bluuebunny/crossref_metadata_2025 huggingface dataset:
Transesophageal Echocardiographic Examination of Left‐Sided Superior Vena Cava and Azygos and Hemiazygos Veins
Authors: NANDA NAVIN C. , PINHEIRO LUIZ , SANYAL RAJAT , JAIN HANS , VAN TUONG B. , ROSENTHAL STEVEN
Published: August 2007

In the present study, we describe our experience in the delineation of the left‐sided superior vena cava, azygos vein, and hemiazygos vein, using transesophageal echocardiography. (ECHOCARDIOGRAPHY, Volume 8, November 1991)
Color Flow Identification of Multiple Ventricular Septal Defects in a Patient with Elevated Pulmonary Vascular Resistance
Authors: SOMMER ROBERT J. , RITTER SAMUEL B.
Published: August 2007

A 12‐year‐old boy with a large ventricular septal defect and elevated pulmonary vascular resistance had surgical closure of his defect. There was a gradual diminution in pulmonary resistance over a 2‐week period. On the twelfth postoperative day, a new systolic murmur was noted, and an additional small muscular ventricular septal defect was diagnosed by color flow Doppler echocardiography. This defect had not been seen on preoperative left ventricular angiography, nor on several postoperative echocardiography studies. The fall in this patient's pulmonary vascular resistance was analogous to the hemodynamic changes typical of a newborn infant. In that context, the timing of the clinical and echocardiographic appearance of the ventricular septal defect is discussed. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Hemodynamic Changes in Left Ventricular Function During Acute Coronary Insufficiency
Authors: CACCIAPUOTI FEDERICO , D'AVINO MARIA , LAMA DIANA , SEPE JOSEPH , VARRICCHIO MICHELE
Published: August 2007

To define the availability of Doppler echocardiography in evaluating left ventricular hemodynamic changes induced by some clinical findings of acute coronary insufficiency, we selected 12 patients with angina and 32 affected by acute myocardial infarction. Doppler echocardiography was performed at hospital admittance and during recovery time. Left ventricular contractility was defined on the systolic aortic flow spectrum by measuring the aortic velocity maximum, the time to peak/left ventricular ejection time ratio, and the cardiac output. During the first examination, left ventricular contractility significantly decreased in patients with angina and in those with acute myocardial infarction. After the acute phase, these parameters slightly improved. Left ventricular diastolic filling was evaluated in the transmitral flow. A decreased E‐wave velocity and an increased late component (A wave) with inversion of the E/A wave ratio were found inpatients with acute myocardial infarction during the first examination. This morphology inverts when the patients stabilize. On the contrary, this ratio stayed above one during and after angina. In this study, we also defined the usefulness of the color Doppler method in setting up criteria to identify some early morphological complications of acute myocardial infarction in 12 patients with acute infarction and a new systolic murmur. This technique showed an ischemic rupture of the ventricular septum in five cases and mitral regurgitation in seven. The color Doppler method has allowed us to obtain a semi‐quantitative assessment of the mitral regurgitation and the location of the ventricular septal defect. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Assessment of Ebstein's Anomaly and Its Surgical Repair Using Transesophageal Two‐Dimensional Echocardiography and Doppler Color Flow Mapping
Authors: FRAM DANIEL B. , MISSRI JOSE , THERRIEN MICHAEL L. , CHAWLA SURENDRA
Published: August 2007

Transthoracic echocardiography is generally accepted as the procedure of choice for diagnosing Eb‐stein's anomaly; however, an optimal evaluation is not always possible due to technical limitations. We have reported the utility of transesophageal echocardiography and Doppler color flow mapping in this condition, particularly for demonstrating structures and flow patterns in the atria and right ventricle. We conclude that in the evaluation of Ebstein's anomaly, these two echocardiography techniques are complementary and together can provide an excellent anatomical and functional assessment. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Ostium Primum Atrial Septal Defect Associated with Obstructive Hypertrophic Cardiomyopathy
Authors: TANGCO ROGELIO V. , MISSRI JOSE C. , CHAWLA SURENDRA K.
Published: August 2007

A 48‐year‐old white male was referred for cardiac catheterization following a bout of near syncope and severe angina. He was diagnosed to have obstructive hypertrophic cardiomyopathy by transthoracic echocardiography (TTE). Right bundle branch block and plethoric chest X ray suggested shunt physiology, which was confirmed on transesophageal echocardiography and angiocardiography to be a primum type of atrial septal defect (primum ASD) with cleft mitral leaflet. He underwent septal myomectomy and patching of the ASD. Surgical pathological specimen revealed enlarged nuclei and myocardial disarray consistent with congenital hypertrophic cardiomyopathy. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Visualization of Aortopulmonary Window by Transesophageal Echocardiography
Authors: BANSAL RAMESH C. , PETRY EUGENE L. , GUNDRY STEVEN , KANAKRIYEH MOHAMMAD S. , KAWAUCHI.† MOTOHIRO , BOUCEK MARK
Published: August 2007

Transthoracic two‐dimensional echocardiography, and Doppler and color flow imaging techniques were utilized to diagnose aortopulmonary window in an infant. Transesophageal echocardiography was used intraoperatively for precise definition of this lesion and its differentiation from other defects in aortopulmonary septation. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Transesophageal Echocardiography in Aortopulmonary Communications
Authors: SAMDARSHI TANDAW E. , MORROW W. ROBERT , NANDA NAVIN C. , COLVIN EDWARD V. , HELMCKE FREDERICK , SANYAL RAJAT , JAIN HANS
Published: August 2007

The assessment of congenital aortopulmonary communications by transthoracic echocardiography may be suboptimal, particularly postoperatively, due to limited acoustic windows. We performed intraoperative transesophageal echocardiograms in six patients with eight proven systemic‐pulmonary communications. Diagnosis included truncus arteriosus (1), aortopulmonary window (1), Waterston anastomosis (3), central Gore‐Tex shunt (1), and modified left Blalock‐Taussig shunt (2). All communications were accurately demonstrated by transesophageal echocardiography (TEE). The transesophageal technique also provided an assessment of the size of the aortopulmonary communications and the proximal pulmonary arteries. In addition, the gradient across some of the communications could be accurately estimated utilizing the high pulse repetition frequency Doppler. On the other hand, only two of the seven aortopulmonary communications were detected by transthoracic echocardiography. Postoperatively, transesophageal imaging demonstrated unobstructed conduit in five of five patients who underwent conduit repair, as well as intact closure of aortopulmonary communications and concomitant closure of ventricular septal defects. (ECHOCARDIOGRAPHY, Volume 8, May 1991)
Left Ventricular Shape and Size in Dilated Cardiomyopathy: Quantitative Echocardiography Assessment
Authors: D'CRUZ IVAN A. , DALY DALE P. , SHROFF SANJEEV G.
Published: August 2007

Left ventricular shape is an aspect of the left ventricular image (on the two‐dimensional echocardiogram) that has hitherto received little attention. Although it has long been known to cardiologists that patients with dilated cardiomyopathy tend to have more spherical hearts than normal individuals, this remained a qualitative “impression,” and a quantitative approach to left ventricular shape is not part of routine clinical echocardiography. The few published studies that did address overall left ventricular shape used a simple length/width ratio as the index of shape. Using left ventricular shape descriptors, which are ratios of various left ventricular dimensions (and area) to each other, we characterized left ventricular shape in normals and in patients with dilated cardiomyopathy in a quantitative manner, independent of left ventricular size. We confirmed the previous “impression” that left ventricular chamber shape is abnormal (more spherical) in patients with dilated cardiomyopathy. We showed that dilated but normally contracting, volume overloaded left ventricles do not show such spherical shape alteration. We have recently found that abnormal spherical shape change of a similar degree to that observed in classical dilated cardiomyopathy is also seen in patients with diffuse hypokinetic cardiomyopathy whose left ventricular chambers are not dilated, or only marginally dilated, beyond the normal range. It may be worthwhile, therefore, to perform the simple measurements and calculations necessary to obtain left ventricular shape descriptors in patients with suspected myocardial disease. (ECHOCARDIOGRAPHY, Volume 8, March 1991)
The Mechanisms and Importance of Tricuspid Regurgitation and Hepatic Pulsations in Dilated Cardiomyopathy: A Review
Authors: GUPTA MILAN K. , SASSON ZION
Published: August 2007

Secondary tricuspid regurgitation is a common finding in dilated cardiomyopathy, being present in up to 90% of patients studied with Doppler echocardiography. It appears to be primarily due to annular dilatation and loss of the sphincter‐like action of the tricuspid annulus during systole. Apical displacement of the papillary muscle and increased chordal tension may also contribute to mal‐coaptation of the tricuspid leaflets in systole. Hepatic pulsations generally occur late in dilated cardiomyopathy, indicating hepatic congestion due to progressive biventricular failure. These are thought to result from secondary tricuspid regurgitation and transmission of the regurgitant v wave to the liver. Careful pulsed‐Doppler studies of the timing of hepatic pulsations in dilated cardiomyopathy often show them to be presystolic, rather than systolic, suggesting that a mechanism other than tricuspid regurgitation may be responsible. (ECHOCARDIOGRAPHY, Volume 8, March 1991)
The Value of Transesophageal Echocardiography in the Diagnosis of Cardiac Metastasis
Authors: HSU TSUI‐LIEH , HSIUNG MING‐CHON , LIN SHOA‐LIN , CHEN CHEN‐HUAN , CHEN CHIN C. , WANG SHIH‐PU , CHANG MAU‐SONG , CHIANG BENJAMIN N.
Published: August 2007

To assess the diagnostic value of transesophageal two‐dimensional echocardiography (TEE) as compared with transthoracic echocardiography (TTE), TTE and TEE were performed in eight consecutive patients (age range from 20 to 76 years, six male and two female) with clinical evidence of malignant tumors arising from the liver (n = 1), lung (n = 3), larynx (n = 1), osteogenic sarcoma (n = 1), lymphoma (n = 1), and yolk sac tumor in the anterior mediastinum (n = 1). In one case, the gastroscope could not be inserted because of tumor compression of the esophagus. Transesophageal echocardiography provided superior imaging in the detection of intracavitary metastatic lesions. In the case of right ventricular outflow tract tumor and greater vessel involvement, TTE may provide more imaging than TEE due to a blind area in this region by the transesophageal approach. In conclusion, TEE is complementary to TTE in the diagnosis of metastatic cardiac tumor.
Unusual Pulmonic Regurgitant Jet on Color Flow Doppler
Authors: D'CRUZ IVAN A. , CRITIKOS JOHN P.
Published: August 2007

We describe the color flow Doppler appearances of an unusually directed jet of pulmonic valve regurgitation in a patient who has had surgery for aortic root dissection. This jet was bluish on color flow Doppler (away from transducer) and diastolic in timing, with peak velocity 1.8 m/sec; it originated at the point of apposition of the pulmonic cusps. These features served to distinguish the jet from that due to an iatrogenic aortic root‐right ventricular fistula. We speculate that the pulmonary trunk was so distorted during surgery on the ascending aorta as to alter alignment of the pulmonic valve cusps, resulting in the unusual direction of the regurgitant jet.
Color Doppler Determination of Regurgitant Flow: From Proximal Isovelocity Surface Areas to Proximal Velocity Profiles: An In Vitro Study
Authors: GIESLER MARTIN OTTO , STAUCH MARTIN
Published: August 2007

There is not yet a completely satisfactory Doppler method for determining the severity of valvular regurgitation. Recently, interest has focused on the so‐called “flow convergence region”. Color Doppler provides a longitudinal velocity profile of the flow convergence region proximal to restrictive orifices. With respect to determination of regurgitant flow rate, we studied the influence of orifice flow rate and orifice size on the proximal velocity profile. In a phantom model, flow across circular orifices was studied. The distance r(v) of discrete velocities detected proximal to the orifice was measured along the flow center line. Velocity profiles were established. (1) Proximal isovelocity surfaces: The radius r(v) also represented the central radius of the proximal isovelocity surfaces. Increases in flow resulted in larger central radii r(v). Application of the continuity equation and analysis of the resulting values yielded a radius and an orifice size dependence of the geometric isovelocity surface shape. Therefore, their surface area and flow rate could not be calculated from these axial measurements alone. (2) Proximal velocity profiles: The resulting hyperbolic velocity profile curves (x axis = velocity [v], y axis = distance [r(v)]) are shifted rightward by increases in flow. In contrast, increases in orifice size make the curve steeper, but large r(v) are not affected. This differential influence of flow rate and orifice size allows orifice size independent determination of flow rate. A nomogram is presented as one possible method for flow determination.
Intravascular Ultrasonic Assessment of Lumen Geometry and Distensibility of the Angiographically Normal Artery: A Correlation with Quantitative Angiography
Authors: THE SALEM H.K. , GUSSENHOVEN ELMA J. , WENGUANG LI , DE FEYTER PIM , SERRUYS PATRICK W. , WILSON RICHARD A. , BOM KLAAS
Published: August 2007

The feasibility of assessing lumen diameter and area using a 30‐MHz mechanically driven ultrasound imaging device was evaluated in vitro in phantoms and in vivo in eight human arteries (six iliac, two brachial). Ultrasound data were compared to angiographic data derived from the cardiovascular angiographic analysis system. In addition, the change of lumen area in a given cardiac cycle was determined in each patient. A close relation between ultrasound and angiography was observed in the phantom studies. In the first three patients there was disagreement; ultrasound images showed larger values compared to the angiographically derived values. Disagreement was related to the use of nominal measurements of the sheath supplied by the manufacturer as calibration. Data on the five other patients showed a close relation between the values derived with ultrasound and angiography. The arterial lumen area revealed a 5%± 2% change during one cardiac cycle. The intra‐ and interobserver variability test showed good correlation for the ultrasound study. This study demonstrates that intravascular ultrasound is an accurate and reproducible technique to measure vascular diameter, lumen area, and arterial wall distensibility in vivo.
Echocardiographic “Eyewitness” of Aortic Valve Vegetation Detachment
Authors: PEREIRA ROBERTO , DE OLIVEIRA WILSON , DE SÁ DEUZENY MARQUES , COSTA MÁRIO GESTEIRA , DE OLIVEIRA LUÍS FERNANDO SALAZAR
Published: August 2007

Embolic phenomena are associated with endocarditis. We report a patient suffering from infective endocarditis, in which the exact moment of detachment of an aortic valve vegetation and subsequent embolization was eyewitnessed during two‐dimensional echocardiography, and the entire episode was recorded on video tape.
Stress Doppler Echocardiography in the Evaluation of Ischemic Heart Disease
Authors: HARRISON MICHAEL R. , SMITH MIKEL D. , CLIFTON G. DENNIS , DeMARIA ANTHONY N.
Published: August 2007

Doppler echocardiography enables convenient, noninvasive evaluation of global, systolic performance at rest and during exercise. Early studies suggested that Doppler parameters of systolic function were sensitive to exercise‐induced myocardial ischemia and could identify patients with severe coronary artery disease. Subsequent investigation, however, has identified several factors in addition to myocardial ischemia that can significantly influence exercise Doppler study results. Thus, in order to obtain reliable information, the many factors that can influence Doppler measurements of aortic flow velocity and acceleration must be accounted for. Further work in this area is likely to produce results that encourage greater application of this technique in experimental and clinical research. At present, the role of stress Doppler echocardiography in the evaluation of ischemic heart disease remains uncertain.
Exercise Doppler: Functional Evaluation of Right Heart Hemodynamics
Authors: HIMELMAN RONALD B. , SCHILLER NELSON B.
Published: August 2007

Exercise echocardiography is a versatile technique that includes not only two‐dimensional imaging, but also Doppler of aortic, mitral, and tricuspid valves. Doppler echocardiography can be useful in the evaluation of global left ventricular systolic and diastolic function, valvular function, transvalvular gradients, and pulmonary artery pressure. The technique lends itself to the study of the cardiac response to exercise in a variety of disease states, including pulmonary, coronary artery, valvular, and congenital heart disease. We review our experience using agitated saline‐enhanced Doppler of tricuspid insufficiency to determine pulmonary artery pressure throughout exercise in chronic lung disease.
Utility and Limitations of Linear Models for Echocardiographic Estimation of Left Ventricular Ejection Fraction by Segmental Wall‐Motion Scoring
Authors: RIFKIN ROBERT D.
Published: August 2007

Although the geometric relation between left ventricular (LV) volume and its internal dimensions is nonlinear, recent clinical study has shown that LV ejection fraction (EF) predicted by a linear combination of segmental contraction scores correlates well with the EF by radionuclide angiography. To determine whether the linear coefficients found by empirical study are consistent with basic geometric principles, we compared the LV EF obtained by exact geometric calculation to the EF predicted using a simple linear combination of segmental contraction scores over a wide range of segmental function, from marked dyskinesis to marked hyperkinesis. We found that an optimal linear equation for global EF on geometric grounds is: Global EF = 4 + 0.28·C1 + 0.24·C2 + 0.12·C3, where C1, C2, and C3 are the mean segmental contraction scores at the base, mid‐left ventricle, and the apex, respectively. The EF predicted by this formula differs by < 6 percentage points from the EF predicted by exact geometry when segmental contraction ranges from normal to akinetic, and the coefficients are in close accord with those found empirically by regression of linearly‐derived EFs against the radionuclide EFs in 50 patients. However, when segmental contraction is significantly hyperkinetic or dyskinetic, agreement with the exact geometric formula is poor. We conclude that: (1) a linear combination of segmental contraction scores can provide reasonable estimates of LV EF over a broad range of contraction; (2) previous, empirically determined linear coefficients are consistent with geometric principles; and (3) exact, nonlinear formulas may be required for ventricles with significant degrees of hyperkinesis or dyskinesis.
The Radionuclide Assessment of Left Ventricular Diastolic Filling: Methodology and Clinical Significance
Authors: SOUFER ROBERT , DEY HOLLEY
Published: August 2007

The radionuclide measurement of diastolic performance may provide a rapid noninvasive index available in the clinical setting. These measurements may be used to detect coronary artery disease, manifestations of hypertensive heart disease, isolated diastolic heart failure, and hypertrophic cardiomyopathy. The various radionuclide methods to measure diastolic filling are influenced by technological considerations, as well as applying the results in the appropriate clinical context. The importance of these derived measurements and how they correspond to various pathophysiological presentations will be discussed.
Systolic Indentation of the Left Ventricular Outflow Tract in Eisenmenger Syndrome
Authors: PARASHARA DEEPAK K. , JACOBS LARRY E. , KOTLER MORRIS N. , MEYEROWITZ COLIN B. , IOLI ALFRED W. , LEDLEY GARY S.
Published: August 2007

Marked bulging of the interventricular septum toward the left ventricle has been described as a reliable index of right ventricular systolic hypertension. We report a patient with Eisenmenger syndrome who has systolic aneurysmal protrusion of the interventricular septum into the left ventricular outflow tract. To our knowledge, this is the first report of systolic indentation of the left ventricular outflow tract in a patient with right ventricular pressure/volume overload.
The Role of Doppler Echocardiography in the Assessment of Left Ventricular Diastolic Function
Authors: STODDARD MARCUS F. , LABOVITZ ARTHUR J. , PEARSON ANTHONY C.
Published: August 2007

The role of Doppler echocardiography of transmitral filling velocities in the assessment of diastolic function in man has not been adequately defined. It is now appreciated that multiple interacting factors such as loading conditions influence the transmitral velocity profile independent of intrinsic left ventricular diastolic function. Extrapolating the status of diastolic function from the transmitral velocity profile is complicated by these factors. The load dependence of ventricular filling has tempered the initial enthusiasm for the clinical application of the Doppler technique. In the present review, studies examining invasive parameters of diastolic function and Doppler indices of diastolic filling are discussed to gain greater insight and understanding of the role of Doppler echocardiography in the noninvasive assessment of diastolic function. These studies have demonstrated a relatively consistent influence of left ventricular relaxation, chamber stiffness, and left atrial pressure on the transmitral velocity filling profile. Impairment of relaxation impedes early filling and may result in a compensatory increase in atrial contribution to filling. An independent decrease in left atrial pressure from altered loading conditions may also reduce filling in early diastole. Increased left ventricular chamber stiffness (i.e., noncompliant left ventricle) impairs atrial contribution to filling and may enhance early filling. Theoretically, reduced left atrial contractility may decrease atrial contribution to filling. Pulmonic vein flow demonstrating increased retrograde flow during atrial systole helps to exclude impaired left atrial contractility. An increased left atrial pressure from altered loading conditions may also augment early filling. Therefore, an invasive or clinical assessment of left atrial pressure as being increased, decreased, or normal greatly aids in the interpretation of the transmitral filling velocity profile when inferences on the status of diastolic function are being made. Diastolic dysfunction is likely when a given pattern of filling cannot be explained on the basis of left atrial pressure. In situations where reasonable estimates on the status of left atrial pressure cannot be done, striking alterations in the transmitral velocity filling profile may be useful.
Doppler Evaluation of Left Ventricular Compliance and Ventricular Filling Abnormalities
Authors: SMITH MIKEL D. , DRINKOVIC NIKSA , HARRISON MICHAEL R. , WISENBAUGH THOMAS , BERK MARTIN R. , DeMARIA ANTHONY N.
Published: August 2007

Left ventricular diastolic dysfunction has recently been recognized as an important factor contributing to the signs and symptoms of a number of common cardiovascular disorders. Both invasive and noninvasive measures of left ventricular compliance and ventricular filling have been developed to assist in the clinical documentation of diastolic performance. However, each of these catheterization and Doppler parameters remains limited as a single descriptor of diastolic function, due to the complexity of factors involved in left ventricular filling and distensibility. The purpose of this article is to review the available data relating Doppler transmitral velocities with clinical descriptors and catheterization measures of left ventricular filling and compliance.
Use of a Mouth Gag Instrument to Facilitate Bite Block Insertion and Prevent Finger and Probe Bites During Transesophageal Echocardiography
Authors: LIGHTY GEORGE W. , HARE CHRISTOPHER L. , KAPLAN DAVID S.
Published: August 2007

Transesophageal echocardiography greatly enhances the examination of patients difficult to image transthoracically. While of low patient risk, a potential for harm from human bites to the echocardiography staff and to the transesophageal probe remains, particularly when dealing with uncooperative patients. This risk potential prompted implementation of additional anti‐bite protection in our universal precautions policy beyond use of a standard mouth guard. A mouth gag instrument was modified by placing latex rubber tubing over the instrument blades. This instrument was inserted into the mouth and set in an open position giving the operator safe access for probe and mouth bite guard insertion. This technique improved access to the patient's mouth and visualization of probe insertion without the mouth bite guard. The mouth gag instrument provided an insertion of the transesophageal probe in impaired or otherwise uncooperative patients, which was safer for the patient, laboratory staff, and the probe itself.
Noninvasive Vascular Laboratory in Clinical Practice
Authors: BANDYK DENNIS F.
Published: August 2007

Noninvasive vascular testing methods have validated application in the evaluation of patients with suspected peripheral arterial, cerebrovascular, or peripheral venous disease. Accurate and reproducible testing requires the use of appropriate instrumentation by experienced technologists, and interpretation of data with verified diagnostic criteria. Noninvasive testing can facilitate clinical decisionmaking by providing quantitative anatomical and hemodynamic data, thereby quantifying functional severity of disease. Duplex ultrasonography is essential instrumentation for cerebrovascular testing to localize and grade occlusive lesions. In peripheral arterial testing, the combination of segmental pressure measurements and waveform (velocity, pulse pressure) analysis should be the initial diagnostic method, with duplex scanning reserved for characterizing hemodynamically abnormal arterial segments. A number of techniques (duplex scanning, B‐mode imaging supplemented by Doppler, venous outflow plethysmography) are appropriate for assessing the venous system for thrombosis, structural abnormalities, and venous valve function. Physicians should be aware of the pitfalls of noninvasive vascular testing and confirm equivocal studies using “gold standard” diagnostic methods such as arteriography and contrast venography.
Bioeffects in Echocardiography
Authors: CARSTENSEN EDWIN L. , DUCK FRANCES A. , MELTZER RICHARD S. , SCHWARZ KARL Q. , KELLER BRADLEY
Published: August 2007

Two mechanisms have been identified through which ultrasound as it is used clinically could produce biologically significant effects. One is heating that results from the absorption of ultrasonic energy by tissues. The other is cavitation, the ultrasonic activation of gas bodies including the potentially violent collapse of small gas bodies in or near tissue that is sometimes called transient or inertial cavitation. The heart, itself, is well perfused and the likelihood of significant heating of the heart tissues in the most extreme conditions known today is negligible. Lung also appears to be relatively immune to heating under diagnostic exposure conditions. In normal echocardiographic procedures, the only tissues that need serious consideration are the ribs. Under extreme conditions, ultrasonic heating of the bone might be as great as 6°C. Nonthermal action of ultrasound has been demonstrated to cause lung hemorrhage at pressure levels on the order of 1 MPa. Although many diagnostic devices produce focal pressures greater than this amount, it appears unlikely that hemorrhage will occur in normal echocardiographic applications. Under certain conditions, pulsed ultrasound can either stimulate or modify the contraction of the heart but the exposures required are not used in normal echocardiographic applications. Since specific devices have been identified who's outputs approach levels required to produce thermal and nonthermal effects, the user should be aware of potential biological effects, particularly in pediatric or obstetric applications, as output levels increase.
The Surgeon's Use of Epicardial Echocardiography During Repair of Congenital Heart Defects
Authors: FONTANA GREGORY P. , UNGERLEIDER ROSS M.
Published: August 2007

Intraoperative echocardiography in the evaluation of congenital heart defects is a useful method to evaluate surgical anatomy, adequacy of repair, and ventricular performance. Since 1987, 733 patients have undergone epicardial echocardiography during repair. The routine use of this technique has led to the reduction in the need for both early and late reoperation.
Multiplane Transesophageal Echocardiography
Authors: PANDIAN NATESA G. , HSU TSUI‐LIEH , SCHWARTZ STEVEN L. , WEINTRAUB ANDREW , CAO QI‐LING , SCHNEIDER ABRAHAM T. , GORDON GEORGE , ENGLAND MICHAEL , SIMONETTI JANET
Published: August 2007

Multiplane transesophageal echocardiography is a new exciting development in echocardiography. We examined the methodology and echo‐anatomic correlations of multiplane transesophageal echocardiography and its clinical applications in 100 patients. We used a 5‐MHz phased array multiplane (OmniPlane) transesophageal probe. In this instrument, the transducer array can be steered through 180° from any transducer location. This provides a vast assembly of imaging planes, allowing for detailed visualization of all dimensions of cardiac anatomy. This report presents our observations on the echocardiographic anatomy seen in various image planes and the unique clinical potential of multiplane transesophageal echocardiography in the diagnostic assessment of cardiovascular disorders. This technique appears to provide incremental diagnostic information that enhances the interpretative ability. Less esophageal probe manipulation is required with consequent decrease in patient discomfort. We conclude that multiplane transesophageal echocardiography enhances the versatility of transesophageal examination and offers many new avenues for developments such as three‐dimensional echocardiography.
Left Ventricular Diastolic Collapse in the Absence of Cardiac Tamponade
Authors: HAVRANEK EDWARD P. , BAILEY WILLIAM M. , ADAIR OLIVIA V.
Published: August 2007

Left ventricular diastolic collapse has been presented in the literature as a sign of cardiac tamponade in the setting of pulmonary hypertension. We report the case of a patient with human immunodeficiency virus (HIV) disease, and associated pulmonary hypertension and pericardial effusion. Left ventricular diastolic collapse was present, but tamponade was not, as judged by failure of pericardio‐centesis to improve cardiac index or symptoms. We suggest that left ventricular diastolic collapse occurred because left ventricular filling was impaired by the hemodynamic consequences of pulmonary hypertension, not by extrinsic compression. Left ventricular diastolic collapse is not pathognomonic for cardiac tamponade in the setting of pulmonary hypertension.
Limitations of the Pressure Half‐Time Method for Estimating Mitral Valve Area in the Presence of Atrial Flutter
Authors: REDDY N. KRISHNA , RAO D. SESHAGIRI , RAJU B. SOMA
Published: August 2007

A patient with congenital ventricular septal defect and acquired rheumatic mitral stenosis with atrial flutter was noninvasively studied. The influence of atrial flutter on Doppler flow patterns across the mitral valve and the limitations of the pressure half‐time method for estimating mitral valve area in the presence of atrial flutter are discussed.
Reproducibility of the Dobutamine‐Atropine Echocardiography Stress Test
Authors: BELLOTTI PAOLO , FIORETTI PAOLO M. , FORSTER TAMAS , McNEILL ALBERT J. , SAID EL‐SAID M. EL , SALUSTRI ALESSANDRO , ROELANDT JOS R.T.C.
Published: August 2007

To assess the reproducibility of dobutamine‐atropine echocardiography testing, two studies (1 to 20 days apart [mean 3.3 days]) were performed in 23 patients with stable effort angina pectoris or chest pain. During the study, 20 (87%) patients were receiving beta blockers alone or combined with nitrates or calcium antagonists. Dobutamine was infused at doses of 10 μg/kg per minute every 3 minutes up to a maximum of 40 μg/kg per minute and this maximal dose was continued for 6 minutes. In patients not achieving 85% predicted maximal heart rate or myocardial ischemia, atropine (0.25–1 mg) was added and dobutamine continued for another 3 minutes, until either an adequate heart rate was achieved or the test was considered positive. During dobutamine infusion, electrocardiographic, echocardiographic, and blood pressure monitoring were obtained in each patient. Side effects including tremor, nausea, palpitation, dizziness, headache, and nonsustained ventricular tachycardia occurred in three patients. The same symptoms, but no ventricular tachycardia, developed during the same stage of the second test. Angina pectoris (eight patients), electrocardiographic changes (six patients), and ischemic wall‐motion abnormalities (six patients) were observed at the same stage of the two tests. The mean values of heart rate, blood pressure, and rate‐pressure product were comparable for each stage in duplicate tests. Our data show that pharmacological stress echocardiography using dobutamine‐atropine has good reproducibility and provides a useful tool for assessing disease progression and the effects of therapeutic interventions in patients with coronary artery disease.
Pitfalls in the Echocardiographic Diagnosis of Intracardiac and Extracardiac Masses
Authors: ALAM MOHSIN
Published: August 2007

Transthoracic and transesophageal two‐dimensional (2‐D) echocardiography remain the procedures of choice for evaluating cardiac mass lesions. Potential errors in diagnosis can be made, however, if the mass lesion's size, shape, mobility, and attachment to other cardiac structures are not clearly delineated. Usually a left atrial myxoma arises from the interatrial septum at the level of the fossa ovalis. Pitfalls in diagnosis occur when the tumor size is very small, or its attachment site is atypical or ill‐defined. Atrial thrombi classically reside in an atrial appendage, but can also form in the body of the left atrium. The presence of atrial fibrillation rhythm, enlarged atrial chamber, prosthetic mitral/tricuspid valves, stenotic mitral/tricuspid valves, low cardiac output state, and spontaneous atrial contrast echoes are all features that favor the mass in question being a thrombus. Ventricular thrombi usually occur with poorly functioning ventricles. The diagnosis of ventricular thrombus should be made with great caution if the systolic function is normal, or if the mass has a band or thread‐like appearance. A thorough knowledge of normal anatomical variants that can mimic pathological lesions is also important for reaching a correct diagnosis. Last but not least, as in all testing modalities, the patient's clinical picture should be correlated with the echocardiographic findings.
Pitfalls in the Echo‐Doppler Assessment of Diastolic Dysfunction
Authors: GRODECKI PATRICIA V. , KLEIN ALLAN L.
Published: August 2007

The Doppler echocardiographic assessment of diastolic function is an essential part of the evaluation of heart failure, pericardial diseases, restrictive and infiltrative cardiomyopathies, and many other conditions. However, the echocardiographic evaluation of diastolic function has several limitations. The sonographer and physician must understand the technical factors, the effects of physiological and pathophysiological conditions, and the dynamics of pseudonormalization, all of which affect the evaluation. This article will review the most recent data essential for the proper performance and interpretation of a transthoracic or transesophageal Doppler echocardiographic examination of diastolic function.
Prognosis in Dilated Myocardial Disease: Influence of Diastolic Dysfunction and Anatomical Changes
Authors: ORTIZ JUAREZ , MATSUMOTO AFONSO Y. , GHEFTER CLAUDIA G.M. , SILVA CARLOS EDUARDO SUAIDE , DURAZZO ANAÍ ESPINELLI , M ANTONIO CARLOS PEREIRA BARRETTO , NANDA NAVIN C.
Published: August 2007

A prospective study has been conducted, in patients with dilated myocardial disease, in order to examine the relation between echocardiographic variables and mortality rate. Patients were divided into two major groups: (1) group A—designed to evaluate the influence of the ventricular filling pattern in the mortality rate. It included 95 patients, followed‐up for a period ranging from 1–23 months (mean = 12.6 months), divided into three subgroups: AF (atrial filling predominant pattern, n = 22); N (normal or “normalized” filling pattern, n = 40), and RF (rapid filling predominant pattern, n = 33); and (2) group B—designed to correlate echocardiographic variables to the 1‐year mortality rate. It included 52 patients divided into two subgroups: survivors (n = 40) and nonsurvivors (n = 12). In group A, a progressive decrease in survival rate was noted on comparing subgroups N to AF to RF. At the 14 months follow‐up a survival rate of 89% was noted in N, 75% in AF, and 50% in RF. Univariate analysis in group B showed high 1‐year mortality rate associated with mitral flow deceleration time ≤ 140 msec (50%, P = 0.003), left ventricular diastolic diameter/thickness ratio ≥ 3.4 (35.3%, P = 0.002), and left atrial index ≥ 25 mm/m2 (40.7%, P = 0.001). The highest mortality rate (61.5%, P = 0.0004) was observed in patients with increased left atrial index and decreased deceleration time. Thus, diastolic dysfunction and anatomical changes, as evaluated by echocardiography, are confident parameters to estimate the prognosis in dilated myocardial disease.
Doppler‐Phonocardiographic Findings in Tricuspid Valve Prolapse
Authors: HANCOCK HOLLY L. , D'CRUZ IVAN A.
Published: August 2007

A loud systolic click was heard at the left lower sternal border and xiphisternal area in a 71‐year‐old man. The click showed striking phasic mobility (with reference to first and second heart sound), becoming late systolic in inspiration and early systolic in expiration. Two‐dimensional echocardiography showed tricuspid valve prolapse as well as mild mitral valve prolapse. Continuous‐wave and color flow Doppler recording of the tricuspid regurgitant jet showed marked phasic variation in duration of late systolic tricuspid regurgitation. Phasic respiratory variation in timing of a systolic click is an important auscultatory sign of tricuspid prolapse, serving to distinguish it from mitral prolapse.
Echocardiography in the Evaluation of Cardiac Sources of Emboli:
Authors: ASINGER RICHARD W. , HERZOG CHARLES A. , DICK CANDACE D. , MICHAUD LILLIAN
Published: August 2007

Cardioembolism is responsible for a significant number of systemic emboli including approximately 15% of all ischemic strokes. Transthoracic echocardiography has contributed to the understanding of cardioembolism and has been used to detect specific and potential cardiac sources of systemic emboli and risk stratify patients with specific clinical findings for subsequent cardiovascular events. Findings from transthoracic echocardiography indicate that stasis is an important prerequisite for intracardiac thrombosis while reversal of stasis and thrombolysis appear operative in embolism of existing thrombus. Transthoracic echocardiography allows a sensitive and specific noninvasive means to detect left ventricular thrombus, valvular vegetation, and intracardiac tumor, lesions that are directly responsible for cardioembolism. Transthoracic echocardiography can also detect lesions that could potentially contribute to cardioembolism but are not specific causes. Examples of these potential lesions include mitral valve prolapse, patent foramen ovale, and interatrial septal aneurysm. Finally, population‐based studies and prospective clinical trials have indicated that the results of transthoracic echocardiography have predictive value for subsequent cardiovascular events and hence provide a means for stratification of patients at risk for cardioembolism. The latter is most notable for the group of patients with nonvalvular atrial fibrillation where left ventricular dysfunction and increased left atrial size are independent predictors for subsequent stroke.
The Role of Transesophageal Echocardiography in the Detection of Left Atrial Thrombi
Authors: MÜGGE ANDREAS , KÜHN HENNING , DANIEL WERNER G.
Published: August 2007

Sensitivity of transthoracic echocardiography in the detection of left atrial thrombi, in particular thrombi confined to the left atrial appendage, is surprisingly low (33%–72%). Concerning the detection of left atrial thrombi, transthoracic echocardiography appears as an inadequate technique in patients with suspected cardiogenic embolism with a success rate of only 0.8% in earlier, and about 3% in recent studies. Imaging from the esophagus substantially increases the detection rate for left atrial thrombi, and is the only clinically relevant semiinvasive technique to diagnose thrombi confined to the left atrial appendage. Transesophageal echocardiography has markedly increased the diagnostic power of cardiovascular ultrasound in patients with suspected cardiogenic embolism and/or atrial fibrillation. Meta‐analysis of pooled studies using the transesophageal approach in these patients revealed thrombi within the left atrial cavity in about 7% and within the atrial appendage in about 12% of cases.
Discrete Subaortic Valvular Stenosis:
Authors: MOVSOWITZ COLIN , JACOBS LARRY E. , EISENBERG SCOTT , MOVSOWITZ HERMAN D. , KOTLER MORRIS N. , IOLI ALFRED I.
Published: August 2007

Transesophageal echocardiography (TEE) is a useful technique in the diagnosis and intraoperative assessment of discrete subaortic stenosis (DSS). It allows clear visualization of the subaortic membrane, which may be missed by transthoracic echocardiography, differentiates DSS from other causes of left ventricular outflow tract obstruction, and accurately detects the presence of associated aortic regurgitation and bacterial endocarditis. Limitations in its use include inadequate visualization of the left ventricular outflow tract by TEE in the presence of a prosthetic mitral valve or mitral annular calcification, and improper alignment of the Doppler cursor across the outflow tract.
Echocardiographic Localization of an Inadvertently Placed Pacing Catheter in the Left Ventricle
Authors: LOUNGANI RAMESH R. , WANAT FRANCIS E. , NANDA NAVIN C. , FINCH ANA
Published: August 2007

This report describes a patient in whom a permanent transvenous pacemaker lead was placed unintentionally across the atrial septum and retained in the left ventricle for nearly 11 years before the error was recognized. A 12‐lead electrocardiogram showed paced complexes with right bundle branch block configuration. This appearance raised suspicion that the pacemaker electrode might be in the left ventricle and this was confirmed by two‐dimensional echocardiography. Two‐dimensional echocardiography is useful for the diagnosis of pacing lead malplacement and should be performed in any patient who develops right bundle branch block pattern on the surface electrocardiogram following pacemaker implantation.
Transesophageal Echocardiographic Diagnosis of Intussusception of the Left Atrial Appendage
Authors: ROBERSON DAVID A. , ARCILLA RENE A. , SACHSTEDER WILLIAM , ILBAWI MICHEL N.
Published: August 2007

Intraoperative postbypass transesophageal echocardiography demonstrated a large pedunculated left atrial mass secondary to invagination of the left atrial appendage into the left atrial cavity. The base of the mass was between the entrance of the left upper pulmonary vein and the posterior attachment of the mitral valve at the atrioventricular groove, and the body of it protruded into the left atrium and mitral funnel. Retraction of the appendage to its normal position resulted in disappearance of the mass. This diagnosis should be considered when a pedunculated mass with these morphological features is encountered in this setting. (ECHOCARDIOGRAPHY, Volume 10, November 1993)
Ebstein's Anomaly:
Authors: SEWARD JAMES B.
Published: August 2007

Ebstein's anomaly, a well‐recognized congenital cardiac abnormality, involves the tricuspid valve and underlying right ventricular myocardium. The two‐dimensional diagnosis and hemodynamic characterization of this anomaly are so confident that cardiac catheterization is no longer necessary in the majority of cases. The varied anatomical abnormalities are discussed and illustrated and compared with other anomalies that should be differentiated from Ebstein's. The most diagnostic feature is an excessive downward displacement of the septal leaflet of the tricuspid valve ≥ 8 mm/m2. More importantly, in order to understand the clinical impact of Ebstein's anomaly, it is important to perform a detailed anatomical and functional echocardiographic profile. Both timing and type of surgery (i.e., repair vs replacement) can be better predicted by this type of detailed noninvasive assessment. Intraoperative and serial follow‐up are a regular part of the overall role of echocardiography in the assessment of Ebstein's anomaly. A thorough echocardiographic evaluation of Ebstein's anomaly is the best means of determining a management course for an individual patient. (ECHOCARDIOGRAPHY, Volume 10, November 1993)
Assessment of the Accuracy of Color Doppler Flow Mapping By Digital Image Analysis
Authors: WALKER PETER G. , KIM YOUNGHO , MURALIDHARAN ETHIRAJAN , MIYAJIMA YASAO , DELATORE JASON , YOGANATHAN AJIT P.
Published: August 2007

An in vitro steady flow experiment was performed in order to test the accuracy of velocity measurements obtained through color Doppler flow mapping (CDFM). Using the American Society of Echocardiography (ASE) flow phantom, low (maximum velocity = 60 cm/sec), medium (maximum velocity = 300 cm/sec) and high (maximum velocity = 600 cm/sec) speed accelerating flow fields, in which multiple aliases were visible, were imaged. A fully automatic computer algorithm was used to unwrap the aliases and to convert the CDFM to digital velocity. Packet size and wall filter frequency on the ultrasound machine were varied and the measured velocity compared to the true velocity. The results show that the velocity obtained in this way from the CDFM is very accurate at the low and medium velocities, but for the high velocity the turbulence is too intense to obtain an accurate result. There was no marked difference between the data for different packet sizes or wall filter settings.