bluuebunny/crossref_metadata_2025 huggingface dataset:
Transesophageal Echocardiographic Spectrum of Calcific Mitral Abnormalities in Patients with End‐Stage Renal Disease
Authors: MADU ERNEST C. , CRUZ IVAN A. D' , WALL BARRY , MANSOUR NAWAR , SHEARIN SUSAN
Published: December 2007

This report provides a morphological description of atypical and unusual mitral and submitral calcifications in patients with end‐stage renal disease. The use of transesophageal echocardiography (TEE) with enhanced image quality and resolution has made possible a detailed evaluation of the distribution and echocardiographic morphology of mitral calcification in end‐stage renal disease. To our knowledge, there has been no such prior report with TEE. Our TEE observations reveal that in addition to the common well known posterior mitral annulus calcification, the following varieties of calcification also exist: basal calcification of both mitral leaflets with sparing of free edges, calcification in the intervalvular fibrosa region, and small calcific excrescences at the bases of both mitral leaflets. These abnormalities have previously received little or no attention. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Severe Dynamic Obstruction of the Left Ventricular Outflow Tract Induced by Dobutamine
Authors: ROLDÁN FRANCISCO‐JAVIER , VARGAS‐BARRÓN JESÚS , ESPINOLA‐ZAVALETA NILDA , KEIRNS CANDACE , ROMERO‐CÁRDENAS ANGEL
Published: December 2007

We present the case of a 63‐year‐old man who developed a subaortic gradient of 182 mmHg during an echocardiographic pharmacological stress study with dobutamine. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Left Atrial Thrombosis After Percutaneous Mitral Valvuloplasty: Resolution with Conservative Management
Authors: ROLDÁN FRANCISCO‐JAVIER , VARGAS‐BARRÓN JESUS , RÍOS MARCO‐ANTONIO MARTÍNEZ , ESPINOLA‐ZAVALETA NILDA , KEIRNS CANDACE , ROMERO‐CÁRDENAS ANGEL
Published: December 2007

We report the detection of a thrombus 72 hours after mitral valvuloplasty through the use of the technique of Inoue. Images obtained by transesophageal echocardiography revealed its localization on the interatrial septum at the level of the transseptal puncture. Although the patient subsequently underwent surgery for the placement of a prosthetic valve in mitral position due to failure of the valvuloplasty, the thrombus resolved with conservative management. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
A Case of Confirmed Nonbacterial Thrombotic Endocarditis with Correlative Transesophageal Echocardiography Findings
Authors: HARRIS KEVIN M.
Published: December 2007

The diagnosis of nonbacterial thrombotic endocarditis is rarely made during life. We describe a patient with non‐Hodgkin's lymphoma with evidence of systemic embolism in which transesophageal echocardiography was useful in establishing the diagnosis. The clinical and echocardiographic features of nonbacterial thrombotic endocarditis should be remembered when a valvular mass is seen on echocardiography. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Transesophageal Three‐Dimensional Echocardiography Assessment of Anomalous Coronary Arteries
Authors: NANDA NAVIN C. , BHAMBORE MAHESH M. , JINDAL AJAY , MISRA VIJAY K. , ANSINGKAR KAMLESH , PURI VIRENDER , JASSER MOHAMED S. , AKSUT SEYDI V. , LIU MING W. , KIRKLIN JAMES K , AALURI SRINIVASA , MUKHTAR OSMAN , LEE TAO YU , HUANG WEN YING , YESILBURSA DILEK , SACHDEV VINNINDER S.
Published: December 2007

We describe the usefulness of transesophageal three‐dimensional echocardiography in the evaluation of anomalously arising coronary arteries in four adult patients recently studied by us. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Prognostic Implications of Myocardial Contractile Reserve in Patients with Ischemic Cardiomyopathy
Authors: GALATRO KATHLEEN , CHAUDHRY FAROOQ A.
Published: December 2007

The extent and degree of myocardial viability is an important parameter in the risk stratification of patients with significant left ventricular dysfuncion due to coronary artery disease (CAD). Although several imaging modalities can identify viable myocardium, dobutamine stress echocardiography has gained considerable importance as an accurate, safe, and reliable method. In patients with significant left ventricular dysfunction secondary to CAD, identifying the presence and extent of contractile reserve and, therefore, viable myocardium, during low dose dobutamine infusion can predict recovery of left ventricular function postrevascularization, survival, and future cardiac events. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Dobutamine Echocardiography for Detection of Viable Myocardium in Ischemic Cardiomyopathy
Authors: SAWADA STEPHEN
Published: December 2007

Inpatients with ischemic cardiomyopathy, revascularization of hibernating or stunned myocardium can result in improvement in global systolic function and prognosis. The recognition that revascularization can alter the course of ischemic cardiomyopathy has fueled the development of noninvasive methods for detection of viable myocardium. Dobutamine echocardiography has established utility as a method for identifying hibernating and stunned myocardium thereby improving the selection of candidates with ischemic cardiomyopathy for revascularization. This manuscript reviews the rationale and methodology for use of low and high dose dobutamine echocardiography for detection of viable myocardium. The predictive value of the technique is discussed and compared with that of other noninvasive imaging methods. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Role of Intravenous Ultrasound Contrast in Stress Echocardiography
Authors: PORTER THOMAS R.
Published: December 2007

Intravenous newer generation perfluorocarbon containing microbubbles have been shown to enhance endocardial borders, especially during harmonic imaging. Although this significantly improves the detection of wall‐motion abnormalities during stress echocardiography, intermittent imaging consistently results in myocardial contrast following intravenous infusions or injections of perfluorocarbon microbubbles. Detection of myocardial perfusion abnormalities during both exercise and pharmacologic stress echocardiography appears to be feasible clinically with either intravenous injections or continuous infusions of microbubbles using intermittent harmonic imaging. Accelerated intermittent harmonic imaging allows one to rapidly acquire both myocardial perfusion and wall motion during exercise and dobutamine stress echocardiography. (ECHOCARDIOGRAPHY, Volume 17, January 2000)
Active Vegetations Can Be Differentiated from Chronic Vegetations by Visual Inspection of Standardized Two‐Dimensional Echocardiograms
Authors: TAK TAHIR , MATHEWS SAJEN , ULENE RICHARD , CHANDRARATNA P.A.N.
Published: December 2007

The ability to differentiate active from chronic valvular vegetations (VEGs) by digital image processing and by visual observation was evaluated in 18 patients with a clinical diagnosis of infective endocarditis (IE). Two‐dimensional echocardiographic (2‐DE) examinations were performed on all patients at diagnosis and after a mean period of 52 days. Two comparable images (active and chronic) from the same patient and in the same phase of the cardiac cycle were digitized, magnified, and displayed on a high resolution monitor. The mean pixel intensity (MPI) was 72 ± 14 in the active stage and 143 ± 23 in the chronic stage (P < 0.0001). The VEG size was 0.64 ± 0.15 cm2 in the active stage and decreased to 0.46 ± 0.17 cm2 in the chronic stage (P < 0.001). Two experienced echocar‐diographers, who were blinded to the age of the VEGs, identified each echocardiographic image as active or chronic based on visual observation of density of the VEGs. The VEGs were correctly identified as active or chronic in 17 out of the 18 patients. In summary, although digital image processing of 2‐DE may be useful, the density of VEGs assessed by visual inspection will help differentiate between active and chronic VEGs of IE. The standardization procedure at the time of the initial study and use of identical gain settings in subsequent studies are key factors in making this distinction.
Differentiation of Intracardiac Tumors and Thrombi by Echocardiography Tissue Characterization: Comparison of an Artificial Neural Network and Human Observers
Authors: GERBER THOMAS C. , FOLEY DAVID A. , ZHENG YI , BEHRENBECK THOMAS , TAJIK A. JAMIL , SEWARD JAMES B.
Published: December 2007

The feasibility of classifying ultrasound images of intracardiac tumors and thrombi with a neural network‐based algorithm was compared with the performance of experienced echocardiographers. The neural network used statistical descriptors of the apparent echocardiographic texture of the masses, and the blinded echocardiographers were given photographic prints of enlarged regions of interest without clinical data. The network classified 66% of the images correctly and the echocardiographers, 83%. The network and echocardiographers agreed in 88% of the images. Human observers usually base their classification of intracardiac masses on clinical data. The echocardiographic texture of tumors is quantitatively different from that of thrombi. This difference can be recognized by a neural network and potentially be useful in assisting with the diagnosis when clinical clues are insufficient.
Can Doppler Systemic Venous Flow Indices Predict Central Venous Pressure in Children?
Authors: RITTER SASKIA , TANI LLOYD Y. , SHADDY ROBERT E. , DAY RONALD W. , ORSMOND GARTH S. , PAGOTTO LUCIANA T. , MINICH L. LUANN
Published: December 2007

Tricuspid valve, superior vena cava (SVC), and hepatic vein Doppler patterns may be abnormal in right heart anomalies and have been used to predict high central venous pressure (CVP) in adults. The purpose of this study was to evaluate the relationship of these systemic venous flow indices to CVP in children. Children undergoing cardiac catheterization were studied prospectively using simultaneous recordings of mean CVP with pulsed‐Doppler tracings of SVC, hepatic vein, and tricuspid valve flow. Systemic venous Doppler measurements included peak velocities and velocity time integrals for ventricular systole (S), ventricular diastole (D), end ventricular systole (B), and atrial systole (A). Tricuspid inflow Doppler E and A waves were recorded also. Patients with significant tricuspid stenosis or regurgitation, systemic venous obstruction, and nonsinus rhythm were excluded. The 42 patients ranged in age from 0.2 to 21.0 years and in weight from 3.0 to 68.0 kg. Mean CVPs ranged from 1 to 17 mmHg. Catheterization indications included hemodynamic evaluation (25 patients), transplant biopsy, (11 patients), and interventional procedures (6 patients). No SVC or tricuspid valve Doppler measurement correlated with CVP. Hepatic vein peak D, peak B, and peak A significantly correlated with CVP (r= 0.34–0.55; P< 0.05, linear regression). For all correlations, the r values were low with significant overlap among patients. Thus, in children, only hepatic vein peak velocities correlate with CVP. Because of the low r values and significant overlap among patients, the currently used Doppler indices have a low sensitivity for predicting CVP in this age group.
Doppler Transmitral and Pulmonary Venous Flow in Young Orienteers and Sedentary Young Adults
Authors: HENRIKSEN E. , KANGRO T. , JONASON T. , FRIMAN G.
Published: December 2007

Doppler filling indices may provide important information on left ventricular diastole and possibly diastolic adaptation in endurance athletes. We therefore undertook a comparative study to obtain reference values for transmitral and pulmonary venous Doppler flow velocities and to characterize differences between young orienteers and young sedentary adults. Seventy‐six elite orienteers (42 female and 34 male; 17–30 years old) and 61 sedentary young subjects (32 female and 29 male; 17–33 years old) underwent echocardiography. No significant differences between the athletes and sedentary controls regarding peak transmitral flow were found, although the athletes had significantly higher peak pulmonary flow velocity during diastole than the sedentary controls (0.69 ± 0.13, 0.61 ± 0.10, 0.78 ± 0.12, and 0.57 ± 0.09 ml sec for female athletes, female sedentary controls, male athletes, and male sedentary controls, respectively). Because no significant differences were revealed in the transmitral flow velocities between the athletes and the sedentary subjects, the relative force between the left atrium and the left ventricle should not diverge during early filling. An increase in pulmonary venous pressure or a decrease in left atrial pressure can augment the force between the pulmonary veins and the left atrium. A rise in pulmonary venous pressure is a hemodynamically unlikely adaptation in endurance athletes; therefore, to maintain the same transmitral pressure with an assumed lower left atrial pressure, the data suggest a more rapid relaxation and an improved left ventricular elastic recoil, which would enable the athletes to achieve a more rapid negative left ventricular pressure change during early filling.
Transesophageal Doppler Echocardiography Study of Pulmonary Venous Flow Pattern in Severe Mitral Stenosis and the Changes Following Balloon Mitral Valvuloplasty
Authors: SRINIVASA. KIKKERI H. , MANJUNATH CHOLENAHALLY N. , DHANALAKSHMI CHANDRASHEKARAN , PATIL CHANDRAKANTH B. , VENKATESH HUCHAPPA V.
Published: December 2007

The studies of pulmonary venous flow‐pattern in mitral stenosis (MS) have given conflicting data about the type of abnormality. This study was undertaken to assess the pulmonary venous flow‐pattern in severe MS and to study the changes occurring after balloon mitral valvuloplasty (BMV). There were 51 patients of MS with sinus rhythm with the mean age of 32.5 ± 9.35 years, 18 males and 33 females. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed before and after BMV. Pulmonary venous flow was recorded by TEE from left upper pulmonary vein (PV). Peak velocities (V) and velocity time integrals (VTI) of systolic wave (S), diastolic wave (D), and atrial reversal wave (A) were measured. The Sv/Dv and SVTIIDVTI were calculated. Mitral valve area (MVA) increased from 0.81 ± 0.18 cm2 to 2.02 ± 0.46 cm2, left atrium (LA) mean decreased from 28.55 ± 6.68 mmHg to 13.88 ± 4.89 mmHg, and cardiac output increased from 3.1 ± 0.86 L/min to 3.7 ± 1.02 L/min. The S, D, and A velocities increased from 33.84 ± 13.55 cm/s, 37.24 ± 11.55 cm/s, and 20.53 ±6.7 cm/s to 59.86 ± 18.25 cm/s, 48.43 ± 12.55 cmls, and 24.94 ± 9.14 cmls, respectively. The VTIs ofS, D, and A waves increased from 4.88 ± 2.24 cm, 6 ± 2.45 cm, and 2 ± 0.88 cm to 10.46 ± 4.23 cm, 8.82 ± 3.61 cm, and 2.34 ± 1.29 cm, respectively. MS leads to reduction in pulmonary flow velocities during all the phases. Successful BMV resulted in improvement of all these velocities, with improvement in systolic fraction being the maximum. These improved flows after BMV appear to be secondary to reduction in LA pressure and improved cardiac output.
Recurrent Myxoma Implanted in the Left Atrial Appendage
Authors: ROLDÁN FRANCISCO‐JAVIER , VARGAS‐BARRÓN JESUS , ESPINOLA‐ZAVALETA NILDA , KEIRNS CANDACE , ROMERO‐CÁRDENAS ANGEL
Published: December 2007

We present the case of a young woman who developed myxomas in multiple cardiac chambers for the third time. One of the tumors was found in the left atrial appendage with the use of transesophageal echocardiography, indicating that this technique is the method of choice for the follow‐up of multiple myxomas.
Diagnosis of a Giant Coronary Aneurysm with Multiple Imaging Modalities
Authors: STROUSE DAVID , KATZ EDWARD S. , TUNICK PAUL A. , WINER HOWARD E. , KRINSKY GLENN A. , GALLOWAY AUBREY C. , KRONZON ITZHAK
Published: December 2007

Echocardiography demonstrated an 8‐cm mass adjacent to the right side of the heart in a 79‐year‐old man with a history of hypertension and a repaired abdominal aortic aneurysm. The results of Doppler echocardiography and magnetic resonance imaging suggested the diagnosis of an unusually large coronary artery aneurysm, and this was confirmed with coronary angiography. At surgery, the 8‐ to 10‐cm coronary aneurysm was resected, and the patient made an uneventful recovery.
Critical Left Ventricular Outflow Tract Obstruction Due to Accessory Mitral Valve Tissue
Authors: CALABRO RAFFAELE , SANTORO GIUSEPPE , PISACANE CARLO , SARUBBI BERARDO , FARINA GABRIELLA , PACILEO GIUSEPPE , CAIANIELLO GIUSEPPE
Published: December 2007

Left ventricular outflow tract (LVOT) obstruction due to anomalous tissue tag arising from the mitral valve is a rare congenital cardiac anomaly. It generally becomes symptomatic during the first decade of life as exercise intolerance, chest pain, or syncope at effort. To date, only a few cases of critical systemic obstruction due to isolated mitral valve anomaly in neonates have been reported. We report the case of a neonate who was a few hours old and was referred in severe clinical condition due to critical left ventricular outflow obstruction resulting from an anomalous tissue tag of mitral valve origin.
Stanford Type A Aortic Dissection in a Hypertensive Patient with Atherosclerosis of Aorta and Aortitis
Authors: BEDELEANU DANIELA , COMAN CATLIN , ENCICA SVETLANA , HAGIU RADU , MOLNAR ADRIAN , CAPALNEANU RADU
Published: December 2007

Dissection of aorta is a serious condition; the main factors are hypertension and diseases of the connective tissue or of collagen. Aortitis syndrome in combination with hypertension and atherosclerosis in association with ascending aortic dissection is rarely seen. We present the case of a 53‐year‐old hypertensive patient whose ascending aortic dissection was associated with pericardial effusion without rupture of the aorta and with pleural effusion. Several unusual aspects of transesophageal echocardiography are described. The intraoperative biopsy revealed inflammatory aortitis with mural hematoma, without giant cells. The literature concerning aortic dissection and aortitis is reviewed.
Pseudoaneurysm Formation After Infected Modified Blalock‐Taussig Shunt: Echocardiography Findings
Authors: JAN SHENG‐LING , HWANG BETAU , FU YUN‐CHIN , CHI CHING‐SHIANG
Published: December 2007

The modified Blalock‐Taussig (B‐T) shunt is well recognized as a palliative procedure for cyanotic congenital heart disease in infants. Pseudoaneurysm formation after a modified B‐T shunt is a rare complication. We present the case of a 9‐month‐old girl with tetralogy of Fallot who had undergone a modified left B‐T shunt at 5 months of age and developed a pseudoaneurysm after an episode of infective endocarditis as detected by echocardiography. Compression of the left bronchus, displacement of the mediastinum to right chest, and paralysis of the left hemidiaphragm were found. Magnetic resonance images, computed tomography scans, aortograms, and selective angiograms demonstrated the presence of a large pseudoaneurysm. The compression syndrome gradually disappeared after aneurysmectomy.
Forensic Echocardiography: A Case in Point
Authors: COTTON J. M. , COOKE J. C. , MONAGHAN M. J.
Published: December 2007

Transthoracic echocardiography (TTE) has an important role in the assessment of patients with acute penetrating chest trauma. We report the case of a 36‐year‐old man who sustained a stab wound to the chest. After admission, he required emergency pericardiocentesis. TTE revealed a traumatic ventricular septal defect and a defect in the anterior mitral valve leaflet. To assess whether these lesions were related to the initial stab wound or the pericardiocentesis, the transducer was positioned over the stab wound, and the lesions were shown to be in the same plane as the entry site, thus ruling out iatrogenic trauma.
Digital Analysis of Myocardial Contrast Echocardiography: A Clinical Study Using an Air‐Filled Agent in Normal Subjects
Authors: GEISER EDWARD A. , MILBURN DEANNA J. , CUNNINGHAM MICHAEL S. , BROWN CHRISTOPHER S. , LIN LANG , WILSON DAVID C.
Published: December 2007

The purpose of the present study was to determine whether direct digital image analysis would allow improved detection of myocardial contrast. Eighteen normal subjects were recruited and separated into two groups. In group 1, the time‐brightness curves of the left ventricular cavity and three myocardial perfusion beds were formed from digitized video tape, with output power and imaging time as secondary variables. In group 2, curves constructed from direct polar digital data were compared, with fundamental and second harmonic image formation as variables. In group 1 subjects, using fundamental imaging, the area under the curve in the left ventricular cavity increased slightly with intermittent imaging. No consistent myocardial opacification was identified. In group 2 subjects, using intermittent imaging, the area under the myocardial curve and peak intensity increased with high output second harmonic imaging in the left anterior descending and right coronary artery regions. Intermittent, second harmonic imaging and digital processing can demonstrate myocardial contrast even with an air‐filled agent.
Impact of Atropine Injection on Heart Rate Response During Treadmill Exercise Echocardiography:A Double‐Blind Randomized Pilot Study
Authors: JOST CHRISTINE H. ATTENHOFER , PELLIKKA PATRICIA A. , McCULLY ROBERT B. , ROGER VERONIQUE L. , OH JAE K. , HEPNER ANNE M. , SEWARD JAMES B.
Published: December 2007

We evaluated the effect of atropine on the heart rate (HR) response during treadmill exercise echocardiography. A potential limitation of treadmill exercise echocardiography is the requirement for postexercise imaging. Rapid recovery of HR and wall motion abnormalities may decrease test sensitivity. A double‐blind randomized study was performed at a tertiary care center. Fifty‐two patients (age, 63 ± 9 years) with known or suspected coronary artery disease were injected with either 0.5 mg of atropine or saline before treadmill exercise echocardiography. HR response during and after exercise was recorded. Atropine resulted in a greater increase in HR before exercise (increase of 15 ± 9vs 5 ± 7 beats per minute, P < 0.0001) and a higher HR rate during the first 5 minutes of exercise (P < 0.05). In recovery, there was an exponential decrease in HR in both atropine and control groups. However, at the end of image acquisition (66 ± 15 seconds), the HR was higher in the atropine group (128 ± 21 vs 115 ± 19 beats per minute, P = 0.02) and remained higher throughout the 10‐minute recovery period (P = 0.0015). Dry mouth was more common after atropine injection (P = 0.005); other side effects were similar. The extent and resolution of myocardial ischemia were comparable in both groups. Atropine injection before treadmill exercise echocardiography results in a higher HR during the acquisition of echocardiographic images; whether atropine could affect the diagnostic accuracy of tread mill exercise echocardiography requires further study.
Enhanced Detection of Ischemic Myocardium by Transesophageal Dobutamine Stress Echocardiography: Comparison with Simultaneous Transthoracic Echocardiography
Authors: CHAUDHRY FAROOQ A. , TAUKE JASON T. , ALESSANDRINI RENATO S. , GREENFIELD STUART A. , TOMMASO CARL L. , BONOW ROBERT O.
Published: December 2007

The diagnostic accuracy of dobutamine stress echocardiography is limited in patients with poor transthoracic acoustic windows. Transesophageal echocardiography (TEE) overcomes these limitations and thus may increase the clinical usefulness of dobutamine stress echocardiography. The present study was designed to compare the diagnostic accuracies of transesophageal and transthoracic dobutamine stress echocardiography for the identification of coronary artery disease (CAD) in a cohort of patients with a higher incidence of poor acoustic windows. Forty‐two male patients (mean age, 66 ± 9 years) underwent dobutamine stress echocardiography with simultaneous transesophageal and transthoracic imaging. Coronary arteriography was performed in 28 patients (67%). Transesophageal imaging adequately visualized 99.6% of left ventricular segments compared with 76.2% visualized by transthoracic imaging (P< 0.0001). There was substantial agreement between the two techniques for segmental wall motion analysis at baseline (kappa 0.76; 95% CI, 0.70–0.82); however, at peak dobutamine dose, agreement was significantly reduced (kappa 0.62; 95% CI, 0.55–0.69). The sensitivity (88% vs 75%), specificity (100% vs 75%), and positive predictive value (100% vs 80%) for the identification of CAD were all superior for transesophageal imaging. Transesophageal imaging correctly identified 11 of the 12 patients (92%) with multivessel disease compared with 5 patients (42%) identified by transthoracic imaging (P< 0.03). There were no major complications. Transesophageal dobutamine stress echocardiography is a safe, feasible, and accurate technique for the identification and risk stratification of patients with CAD. Transesophageal imaging appears to be superior to transthoracic imaging for identifying both the presence and extent of CAD, specifically in patients with poor acoustic windows.
Transesophageal Echocardiographic Identification of a Descending Aortic Aneurysm Rupture into the Left Lung
Authors: AALURI SRINIVASA R. , MILLER ANDREW , NANDA NAVIN C. , MUKHTAR OSMAN , ANSINGKAR KAMLESH , HUANG WEN YING , PURI VIRENDER , BERLAND LINCOLN L. , MCGIFFIN DAVID C.
Published: December 2007

This case report describes a patient in whom a descending aortic aneurysm ruptured into the left lung, producing hemoptysis. With transesophageal echocardiography, we were able to define the site and extent of the aneurysm, as well as the two sites of rupture into lung tissue.
Mitral Regurgitation: Comprehensive Assessment by Echocardiography
Authors: PATEL AYAN R. , MOCHIZUKI YUKA , YAO JIEFEN , PANDIAN NATESA G.
Published: December 2007

Two‐dimensional and Doppler echocardiography have become the major modalities for the assessment of mitral regurgitation. The combined use of these techniques provides information regarding the morphology of the valvular apparatus as well as the severity of regurgitation. Transesophageal and three‐dimensional echocardiography provide a more‐detailed evaluation of valve morphology, which can be valuable in determining suitability for valve repair. In patients with severe mitral regurgitation, echocardiographic assessment of ventricular size and function plays a critical role in determining the optimal timing of surgery.
Aortic Regurgitation: Quantitative Methods by Echocardiography
Authors: EKERY DEBORAH L. , DAVIDOFF RAVIN
Published: December 2007

Quantification of aortic regurgitation (AR) is a common and difficult clinical problem. The severity of regurgitation has traditionally been estimated with the use of contrast aortography, which is impractical as a screening tool or for serial examinations. In the past two decades, Doppler echocardiography has emerged as an important tool in the quantification ofAR. Pulsed Doppler mapping of the depth of the regurgitant jet into the left ventricle was one of the initial echocardiography methods used for this purpose. The slope and pressure (or velocity) half‐time of continuous‐wave Doppler profiles of regurgitant jets are also useful. These Doppler techniques may be used to determine the regurgitant volume or regurgitant fraction in patients with AR. The use of color Doppler to measure the height (or cross‐sectional area) of the regurgitant jet relative to the height (cross‐sectional area) of the left ventricular outflow tract is both sensitive and specific in the quantification of AR. More recently, the continuity principle has been used to determine the effective aortic regurgitant orifice area, which increases as AR becomes more severe. Although this is a promising tool, calculation of this value is not yet common practice in most echocardiography laboratories. Although no single echocardiographic technique is without limitations, all have some validity, and it is reasonable to use a combination of them to obtain a composite estimate of the severity ofAR.
Reliability of Intraoperative Transesophageal Echocardiography During Tetralogy of Fallot Repair
Authors: JOYCE JAMES J. , HWANG EUGENE Y. , WILES HENRY B. , KLINE CHARLES H. , BRADLEY SCOTT M. , CRAWFORD FRED A.
Published: December 2007

There is limited information available concerning the accuracy of intraoperative transesophageal echocardiography (TEE) in predicting the extent of residual abnormalities after recovery from surgical repair of tetralogy of Fallot. Therefore, we investigated differences between the results of final postbypass TEE and those of postrecovery (mean, 6 days after surgery) transthoracic echocardiography in a total of 28 consecutive pediatric patients who underwent repair of tetralogy of Fallot with biplane or multiplane TEE. Both postbypass and postrecovery echocardiographic examinations included measurements of the right ventricle (RV)‐main pulmonary artery (PA) and the main PA‐branch PA peak instantaneous gradients, the degree of pulmonary valvar insufficiency, and color Doppler interrogation of the ventricular septum for residual defects. The RV‐main PA gradient did not change significantly: 15 ± 13 vs 18 ± 14 mmHg (postbypass versus postrecovery, mean ± SD). None of the patients had a decrease of ≥ 10 mmHg; and only one patient had an increase of ≥: 15 mmHg. There also was no change in the degree of pulmonary insufficiency (3.0 ±1.2 versus 3.1 ± 1.1, using a scale of 0 to 4). Only one of the seven very small (≤ 2 mm) residual ventricular septal defects was not discovered during postbypass TEE. However, postrecovery transthoracic echocardiography detected significant branch PA stenosis (peak gradient, ≥ 15 mmHg) in five patients (18%) that was not detected during postbypass TEE (P < 0.03). Of the branch PA stenoses that were not detected during TEE, four were left and one was right. Conclusions: Postbypass TEE after tetralogy of Fallot repair reliably predicts residual postrecovery hemodynamic abnormalities, except for branch PA stenosis.
Two‐Dimensional Color Doppler Echocardiography Imaging of a Gerbode Defect: A Case Report
Authors: ERDÖL CEVDET , GÖKÇE MUSTAFA , ÇELIK SLÜKRÜ , BAYKAN MERIH , ÖREM CIHAN , BAYRAM ALI
Published: December 2007

A Gerbode defect is a ventricular septal defect that communicates directly between the left ventricle and the right atrium. The pathology may be due to a congenital defect, can result from trauma, or can occur after endocarditis or aortic valve replacement. We report the case of a 20‐year‐old man who has a defect between the left ventricle and the right atrium (Gerbode defect) that was diagnosed with two‐dimensional color Doppler echocardiography.
Aortic Dissection with Fistula to Right Atrium After Heart Transplantation: Diagnosis by Transthoracic and Transesophageal Echocardiography
Authors: CARUSO AURELIO , IARUSSI DIANA , MATERAZZI CRESCENZO , DIALETTO GIOVANNI , COVINO FRANCO , BOSSONE EDUARDO , COTRUFO MAURIZIO
Published: December 2007

Aortic dissection with rupture into the right atrium is an extremely rare and rapidly fatal condition that may occur after cardiac surgery. We report the case of a 59‐year‐old woman with a 6‐year history of heart transplantation who presented with subacute illness characterized by chest pain and severe cardiac decompensation accompanied by a continuous murmur in the precordium. The diagnosis of aortic dissection complicated by right atrial fistula was made by the combination of transthoracic and transesophageal echocardiographic examination.
Echocardiography Diagnosis of a Stenotic Double Orifice Parachute Mitral Valve with a Single Papillary Muscle
Authors: YESILBURSA DILEK , MILLER ANDREW , NANDA NAVIN C. , MUKHTAR OSMAN , HUANG WEN YING , ANSINGKAR KAMLESH , PURI VIRENDER , BOURGE ROBERT C. , HSIUNG MING , McGIFFIN DAVID C.
Published: December 2007

We present the case of a patient with a single papillary muscle that is supporting both orifices of a stenotic double orifice mitral valve. With the use of both transthoracic and transesophageal echocardiography, we were able to prospectively define this entity, which was confirmed at surgery.
Role of Transthoracic Echocardiography in Atrial Fibrillation
Authors: ASINGER RICHARD W.
Published: December 2007

Atrial fibrillation is a major clinical problem that is predicted to be encountered more frequently as the population ages. The clinical management of atrial fibrillation has become increasingly complex as new therapies and strategies have become available for ventricular rate control, conversion to sinus rhythm, maintenance of sinus rhythm, and prevention of thromboembolism. Clinical and transthoracic echocardiographic features are important in determining etiology and directing therapy for atrial fibrillation. Left atrial size, left ventricular wall thickness, and left ventricular function have independent predictive value for determining the risk of developing atrial fibrillation. Left atrial size may have predictive value in determining the success of cardioversion and maintaining sinus rhythm in selected clinical settings but has less value in the most frequently encountered group, patients with nonvalvular atrial fibrillation, in whom the duration of atrial fibrillation is the most important feature. When selecting pharmacological agents to control ventricular rate, convert to sinus rhythm, and maintain normal sinus rhythm, transthoracic echocardiography (TTE) allows noninvasive evaluation of left ventricular function and hence guides management. The combination of clinical and transthoracic echocardiographic features also allows risk stratification for thromboembolism and hemorrhagic complications in atrial fibrillation. High‐risk clinical features for thromboembolism supported by epidemiological observations, results of randomized clinical trials, and meta‐analyses include rheumatic valvular heart disease, prior thromboembolism, congestive heart failure, hypertension, older (> 75 years old) women, and diabetes. Small series of cases also suggest those with hyperthyroidism and hypertrophic cardiomyopathy are at high risk. TTE plays a unique role in confirming or discovering high‐risk features such as rheumatic valvular disease, hypertrophic cardiomyopathy, and decreased left ventricular function. Validation of the risk stratification scheme used in the Stroke Prevention in Atrial Fibrillation‐III trial is welcomed by clinicians who are faced daily with balancing the benefit and risks of anticoagulation to prevent thromboembolism inpatients with atrial fibrillation.
Transesophageal Echocardiography‐Guided Cardioversion of Atrial Fibrillation
Authors: GRIMM RICHARD A.
Published: December 2007

Transesophageal echocardiography‐guided anticoagulation management of patients with atrial fibrillation undergoing cardioversion has evolved over the past decade as a viable alternative to conventional anticoagulation management. Its use grew out of a need for a more predictable, dependable, and convenient approach to this difficult management dilemma, which has become increasingly prevalent in practice as an increasing number of patients present to clinics and hospitals with atrial fibrillation. In addition to its use in risk stratification of patients scheduled to undergo cardioversion, this management strategy allows for early cardioversion, which enables a minimal delay in proceeding from the diagnosis to the institution of therapy (electrical cardioversion). This review explores the evolution of the transesophageal echocardiography‐guided strategy, the advantages and disadvantages of its use, and possible modifications to the strategy that would allow for a more convenient, practical, and more widely acceptable approach in the near future.
Risk of Thromboembolism in Acute Atrial Fibrillation or Atrial Flutter
Authors: STODDARD MARCUS F.
Published: December 2007

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia, predominating in the elderly, with stroke as a potentially devastating complication. Prevention of the thromboembolic sequelae from AF remains a central focus of practicing clinicians. Although the risk of thromboembolism in chronic AF is well recognized, less is known about the potential risk of systemic embolism in acute AF. In addition, recent data support the notion of a group at considerable risk of embolism from atrial flutter, an arrhythmia typically believed to bestow little increased risk of thromboembolism. The mechanism of thrombus formation, embolization, and resolution in atrial arrhythmias is not well defined, particularly in that of acute AF or atrial flutter. The traditional concept proposes that atrial thrombus forms only after > 2 days ofAF and embolizes by being dislodged from increases in shear forces. This widely accepted concept further holds that newly formed atrial thrombus, in the setting of AF, organizes over a span of 14 days. The results of studies based on observations from transesophageal echocardiography examinations have provided provocative insight into the temporal sequence of atrial thrombus formation, embolization, and resolution in AF or atrial flutter and have expanded the traditional concept of thromboembolism in these atrial dysrhythmias. Namely, left atrial thrombus may form before the onset ofAF in the face of sinus rhythm. Conversion to sinus rhythm may increase the thrombogenic milieu of the left atrium. Importantly, atrial thrombus may form in the acute phase ofAF. Last, thrombi may require > 14 days to become immobile or to resolve. Findings similar to those of acute AF have been reported in patients with atrial flutter and coexisting cardiac pathology. On the basis of these emerging insights fostered by the use of transesophageal echocardiography, it appears appropriate to consider anticoagulation in patients presenting with acute AF or atrial flutter with coexisting cardiac pathology predisposing to left atrial thrombus.
Economic Aspects of Transesophageal Echocardiography and Atrial Fibrillation
Authors: BECKER EDMUND R. , CULLER STEVEN D. , SHAW LESLEE J. , WEINTRAUB WILLIAM S.
Published: December 2007

Cardiovascular disease is the leading cause of complications and death in the United States, affecting nearly 60 million Americans in 1998 and costing an estimated $274.2 billion. A major contributor to the costs of cardiovascular disease is atrial fibrillation (AF). AF is the most common sustained arrhythmia and affects > 2.2 million people and ˜ 5% of all persons over the age of 60. Transesophageal echocardiography (TEE) with short‐term anticoagulation has been proposed as a viable strategy to guide patients with AF. Here, we (1) review the current environmental context for a TEE‐guided approach, (2) summarize the existing literature on the economic aspects of TEE, and (3) outline an economic framework for an economic analysis of TEE investigation or any major clinical therapy. We conclude that more powerful analytical tools are evolving to analyze the important economic, clinical, and social aspects of a patient's medical encounter.
Prognostic Value of 12‐Lead Electrocardiogram During Dobutamine Stress Echocardiography
Authors: Dhond Milind R. , Nguyen Thanh , Whitley Teresa B. , Donnell Kristi , Bommer William J.
Published: December 2007

The aim of this study was to assess the prognostic value of the 12‐lead electrocardiogram (ECG) obtained during dobutamine stress echocardiography (DSE) in predicting subsequent cardiac events. We retrospectively analyzed 345 patients undergoing DSE in 1992–1994 and selected those patients with negative echo results for ischemia. Of the 200 patients with negative DSE results, a separate analysis of their ECG data was performed with results reported as either positive, negative, or nondiagnostic for ischemia. Follow‐up was performed through a physician chart review and direct telephone contact. Event rates were determined for hard (myocardial infarction or cardiac death) and soft (hospitalization for angina and/or congestive heart failure, coronary angioplasty, or coronary artery bypass graft surgery) cardiac events occurring after the negative DSE for up to 6 years after the test. Death was also determined by referencing the patients' data with mortality data available on the Internet. There were 143 patients with ECG data reported as negative and 40 patients with ECG data reported as positive for ischemia. The hard and soft event rates were 1.5% and 9% per patient per year in the ECG negative group and 2% and 11% in the ECG positive group. There were no statistical differences in event rates between the two groups during the 5‐year follow‐up period. Our results suggest that the ECG result obtained during DSE does not confer any incremental prognostic value over the echo result.
Measurement of Left Ventricular Volumes and Ejection Fraction After Intravenous Contrast Agent Administration Using Standard Echocardiography Equipment
Authors: Nagy AndráSs , Borbás Sarolta , Lengyel Mária
Published: December 2007

The enhancement of endocardial border delineation using second harmonic imaging and contrast administration improves the measurement of ventricular volumes. In the majority of existing echocardiography equipment, however, harmonic imaging is not yet available. The aim of this study was to assess the feasibility of the measurement of left ventricular volumes and ejection fraction after intravenous administration of the contrast agent Levovist using standard echocardiography equipment and fundamental imaging modality. In 10 patients with good‐quality two‐dimensional echo imaging, 4 g (400 mg/mL concentration) of Levovist was injected intravenously. Hewlett‐Packard Sonos 2000 ultrasound equipment without second harmonic imaging capability was used. To avoid the destruction of microbubbles, the echo machine was set to produce only one end‐systolic and one end‐diastolic frame in each cardiac cycle (dual triggering). Native and contrast imaging measurements of left ventricular volumes and ejection fractions calculated by modified Simpson's rule were compared in the fundamental mode. Intraobserver and interobserver variability values were assessed. End‐diastolic volumes in native continuous and triggered mode and by contrast echo were 126 ± 48, 121 ± 46, and 130 ± 50 mL, respectively (NS), whereas end‐systolic volumes were 79 ± 48, 76 ± 45, and 79 ± 46 mL, respectively (NS). Calculated ejection fraction using the three different imaging modalities were 0.41 ± 0.16, 0.41 ± 0.16, and 0.42 ± 0.16 (NS). The intraobserver and interobserver reproducibility values were excellent in triggered mode. Standard echocardiographic equipment with fundamental imaging modality in the triggered mode is suitable for the measurement of left ventricular volumes after intravenous Levovist administration. In clinically difficult patients, contrast echocardiography in triggered mode may be applied even if echocardiographic equipment does not have harmonic imaging possibility.
Left Circumflex Coronary Artery‐to‐Left Atrium Fistulas Detected by Transesophageal Echocardiography in Heart Transplant Recipients
Authors: Gascueña Raül , Fernández Sagrario , Delgado Juan , Gömez Miguel Angel , de Lombera Federico , Santos Miguel , Escribano Pilar
Published: December 2007

Coronary fistulas are uncommon after heart transplantation. We report two cases of fistulas from an atrial branch of the circumflex coronary artery to the left atrium after heart transplantation. This has not been previously reported in the literature. They were detected with transesophageal echocardiography, and images are shown for the first time. Transesophageal echocardiography may be useful in the follow‐up of heart transplant recipients.
A Technique for Performing Transesophageal Echocardiography in Patients with Zenker's Diverticulum
Authors: Wells Gretchen L. , Gilliam John , Kitzman Dalane W.
Published: December 2007

A patient with a large Zenker's diverticulum and narrow, angulated passageway successfully underwent transesophageal echocardiography using a pediatric endoscope, short esophageal over‐tube, and a pediatric transesophageal echocardiographic probe.
Assessment of Myocardial Perfusion by Power Contrast Imaging Using a New Echo Contrast Agent
Authors: Nanda Navin C. , Miller Andrew , Puri Virender K. , Fan PoHoey , Tiemann Klaus , Becher Harold , Main Joan , Batra Sanjay
Published: December 2007

In a patient with previously documented myocardial infarction, we assessed myocardial perfusion by using power contrast imaging and a newer intravenous echo contrast agent. The images were captured and stored digitally, and various image processing algorithms were used to assess myocardial perfusion. An apical perfusion defect was clearly visualized, and it correlated with radionuclide findings.
Diagnostic and Prognostic Use of Stress Echocardiography in Stable Patients
Authors: Smart Steven C. , Sagar Kiran B.
Published: December 2007

Stress echocardiography is an effective diagnostic and prognostic technique in stable patients with known or suspected coronary artery disease (CAD), myocardial infarction, or chronic left ventricular dysfunction and those undergoing noncardiac surgery. Stress echocardiography is sensitive and specific for the detection and extent of CAD. Negative tests confer a high negative predictive value for cardiac events regardless of the clinical risk. Positive studies confer a high positive predictive value for ischemic events in patients with intermediate to high clinical risk. Stress echocardiography provides incremental prognostic information relative to clinical, resting echocardiographic, and angiographic data. Meta‐analysis studies have shown that the diagnostic and prognostic information provided by stress echocardiography is comparable to that from radionuclide scintigraphic stress tests. Stress echocardiography may be more specific for the detection and extent of CAD, whereas radionuclide scintigraphy may be more sensitive for one‐vessel disease. Sensitivities are similar for the detection and extent of disease in patients with multivessel CAD.
The Role of Stress Echocardiography in Children
Authors: Pahl Elfriede , Duffy C. Elise , Chaudhry Farooq A.
Published: December 2007

Exercise and pharmacological stress echocardiography are well‐accepted techniques of evaluating coronary artery disease in adults. In children, however, experience with stress echocardiography is limited and continues to evolve. The objective of this focused review was to describe the experience with exercise and dobutamine stress echocardiography in the pediatric population, with an emphasis on technique, current indications, and future directions. Experience is reported in children with prior Kawasaki disease or heart transplant recipients, as well as patients with congenital coronary abnormalities. In addition, stress echocardiography has been used in patients who have undergone coronary artery bypass graft surgery to evaluate short‐ and long‐term graft patterning. Stress echocardiography appears to be a feasible, safe, and useful modality for the noninvasive assessment of flow‐limiting stenosis in the pediatric population and can be used serially in the routine follow‐up and risk stratification in children at risk for coronary events.
Contrast Echocardiography: Clinical Utility
Authors: Maurer Gerald
Published: December 2007

This article reviews the advances made by the echocardiography contrast agents from their first appearance in the early 1970s with homemade preparations up to the new generation of transpul‐monary contrast agents made of small microbubbles capable of transversing the lung's capillary bed. The great progress in contrast agent development has kept pace with the progress made by echocar‐diographic equipment, thus making the study of myocardial perfusion in the clinical settings a near‐future reality. This article also discusses the medical need that myocardial contrast echo has the potential to satisfy.