sheath, a standard echocardiographic transducer is placed directly onto the epicardial surface. The heart is imaged in multiple tomographic planes developed specifically for intraoperative use: the parasternal equivalent; aortopulmonary sulcus; subcostal equivalent; and aorta‐superior vena cava transducer positions. Two‐dimensional echocardiography is useful to assess the morphology of valves and the size and function of cardiac chambers. Doppler color flow mapping provides a semi‐quantitative assessment of the severity and physiological mechanism of valvular regurgitation. Continuous‐wave Doppler echocardiography is used to estimate gradients across stenotic valves. This comprehensive appraisal of cardiac anatomy and flow is useful in the pre‐ or postcardiopulmonary bypass phase of cardiac surgery. This review focuses on the technique of intraoperative echocardiography and its applications in valve reconstruction operations with specific emphasis on the epicardial imaging planes.
Intraoperative Echocardiography for Surgical Repair of the Aortic Valve and Left Ventricular Outflow Tract
Authors: CURRIE PHILIP J. , STEWART WILLIAM J.
Published: August 2007

Valve conservation surgery represents an exciting advance in the evolution of valve surgery. Recent studies have shown the significant advantages of mitral valve repair over valve replacement. While there are significant advantages for valve repair, the surgeon requires a greater understanding of the mechanism of valvular dysfunction prior to repair and requires an accurate means to assess the adequacy of the repair in the operating room immediately following the repair. Intraoperative echocardiography with color flow Doppler mapping provides immediate and accurate assessment of cardiac anatomy, hemodynamics, and valve integrity. These data are vital for optimal intraoperative surgical decision making. Intraoperative echocardiography has an important role in the evaluation in patients undergoing surgery to the aortic valve and left ventricular outflow tract by the delineation of presence and mechanism of left ventricular outflow tract obstruction, the quantification of severity of the left ventricular outflow tract gradient, the severity and mechanism of aortic regurgitation, the distribution and severity of left ventricular hypertrophy, and identification of associated lesions such as mitral regurgitation. Aortic valve conservation surgery is more complex than mitral valve surgery. The surgical techniques for aortic valve repair have been slower to evolve than mitral repair with a much smaller percentage of patients currently suitable for valve repair. However, with the aid of intraoperative echocardiography, the future shows similar promise that has already been fulfilled with mitral valve repair. Even in its infancy, intraoperative echocardiography has become indispensable to the innovative cardiac surgeon. However, without consideration of adequate echocardiographic training, incorrect echocardiography diagnoses can lead to inappropriate surgical decisions.
Percutaneous Balloon Valvuloplasty and Coronary Angioplasty: What Kind of Guidance Would be Useful During the Performance of These Procedures?
Authors: SALEM DEEB N. , PANDIAN NATESA G. , UDELSON JAMES
Published: August 2007

Major advances have occurred during the last decade in the management of coronary arterial and valvular diseases using catheter‐based treatment modalities. These methods, however, are still plagued by technical difficulties in the performance of the procedures because of the lack of appropriate guidance, and complications because of difficulties in patient selection. This review article deals with the various problems related to percutaneous balloon valvuloplasty and coronary angioplasty, outlines the specific needs in terms of guidance and discusses the possible guiding potential of intravascular ultrasound imaging methods.
Pulmonary Hypertension as a Marker for Perivalvular Regurgitation Following Mitral Valve Replacement
Authors: TISCHLER MARC D. , LEE RICHARD T.
Published: August 2007

Pulmonary hypertension is frequently present in patients with mitral valve disease. Several longitudinal studies have demonstrated regression of pulmonary hypertension following successful mitral valve replacement. We describe 12 consecutive patients in whom noninvasive detection of pulmonary hypertension following mitral valve replacement provided early evidence of perivalvular regurgitation.
Transesophageal Echocardiographic Evaluation of Mechanical Biventricular Assist Device
Authors: PARKS JAMES M. , NANDA NAVIN C. , BOURGE ROBERT C. , HOLMAN WILLIAM L. , KIRKLIN JAMES K.
Published: August 2007

The usefulness of transesophageal echocardiography in the assessment of mechanical biventricular assist devices is described.
Multiple Secundum Type Atrial Septal Defects: Identification by Transthoracic Color Doppler Echocardiography
Authors: RAINER REBECCA S. , WANAT FRANCIS E. , NANDA NAVIN C. , CHANG LEANG KAI
Published: August 2007

This case illustrates the utility of two‐dimensional color Doppler echocardiography in detecting and localizing multiple atrial septal defects not consistently demonstrated by standard two‐dimensional echocardiography.
Feto‐Maternal Circulatory Changes Related to Placenta Morphology in Diabetes Mellitus
Authors: OLOFSSON PER , LAURINI RICARDO N. , LINGMAN GÖRAN , MARSÁL KAREL
Published: August 2007

Combined real‐time Doppler ultrasound blood flow measurements were carried out in 20 diabetic pregnant women in the third trimester. The placenta morphology was examined with emphasis on maturation, centrocotyledon hemorrhage, villous edema, and ischemia, ischemic villitis, infarction, perivillous fibrin deposition, thrombosis, and inflammatory changes of membranes and fetal placental vessels. Ten out of 17 cases with placenta pathology had normal blood flow measurements. Centrocotyledon hemorrhage (n = 8) was associated with a higher pulsatility index in the fetal aorta and development of fetal distress and obstetric intervention in labor. The higher number of hemorrhages, the greater the risk of intervention. The pulsatility index was normal in the umbilical artery. The uterine artery pulsatility index showed no correlation to the hemorrhages. Ischemic villitis and infarction were not found in any placenta, suggesting that there were no cases of advanced placental dysfunction. Placental immaturity, found in 11 cases, was not associated with any flow anomalies. Centrocotyledon hemorrhage seemed to be the earliest morphological abnormality affecting blood flow in the feto‐maternal circulation in diabetic pregnancy. Centrocotyledon hemorrhage might be the first sign of placental microflow disturbance, possibly affecting fetal oxygenation, but not the total placental vascular bed resistance.
Transesophageal Echocardiography in Pediatrics: Technique and Limitations
Authors: ROBERSON DAVID A. , MUHIUDEEN ISOBEL A. , SILVERMAN NORMAN H.
Published: August 2007

This review summarizes our experience with transesophageal echocardiography in 92 pediatric patients in order to delineate the capabilities and limitations of this new technique. Transesophageal echocardiography was found to be a valuable clinical tool in intraoperative analysis and in the small subpopulation of pediatric patients with limited precordial echocardiography. Further refinements in transducer design are required to allow complete analysis of congenital cardiac anomalies.
Echo Contrast Agents Improve Flow Display of Color Doppler: In Vitro Studies
Authors: BIBRA HELENE VON , STEMPFLE HANS‐ULRICH , POLL ALEXANDER , SCHLIEF REINHARD , EMSLANDER HANS
Published: August 2007

Flow detection by color Doppler is impaired by low velocity of flow and increasing attenuation and depth of ultrasound penetration. The effects of increased echogenicity on flow detection, (Toshiba SSH 65A) were thus studied in a flow model, which yielded similar strengths of Doppler signals as seen in the clinical routine, by adding microbubble solutions to the blood analog fluid (45% aqueous glycerin) arid comparing signal strength (score 0–5) prior to and after contrast. The flow within the plexiglass tube with < 3° angle of coincidence for Doppler interrogation was laminar with a parabolic velocity profile at physiological velocities and pressures. In comparison with various contrast agents at a flow velocity of 18 cm/sec and 19 dB attenuation, flow was not detectable in control color Doppler, after 4 mL of the blood analog fluid, and after 4 mL of an agitated saline solution 9 mg/mL, but visible after 4 mL ofEchovist, a polysaccharide solution with reproducible bubble size and concentration and after 4 mL of an agitatedpolygelatin solution. Increasing concentration ofEchovist (50–400 mg/mL) improved flow detection. Echovist 200 mg/mL enhanced the score by 1.1 + ‐0.6 for velocities 5–20 cm/sec (P < 0.01), by 1.6 + ‐ 0.8 for 40–100 cm/sec (P < 0.001), and by 1.1 + ‐ 0.6 for velocities > 150 cm/sec (P < 0.001). Echovist also caused significant (P < 0.01) increase of signal strength with increasing attenuation (10,19, 29 dB) and in < 8 cm versus > 8 cm penetration depth (P < 0.001). Echo contrast agents improve display of low intensity Doppler signals, particularly in color Doppler technique. Agents like Echovist with reproducible bubble size and concentration are superior to hand agitated solutions. Physical limitations of flow detection may be compensated by increased echogenicity. This offers considerable improvement in diagnostic accuracy of color Doppler. (ECHOCARDIOGRAPHY, Volume 8, September 1991)
Doppler Echocardiographic Analysis of Left Ventricular Diastolic Blood Flow
Authors: CURTIUS JULIUS MICHAEL , GAEBEL KLAUS , FRICKE STEFANIE , WELSLAU RUTH , POTHOFF GUENTHER
Published: August 2007

We analyzed the diastolic flow pattern in the left ventricle by means of pulsed Doppler echocardiography in 150 consecutive patients (51 ± 14 years old) with various cardiac conditions. The flow pattern typical of the left ventricular inflow tract (E and A) was duplicated in the outflow tract and on the lateral wall in the form of a reversed biphasic pattern (E* and A*) extended into the phase ofisovolumic contraction. E* was delayed by 72 ± 44 msec compared to E, A* was only delayed by 47 ± 31 msec compared to A (a significant difference in the delays, P < 0.0001). In patients with left ventricular hypertrophy (n= 23), the delay of E* compared to E was greater than in normal subjects (n= 60) (91 ± 52 as compared to 66 ± 37 msec; P < 0.01). In three patients with constrictive pericarditis, the delay A/A* was greater than the delay E/E*, in contrast to the situation in normal subjects and patients with left ventricular hypertrophy. During isovolumic relaxation, acceleration of flow toward the apex was found near the septum in 77% of the patients. In 20 patients, an intraobserver, interob‐server, cycle‐to‐cycle, technician‐to‐technician, and day‐to‐day test of the variability of 19 Doppler parameters was carried out. In general, the largest differences were shown in the day‐to‐day and the technician‐to‐technician testing. Of the inflow tract measurements, VmaxE and Vmax A and their time‐velocity integrals were readily reproducible. The reproducibility of acceleration and deceleration slope measurement was not so good. In the outflow tract, VmaxE*, the time‐velocity integral of E* and the delay between A and A* were well reproducible. No sources of variability specific to individual patients were shown for the flow during the isovolumic relaxation phase, but there were significant differences in the technician‐to‐technician and interobserver variability testing. Thus, information on diastolic flow behavior in the left ventricle may be obtained by Doppler echocardiography. This provides more information than that obtainable by analysis of the inflow profile alone. The addition of these parameters to analysis of transmural flow patterns might allow enhanced appraisal of abnormalities not only in muscular relaxation but also in chamber compliance. (ECHOCARDIOGRAPHY, Volume 8, September 1991)
Innocent Bystander or Marker of Pathology!
Authors: KOCHAR GURPREET , JACOBS LARRY E. , BLONDHEIM DAVID S. , KOTLER MORRIS N.
Published: August 2007

Mitral annular calcification is known to be associated with conduction abnormalities, embolic phenomena, endocarditis, mitral regurgitation, and thromboembolic cerebrovascular events in the younger population. The size of our elderly population is growing dramatically with the fastest growth in those aged greater than 85 years. The incidence of mitral annular calcification increases sharply in these “very elderly group of patients.” To determine if mitral annular calcification in the elderly patients has the same implications as in the younger population, electrocardiographic and echocardiography (M‐mode, two‐dimensional, Doppler) data from 553 octogenarian patients who were referred for a variety of clinical indications were analyzed. Patients with mitral annular calcification were quantified into mild, moderate, and severe, and the association of each was determined with various cardiac abnormalities. Mitral annular calcification was found in 59% of the octogenarian patients. Out of these, mild mitral annular calcification was present in 38%, moderate in 40%, and severe mitral annular calcification in 22% of the patients. Mild mitral annular calcification was not associated with an increased incidence of any cardiac abnormalities. Moderate mitral annular calcification was also not associated with any increased incidence of significant aortic stenosis, conduction abnormalities, and enlarged left ventricular size. However, severe mitral annular calcification was associated with all these findings. Moderate and severe mitral annular calcification were associated with significant mitral regurgitation and left ventricular hypertrophy. Thus, in the majority of elderly patients with mild and moderate mitral annular calcification (78%), its presence merely represents an aging process and an innocent bystander as compared to elderly patients without mitral annular calcification. However, only severe mitral annular calcification is strongly associated with cardiac abnormalities. Therefore, quantification of mitral annular calcification in the elderly is important before associating it with various cardiac abnormalities. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Echocardiography of Dilated Cardiomyopathy in Children
Authors: CHEN SU‐CHIUNG
Published: August 2007

Echocardiography is useful and reliable in the diagnosis and management of children with dilated cardiomyopathy. M‐mode echocardiography provides quantitative information of left ventricular and left atrial dimensions and left ventricular wall thickness. Left ventricular function including shortening fraction, mean velocity of circumferential fiber shortening (Vd), systolic time intervals, left ventricular wall thickening and thinning rate, isovolumic contraction time, and wall stress can be derived from M‐mode study. Left ventricular and left atrial dimensions are usually 1.5 times normal. Left ventricular systolic function is markedly reduced. Shortening fraction can be easily obtained and is the most informative index for assessing the severity of illness. Very low shortening fraction at presentation and follow‐up (12–15%) is a poor prognostic sign. Two‐dimensional echocardiography is valuable for excluding valvular lesion or coronary artery anomaly and detection of intracardiac thrombus. The left ventricular free wall is usually more severely affected than the ventricular septum as seen by two‐dimensional echocardiography. (ECHOCARDIOGRAPHY, Volume 8, March 1991)
Fetal Echocardiography
Authors: WILLIAMS ROBERTA G.
Published: August 2007

Examination of the fetus offers a unique opportunity to understand the true scope of congenital and early acquired cardiac lesions. Diagnosis and management of arrhythmias remain the predominant use of these techniques. Structural heart disease can be completely characterized by two‐dimensional andDoppler examination. Such studies enhance our understanding of heart disease and also provide the family and patient care team with valuable information for the planning of neonatal management. These advances in technology and emphasis on increased fetal salvage are expected to usher in the next age of surgical intervention in the fetus with structural heart disease. The ability to examine the fetus at increasingly earlier stages of gestation will provide invaluable means for unraveling the secrets of the origins of many cardiovascular alternations. (ECHOCARDIOGRAPHY, Volume 8, March 1991)
Stress Echocardiographic Techniques: An Overview
Authors: CHILD JOHN S.
Published: August 2007

The choice of upright or supine exercise, pharmacological agents, or atrial pacing for the induction of ischemia depends on the goals and the imaging modality. Dynamic stress echocardiography has improved diagnostic accuracy over and above the stress electrocardiogram. Indications include patients with atypical symptoms, prior nondiagnostic stress electrocardiograms, or baseline electrocardiographic abnormalities. Pharmacological agents coupled with echocardiography do well in the high‐risk preoperative patient (e.g., abdominal aneurysmectomy) or in those unable to walk due to orthopedic, neurological, or peripheral vascular disease. When there is uncertainty as to the physiological significance of anatomical (angiographic) stenosis, dynamic stress echocardiography in the ambulatory patient or atrial pacing (or beta‐agonist pharmacological stressors) in the catheterization laboratory are useful. The accuracy of stress echocardiography for detection of ischemia in the follow‐up of interventional procedures or for postmyocardial infarction risk stratification is superior to standard stress electrocardiography alone.
Biopsy of a Right Atrial Mass Under Transesophageal Echocardiographic Guidance
Authors: GUTTAS JEFFREY J. , BRENT BRUCE N. , KERSH EDWARD
Published: August 2007

Transesophageal echocardiography was utilized to accurately define a right atrial mass and safely guide transvenous biopsy, resulting in accurate diagnosis and appropriate treatment. Although transthoracic echocardiography was utilized to detect the mass, transesophageal echocardiography provided detail that allowed safe localization and biopsy of the mass.
Stress Echocardiography Versus Radionuclide Stress Techniques
Authors: ROLDAN CARLOS A. , CRAWFORD MICHAEL H.
Published: August 2007

The different modalities of stress echocardiography and stress thallium‐201 imaging have comparable sensitivity, specificity, and overall predictive accuracy in the diagnosis and prognosis of coronary artery disease. They are also comparable in the assessment and follow‐up of patients treated with thrombolytic therapy or who have undergone percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery. Stress radionuclide ventriculography has a lower sensitivity and specificity as compared to stress echocardiography and stress thallium. Dipyridamole thallium has a higher sensitivity as compared to dipyridamole echocardiography in the diagnosis and prognosis of coronary artery disease. New techniques such as dobutamine echocardiography, adenosine stress thallium‐201, and adenosine echocardiography have individually shown high sensitivities, specificities, and accuracy. However, further studies are needed on their comparative value. The major advantages of stress echocardiography over radionuclide stress techniques are: lack of radiation exposure; less expense; less time consumption; less personnel required; and greater availability. Its major disadvantage, however, is the inability to obtain adequate studies in all patients.
Disc Escape After Minor Strut Fracture in a Björk‐Shiley Mitral Valve Prosthesis
Authors: VILACOSTA ISIDRE , ROMÁN JOSE ALBERTO SAN , CAMINO ASUNCIÓN , CASTAÑÓN JOSÉ , GIL MANUEL , LLANA RAMIRO DE LA , ALMERIA CARLOS , HARGUINDEY LUIS SÁNCHEZ
Published: August 2007

A case is presented in which the minor strut of a Björk‐Shiley mitral prosthesis fractured 11 years postoperatively. The relevant diagnostic contributions of transthoracic and transesophageal echocardiography are discussed.
The Scientific Basis for the Relations Between Pulsed‐Doppler Transmitral Velocity Patterns and Left Heart Chamber Properties
Authors: YELLIN EDWARD L. , MEISNER JAY S. , NIKOLIC SRDJAN D. , KEREN GAD
Published: August 2007

This article presents a didactic approach toward understanding the complex relations between transmitral flow patterns and cardiac properties. We start with some observations, obtained noninvasively, from normal and diseased human hearts, and supplement them with noninvasive and invasive observations from the dog laboratory. We then formulate a conceptual approach that is consistent with a physical interpretation of the data, and that enables us to clarify the roles of the active and passive properties of the left atrium and left ventricle. These basic concepts are incorporated into a computational model wherein the properties of the cardiovascular system can be varied to simulate physiological and pathological states of diastolic function to produce normal and abnormal ventricular flow patterns. We present examples of normal hearts, pressure overload hypertrophy, dilated failing hearts, and ventricles with poor compliance but apparently normal flow patterns. Various isolated perturbations of interest were performed in each of these conditions; and finally, we studied the effects on diastolic indices of a systematic variation of the time constant of ventricular relaxation, and of cardiac output. Among the interesting findings are: flow patterns that mimic mitral stenosis can be created by the properties of the ventricle as well as by the properties of the mitral apparatus; the A/E ratio is greater than normal in the dilated ventricle and in the hypertrophied ventricle with slowed relaxation; and in both conditions, the A/E ratio also increases with decreased cardiac output. Thus, changes in stroke volume, whether due to diastolic or to systolic function, will change indices of diastolic function. Finally, in concentric hypertrophy: large increases in atrial contractility are a necessary condition for large A/E ratios; and slowed ventricular relaxation by itself is incapable of producing a slowed deceleration of early filling; incomplete relaxation and myocardial viscoelasticity are also required.
Determinants of Decreased Early Ventricular Filling in Man: A Role for External Forces
Authors: DAVIDSON WILLIAM R. , PASQUALE MICHAEL J. , COPENHAVER GARY , ARONOFF ROBERT D.
Published: August 2007

The determinants of reduced early left ventricular filling and their relative importance were examined in 14 subjects with an ejection fraction > 40%. Simultaneous high‐fidelity left ventricular pressure, mitral annular Doppler velocity recordings, and two‐dimensional echocardiographic data were used. Pressure‐volume curves were created from pressure/echocardiographic/Doppler data and the chamber stiffness constant calculated. The influence of changing filling pressure was examined by studying subjects before and after ventriculography. The ventricular relaxation time constant, chamber stiffness constant, mean right atrial pressure (an index of pericardial restraint and/or ventricular interaction), pulmonary wedge pressure, and heart rate were analyzed for their influence on Doppler filling parameters: isovolumic relaxation time, peak early (E) and atrial (A) filling velocities, and the E/A ratio. The relaxation time constant was the primary determinant of isovolumic relaxation time (r = 0.82, P<0.001). Prolonged relaxation also caused a decrease in the E/A ratio (r=0.73, P<0.001) and early filling. Peak atrial filling velocity and its integral decreased as chamber stiffness rose (P<0.005). Pulmonary wedge pressure had only a modest influence on early filling (r=0.46, P<0.05). Ventriculography did not eliminate the influence of stiffness and relaxation on filling, although it caused early filling and the E/A ratio to rise and isovolumic relaxation time to shorten. Filling became earlier with increasing right atrial pressure and upward pressure‐volume curve shifts. In multivariate regression the E/A ratio was influenced independently by relaxation, filling pressure, right atrial pressure, and chamber stiffness. We conclude that isovolumic relaxation time is a useful measure of ventricular relaxation. However, the E/A ratio is too complex to allow characterization of diastolic function when used alone. Finally, pericardial restraint and/or ventricular interaction during a volume load may confound the relationship between filling pattern and intrinsic ventricular diastolic properties.
Lipomatous Hypertrophy of the Interatrial Septum
Authors: JORNET AGUSTI , BATALLA JOSEP , USON MARIANO , MALLOL ANNA , REIG JOSEP , PETIT MARIUS
Published: August 2007

Lipomatous hypertrophy of the interatrial septum is a clinicopathological entity defined as an accumulation of fatty tissue exceeding 15 mm in thickness in the interatrial septum above the fossa ovalis. It is clinically associated with atrial electric abnormalities, interference with venous return, and sudden death. Transesophageal echocardiography is superior to transthoracic echocardiography for the study of the interatrial septum. We describe one case of lipomatous hypertrophy of the interatrial septum in which transesophageal echocardiography was used, we believe for the first time, to study the interatrial septal anatomy.
Verification of the Tip Position of the Intra‐Aortic Balloon Pump Catheter by Perioperative Transesophageal Echocardiography
Authors: YANG MIN‐WEN , WANG KUO‐YANG , LIN CHUNG‐YUAN , CHAN KWOK‐HON , LEE TAK‐YU , YU TARNG‐JENN , CHENG KWOK‐KUEI
Published: August 2007

In some patients with advanced heart disease, low cardiac output may develop immediately after coronary artery bypass grafting (CABG). Appropriate measures are often required to ensure adequate perfusion of vital organs in such patients. Of the invasive rescue measures chosen for the support of low cardiac output, the intra‐aortic balloon pump (IABP) prevails. In common practice, a fluoroscope or x‐ray unit is used to guide the insertion of the IABP catheter to the correct position. Transesophageal echocardiography (TEE) can accomplish this more conveniently. Here we report on two cases of misplacement of the IABP catheter, one in the false lumen of a dissected upper abdominal aortic aneurysm and the other in the lumen of the inferior vena cava, both of which were diagnosed intraoperatively by TEE in CABG patients. The applications of TEE in the perioperative period are continuously expanding. One such application of TEE is the assessment of IABP catheter position.
Evaluation of Leg Perfusion During Exercise Using Technetium 99m Sestamibi
Authors: WANN L. SAMUEL , HELLMAN CHARLES , DORROS GERALD
Published: August 2007

Thirty patients with occlusive peripheral vascular disease underwent clinical examination, segmental blood pressure determinations, intra‐arterial digital subtraction angiography, and treadmill stress testing with injection of technetium 99m sestamibi at peak exercise. Radionuclide images of the thighs, calves, and feet showed clear delineation of major muscle groups. Diminished radiotracer distribution was closely correlated with the presence of occlusive vascular disease on angiography and with the presence ofclaudication and reduced segmental blood pressure. A quantitative scheme based on pixel intensity was developed to compare areas of regional perfusion.
Transesophageal Color Doppler Flow Imaging in the Evaluation of Prosthetic Cardiac Valves
Authors: HSIUNG MING‐CHON , KU CHANG‐SHENG , WEI JEN , DING YU‐AN , LIN CHEN‐CHEE , WANG DANG JIEN , SHIEH SHYH‐MING , LIN KO‐CHOW
Published: August 2007

To determine the value of transesophageal echocardiography in the assessment of prosthetic cardiac valves, 11 patients with clinically suspected cardiac prosthetic valve dysfunction were studied by transesophageal two‐dimensional imaging, as well as by color Doppler flow mapping. Among these 11 patients, there were 10 with biological tissue valves and 3 with metallic valves (1 Bjork‐Shiley, 2 St. Jude). Nine patients had replacement of mitral valves alone. The remaining two had received both mitral and aortic prostheses. The degree of mitral regurgitation was graded by transesophageal color Doppler according to the area of the regurgitant jet visualized. The degree of aortic regurgitation was graded by the jet height/left ventricular outflow height ratio method. All transesophageal studies were performed without complication and all were well tolerated. The pathological morphology of the cardiac prosthesis was clearly visualized by transesophageal two‐dimensional imaging and subsequently proven at surgery. Of those tested, one patient was found to have a torn leaflet, one had a dislodged leaflet, one patient had paravalvular leakage, four had cusp vegetations, and five patients had prosthetic degeneration for other reasons. Mitral regurgitation was graded as absent in one patient, mild in two patients, moderate in two patients, and severe in six patients. Aortic regurgitation was graded as severe in both patients with aortic prostheses. We conclude that in patients with clinically suspected cardiac prosthetic dysfunction, transesophageal two‐dimensional imaging combined with color Doppler can provide reliable information that corresponds to surgical findings.
Color Flow and Conventional Echocardiography of the Marfan Syndrome
Authors: ALDRICH HARRY R. , LABARRE ROBERT L. , ROMAN MARY J. , ROSEN STACEY E. , SPITZER MARIANE C. , DEVEREUX RICHARD B.
Published: August 2007

Imaging and color flow Doppler echocardiography are an integral part of any evaluation of a patient with the Marfan syndrome. The major cardiovascular manifestations of this condition are aortic dilation, which may involve the proximal and distal aorta, aortic regurgitation, aortic dissection, mitral valve prolapse, and mitral regurgitation. Patients who have the Marfan syndrome should have serial echocardiograms to measure aortic root diameter carefully at the sinuses of Valsalva and subsequent levels (sinotubular junction, arch, descending and abdominal aorta). Additionally, color Doppler echocardiography assists in the diagnosis of aortic dissection and facilitates evaluation of the severity of aortic and mitral regurgitation that commonly complicate the Marfan syndrome. The risk of aortic dissection, which is the most serious manifestation of the Marfan syndrome, increases as the aorta enlarges. Therefore, elective composite graft surgery is recommended when the aortic root size reaches 60 mm, regardless of symptom status, or 55 mm in the presence of severe aortic regurgitation. Surgical replacement of the aortic root with a composite graft does not end the disease process. Color flow Doppler is useful in the diagnosis ofdehiscence of the conduit sewing ring, coronary artery aneurysm, distal aortic dissections, and prosthetic valve dysfunction.
Multiplane Transesophageal Echocardiographic Imaging and Three‐Dimensional Reconstruction
Authors: NANDA NAVIN C. , PINHEIRO LUIZ , SANYAL RAJAT , ROSENTHAL STEVEN , KIRKLIN JAMES K.
Published: August 2007

This study presents our preliminary experience in multiplanar transesophageal echocardiography. In addition, an attempt was made in one patient to reconstruct the left ventricle in three dimensions using the sequential planes obtained from the multiplanar approach.
BOOK REVIEW
Authors: D'Cruz Ivan A.
Published: August 2007

DOPPLER ECHOCARDIOGRAPHY: THE QUANTITATIVE APPROACH. Edited by A.J. Labovitz and G.A. Williams
Spontaneous Echo Contrast in Patients with Sinus Rhythm but Poor Atrial Contraction
Authors: ROUDAUT RAYMOND , DURANDET PHILIPPE , LEHERISSIER ARNAUD , GOSSE PHILIPPE , KOCH MICHEL , DALLOCCHIO MODESTE
Published: August 2007

Spontaneous echo contrast in the left atrium in patients with sinus rhythm is unusual. The aim of this study was to assess the mechanism of this phenomenon and any clinical implications. We studied 90 consecutive patients using transesophageal echocardiography. Spontaneous echo contrast was seen within the left atrium in 29 patients, 11 of whom were in sinus rhythm. In patients with spontaneous contrast and sinus rhythm, the underlying diseases were: mitral insufficiency (5), mitral stenosis (1), mitral prostheses (2), congestive cardiomyopathy (1), hypertrophic cardiomyopathy (1), and heart transplantation (1). Spontaneous echo contrast tended to be faint in this group (10/11). The left atrium was enlarged in all, with subjective poor atrial contraction. Furthermore, reduced mitral A wave suggested an impairment of left atrial contractility. Holter monitoring demonstrated paroxysmal atrial fibrillation in five subjects. Two patients had a history of transient ischemic attacks. No atrial thrombus was observed in any patient. The demonstration of spontaneous echo contrast with transesophageal echocardiography does not seem uncommon even in patients in sinus rhythm. This may indicate an increased risk of thromboembolism.
Quantification of Asymmetric Valvular Regurgitant Jets by Color Doppler Ultrasound In Vitro
Authors: STEWART SANDY F.C. , BURTÉ FRANÇOISE , CLARK RICHARD E.
Published: August 2007

Accurate quantification of regurgitant jets in natural and prosthetic heart valves has been a goal of health care workers and researchers for many years. One promising new method applies the law of conservation of momentum transfer to velocities measured by color Doppler ultrasound to calculate the flow rate in the jet. One complicating factor is that regurgitant jets from real heart valves may be highly asymmetric. The purpose of this investigation was to determine whether the accurate calculation of the flow rate in asymmetric jets imaged by color Doppler requires an asymmetric formulation of the conservation of momentum transfer, combined with a method for imaging the jet in three dimensions. Asymmetric jets issuing from narrow slits were imaged in an in vitro, steady flow system. The ultrasound transducer was rotated around the jet axis to image the jet in three dimensions. The three‐dimensional imaging confirmed that jets from slits are indeed asymmetric, but become relatively axisymmetric far from the orifice. Images were analyzed by computer and the calculated flows compared to measured flows. The accuracy of an asymmetric formulation of the conservation of momentum transfer method was compared to a simpler, axisymmetric formulation. If axisymmetry was assumed in asymmetric jets, significant errors in the calculated flow rates occurred. In these cases, the calculated flow also varied widely with distance from the orifice. When asymmetry was taken into account, the errors were considerably reduced. The results suggests that, in asymmetric jets, the momentum transfer is convected around the jet axis.
Premature Pulmonary Valve Opening in Cardiac Amyloidosis
Authors: POPOVIĆ ALEKSANDAR D. , NEŠKOVIĆ ALEKSANDAR N. , MILOVANOVIĆ BRANISLAV , PUTNIKOVIĆ BILJANA , SEFEROVIĆ PETAR , HADŽAGIĆ IZUDIN
Published: August 2007

Premature pulmonary valve opening has been described in various conditions associated with increased right ventricular end‐diastolic pressure. Although cardiac amyloidosis belongs to this category of diseases, abnormalities of pulmonary valve motion have not been reported in this setting. This article describes premature pulmonary valve opening in a patient with cardiac amyloidosis.
VariomatrixTM—A Newly Developed Transesophageal Echocardiography Probe with a Rotating Matrix Biplane Transducer
Authors: OMOTO RYOZO , KYO SHUNEI , MATSUMURA MAKOTO , YAMADA ELINA , MATSUNAKA TOSHIYUKI
Published: August 2007

The recently developed multiplane transesophageal echocardiography (TEE) probes cannot provide real‐time synchronous biplane imaging. We have developed a new “VariomatrixTM” probe that combines the advantages of the rotating mechanism of the multiplane probe with the capability of providing simultaneous, side‐by‐side imaging. Its advantages are: (1) easy manipulation to obtain the optimal planes; (2) avoidance of excessive movement of the probe inside the esophagus; (3) assessment of oblique planes that are not viewed with the usual biplane probe; (4) better understanding of the continuity of structures by the simultaneous, side‐by‐side biplane, rotating images, providing clearer three‐dimensional conception; and (5) shorter examination time by providing a 180° imaging range by rotating the transducer just 90°.
Pitfalls in the Color Doppler Diagnosis of Valvular Regurgitation
Authors: EBRAHIMI RAMIN , GARDIN JULIUS M.
Published: August 2007

Color Doppler flow mapping of the regurgitant jet is frequently used as a means of assessing the severity of valvular regurgitation. Although convenient, this method of assessing valvular regurgitation is subject to a number of hemodynamic and technical factors that may limit its accuracy. Variations in hemodynamic and structural factors such as orifice size, jet geometry, receiving chamber constraints, afterload, fluid viscosity, heart rate, and cardiac output may have profound effects on the measured regurgitant jet area. Variations in scanning and machine factors, such as scanning direction, Doppler angle, frame rate, color display algorithms, pulse repetition frequency (PRF), system gain, packet size, carrier frequency, wall filter, and transmit power have been shown to alter the measured regurgitant jet area significantly. Despite these limitations, color flow Doppler provides a relatively reliable noninvasive method for semiquantitative assessment of valvular regurgitation. Obviously, standardization of the design and application of the various available color mapping algorithms, as well as other machine and hemodynamic factors, would help provide more reliable and reproducible quantitative information about the degree of valvular insufficiency.
Transesophageal Echocardiography for Prosthetic Valve Evaluation:
Authors: FLACHSKAMPF FRANK A. , LEHMANN CHRISTIAN , KLUES HEINRICH , RÜDELSTEIN RALPH , HANRATH PETER
Published: August 2007

Transesophageal echocardiography provides excellent images of mitral and aortic prostheses, due to its higher resolution and less interference from other cardiac structures. Since the introduction of transesophageal echocardiography, it has proved to be valuable for the evaluation of prosthetic heart valves. “Classic” indications include the evaluation of prosthetic valve endocarditis, the search for paravalvular abscesses, and the assessment of regurgitation in mechanical, especially mitral, prostheses. New technical developments such as biplane or multiplane transducers enhance the diagnostic capabilities of the technique. Transesophageal echocardiography can also have advantages in recognizing obstructive lesions such as thrombi or pannus, and help understand the complex morphology of prostheses in grafts. Transesophageal echocardiography should be considered a backup technique whenever transthoracic echocardiography, which always remains the primary approach, is inconclusive or negative in the presence of clinically suspected prosthetic valve malfunction.
Intraoperative Echocardiography By a New Miniaturized Epicardial Probe:
Authors: MELONI LUIGI , ARU GIORGIO M. , ABBRUZZESE PIETRO A. , CARDU GABRIELE , RICCHI ALESSANDRO , MARTELLI VALENTINO , CHERCHI ANGELO
Published: August 2007

Miniaturized probes constitute recent progress in the field of epicardial echocardiography. We recently used a new miniaturized probe, derived from a standard transesophageal probe, in a series of 12 adult patients who underwent cardiac surgery in order to test the possibility of obtaining new views for epicardial imaging. This study demonstrates the feasibility and safety of performing intraoperative echocardiography when using a miniaturized epicardial probe. This probe may be placed on a broader epicardial and vascular area, thus overcoming the size limitations of the commonly used epicardial probes. The major limitation found with the miniaturized probe, however, was the inability to obtain a true four‐chamber view from the ventricular apex, due to the difficulty of holding the probe motionless between the apex and the diaphragm while the heart is beating. Although extensive experience with larger groups of patients and different pathologies will be required to define the full potential of this new probe, the advent of the miniaturized probe may further expand the applicability of epicardial echocardiography in pediatric patients during surgery for congenital heart disease.
Protruding Atheromas in the Thoracic Aorta:
Authors: TUNICK PAUL A. , KRONZON ITZHAK
Published: August 2007

Up to 40% of stroke patients do not have an obvious etiology for their illness. Because transthoracic echocardiography is often negative in these patients, there has been increasing enthusiasm for transesophageal echocardiography (TEE) as a newer tool for evaluating patients with embolic disease. In a study of patients referred because of unexplained stroke or transient ischemic attacks, the most common finding was protruding atheroma in the aortic arch. In a case control study, protruding aortic atheromas were found in 33 of the 122 patients with emboli (27%). Mobile components to the atheromas were found in 11 case patients, and there were no mobile components found in any control patients. It is also possible that protruding aortic atheromas may play a role in patients with other sources of emboli (e.g., carotid disease). Atheromas may also cause emboli during catheterization, balloon pump placement, and cardiopulmonary bypass. The pathological composition of the lesions seen on TEE has been atheroma with superimposed thrombus. The correct treatment for patients with embolization due to protruding aortic atheromas has not yet been determined, although anticoagulation may play a role, since the mobile components to these lesions appear to be thrombus. We have recommended surgery for several patients. However, the operation is a major one with major potential complications, including aortic dissection. TEE should be done in patients with unexplained emboli, and it may also play a role in patients with other sources of embolization. TEE should be considered in elderly patients or those with extensive vascular disease before cardiac catheterization or heart surgery. In addition, cannulation techniques during bypass can be modified to avoid atheromas. The ideal medical and/or surgical approaches to patients with protruding atheromas remain to be clarified.
The Role of Echocardiography in the Evaluation of Cardiac Source of Embolism:
Authors: BLACK IAN W. , STEWART WILLIAM J.
Published: August 2007

Left atrial (LA) spontaneous echo contrast, also known as “smoke”, is a frequent transesophageal echocardiographic finding characterized by swirling, smokelike echoes in the LA cavity or appendage. LA smoke is associated with conditions favoring stasis of LA blood, including atrial fibrillation, mitral stenosis, the absence of mitral regurgitation, and LA enlargement. LA spontaneous echo contrast is a marker of previous embolic events in patients with atrial fibrillation, mitral stenosis, or mitral valve replacement. Most LA thrombi are accompanied by smoke. Recent studies show that LA spontaneous echo contrast is also associated with increased fibrinogen, hematocrit, and blood viscosity, indicating a relatively hypercoagulable state in addition to stasis. These findings suggest that LA spontaneous echo contrast is a manifestation of erythrocyte aggregation, and that hematologic factors may contribute to the association between spontaneous echo contrast and thromboembolism.
Doppler Echocardiographic Evaluation of Ventricular Septal Defects in Adults
Authors: RAHKO PETER S.
Published: August 2007

Ventricular septal defects account for 10% to 15% of all congenital heart defects observed in adults. The type of defects observed tend to fall at the extreme ends of the spectrum: small restrictive defects with minimal shunts, and large nonrestrictive defects associated with severe occlusive pulmonary vascular disease. Doppler echocardiography has evolved into a powerful diagnostic modality that comprehensively evaluates the anatomical and pathophysiological consequences of a ventricular septal defect. The spectrum of findings caused by ventricular septal defects is the subject of this review.
Prenatal Diagnosis and Hemodynamics in Tetralogy of Fallot, Absent Pulmonary Valve with Endocardial Fibroelastosis, and Hydrops Fetalis
Authors: CHAN KWOK CHIU , KLINE CHARLES H. , FYFE DEREK A.
Published: August 2007

Tetralogy of fallot with absent pulmonary valve is rare. We report the antenatal diagnosis of this condition in early mid‐semester. In this unusual case, the patient presented with hydrops fetalis. The pathophysiology is discussed. (ECHOCARDIOGRAPHY, Volume 10, November 1993)
Two‐Dimensional Doppler Color Flow Imaging in Adults with L‐Transposition of the Great Arteries
Authors: HOPKINS WILLIAM E. , WAGGONER ALAN D. , VILA‐ROMAN VICTOR DA , PEREZ JULIO E.
Published: August 2007

Abnormalities of the left atrioventricular (AV) (tricuspid) valve and pulmonic stenosis are part of the spectrum of manifestations in patients with corrected transposition of the great arteries (L‐TGA). However, the utility of Doppler color flow imaging combined with two‐dimensional echocardiography in L‐TGA has not been established. Thus, we evaluated 14 adults (mean age 33 ± 8 [SD] years) with L‐TGA. Two‐dimensional echocardiography demonstrated Ebstein's anomaly in five patients. Color flow imaging detected left AV valve regurgitation in 13 (moderate to severe in six); the other patient had a prosthetic valve. Right AV valve regurgitation was detected in two (mild in both). Aortic regurgitation was present in five (moderate in three). Pulmonic regurgitation was present in nine (moderate to severe in three). Pulmonic stenosis was detected in three (subvalvular in two, valvular in one) and two patients had pulmonary atresia. One patient had a bicuspid aortic valve with mild stenosis. Mean right ventricular ejection fraction (apical, area‐length) was 44%; only 1 of 9 patients had a value > 55%. Thus, two‐dimensional Doppler echocardiography with color flow imaging detects a high incidence of systemic AV valvular regurgitation and reduced right (systemic) ventricular systolic function in adults with L‐TGA. (ECHOCARDIOGRAPHY, Volume 10, November 1993)
Transesophageal Echocardiographic Findings in Primary Leiomyoma of Inferior Vena Cava
Authors: LOUNGANI RAMESH R. , NANDA NAVIN C. , SANYAL RAJAT S. , FINCH ANA , WINOKUR THOMAS S. , PACIFICO ALBERT D.
Published: August 2007

We describe for the first time the usefulness of transesophageal echocardiography for the identification of a primary leiomyoma of the inferior vena cava, which originated near its junction with the right atrium. A portion of the tumor was initially visualized in the right atrium during a transthoracic echocardiographic study, but its attachment in the inferior vena cava was evident only by transesophageal echocardiography using the transgastric approach. (ECHOCARDIOGRAPHY, Volume 10, November 1993)