Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection

BACKGROUND

Acute aortic dissection is a cardiovascular emergency that requires prompt diagnosis and treatment. Transesophageal echocardiography is the current standard diagnostic imaging modality in many medical centers. Aortic intramural hematoma is a variant of aortic dissection whose natural history and prognosis have not been well studied. We performed transesophageal echocardiography in patients with aortic intramural hematoma to determine the echocardiographic characteristics and echocardiographic evolution of this lesion, impact on patient management, and patient outcome.

METHODS AND RESULTS

Twenty-one consecutive patients with aortic intramural hematoma confirmed anatomically (four patients) or with an additional diagnostic imaging technique (17 patients) underwent a transesophageal echocardiographic examination. Fifteen patients with longstanding hypertension had chest or back pain, and the intramural hematoma was visualized in the ascending aorta (n = 4), along the whole aorta (n = 4), in the descending aorta (n = 6), or in the aortic arch (n = 1). The thickening of the aortic wall was crescentic. Patients with ascending aortic intramural hematoma had the following results: two patients died suddenly, three patients underwent surgery because of increased aortic wall thickening (one patient) or secondary intimal tear (two patients), and the remaining three patients had regression of the hematoma. Patients with hematoma confined to the descending aorta and the patient with aortic arch involvement (n = 7) had a different result: one patient died from aortic rupture and the remaining six patients did well. Six patients had a traumatic aortic injury, and the intramural hematoma was located along the descending thoracic aorta. The thickening of the aortic wall was circular in five patients and crescentic in one. Three of these patients had normalized thickness of the aortic wall on follow-up transesophageal echocardiographic studies. The other three patients died from multiorgan system failure. Aortography showed a reduction of the diameter of the aortic lumen in four patients; diameter in the remaining 17 patients was normal.

CONCLUSIONS

Aortic intramural hematoma can be detected and monitored by transesophageal echocardiography but not by aortography. Two types of aortic intramural hematoma can be distinguished: (1) traumatic of good prognosis and (2) nontraumatic, which can be an early stage of the classic aortic dissection, with bad prognosis in cases involving the ascending aorta.

Right ventricular asynergy during dobutamine-atropine echocardiography

OBJECTIVES

We sought to analyze right ventricular contractility during dobutamine infusion in patients with right coronary artery disease and to elucidate whether the development of right ventricular asynergy aids in characterizing a right coronary artery stenosis.

BACKGROUND

Clinical investigations are emphasizing the importance of right ventricular function in patients with coronary artery disease. Thus, prognosis of patients with inferior myocardial infarction is influenced by right ventricular function. This study describes the echocardiographic and electrocardiographic findings during dobutamine-atropine echocardiography in patients with right coronary artery disease.

METHODS

We studied 31 patients with isolated right coronary artery disease and no previous myocardial infarction. Six patients with poor acoustic window were excluded (feasibility 80%). The remaining 25 patients underwent dobutamine-atropine echocardiography. A right coronary artery stenosis located before the origin of the right ventricular branches was considered proximal; otherwise, it was considered distal.

RESULTS

Right ventricular asynergy during dobutamine-atropine testing developed in 17 patients (sensitivity 68%); 14 had proximal and 3 had distal right coronary artery disease. The following segments were involved: inferior (n = 17), lateral (n = 5) and outflow tract (n = 1). No patient showed anterior asynergy. All 17 patients had left ventricular asynergy as well. Ischemia-free time was 10.7 +/- 6.2 (mean +/- SD) min for the right ventricle and 8.9 +/- 5.2 min for the left ventricle (p < 0.05). Ischemic ST changes were recorded in 15 patients (in standard leads in 14 and in right precordial leads in 8). All patients with right precordial changes showed ST elevation and had right ventricular asynergy (sensitivity and specificity for right ventricular asynergy 47% and 100%, respectively). A control group of 25 patients with no right coronary artery disease (5 with no disease, 15 with left anterior descending and 5 with left circumflex coronary artery disease) underwent dobutamine echocardiography. Right ventricular asynergy developed in two patients with left anterior descending artery stenosis (specificity 92%); in both, the anterior wall was affected.

CONCLUSIONS

Echocardiography during dobutamine infusion is a reliable technique for assessing right ventricular dysfunction in patients with right coronary artery disease. Right ventricular contractility can be assessed during dobutamine echocardiography in selected patients.

[A non-invasive test choice for the diagnosis of coronary disease in women]

BACKGROUND AND PURPOSE

Regarding coronary heart disease, women have often been excluded from clinical trials. Current practical recommendations are thus based on studies in men. To identify the non invasive technique of choice in detecting coronary artery disease in women, a study with different diagnostic tests has been undertaken.

METHODS

Exercise stress test, dipyridamole echocardiography (0.84 mg/kg), dobutamine echocardiography (up to a total dose of 40 micrograms/kg per minute and atropine if necessary), MIBI-SPECT during dobutamine infusion and coronary angiography, were performed in 40 consecutive women with chest pain and no previous history of coronary artery disease.

RESULTS

The four tests had similar sensitivity: exercise stress test (80%; CI 95%, 52-94), dipyridamole echocardiography (80%; CI 95%, 56-93), dobutamine echocardiography (80%; CI 95%, 56-93) and scintigraphy MIBI-SPECT (85%; CI 95%, 61-95). The specificity of dipyridamole echocardiography (100%; CI 95%, 83-100) and dobutamine echocardiography (90%; CI 95%, 67-98) was higher than that of exercise stress test (50%; CI 95%, 22-78) and MIBI-SPECT (65%; CI 95%, 41-84). The positive predictive values of dipyridamole and dobutamine echocardiography were 100% and 88% respectively.

CONCLUSIONS

The feasibility of exercise stress test in women is inferior to that of the other techniques. The sensitivity of the four tests to diagnose coronary artery disease is similar. The specificity of dipyridamole echocardiography and dobutamine echocardiography is higher than that of exercise stress test and MIBI-SPECT. Stress echocardiography can be considered the non invasive technique of choice for diagnosing coronary artery disease in women.

Dipyridamole and dobutamine-atropine stress echocardiography in the diagnosis of coronary artery disease. Comparison with exercise stress test, analysis of agreement, and impact of antianginal treatment

STUDY OBJECTIVES

To compare the usefulness of dipyridamole echocardiography, dobutamine-atropine echocardiography, and exercise stress testing in the diagnosis of coronary artery disease and to analyze the agreement among the tests.

DESIGN

Performance of these three tests in random order on a consecutive cohort of patients.

SETTING

A tertiary care and university center.

PATIENTS

One hundred two consecutive patients with chest pain and no history of coronary artery disease.

INTERVENTIONS

Dipyridamole echocardiography, dobutamine-atropine echocardiography, exercise stress testing, and coronary angiography.

MEASUREMENTS AND RESULTS

Dobutamine-atropine test was positive in 49 (77%) of 63 patients with coronary artery disease, dipyridamole test in 49 (77%), and exercise stress test in 44 (68%; p = NS). Both echocardiographic tests showed an overall specificity (dipyridamole, 97%; dobutamine, 95%) higher than exercise stress test (79%; p < 0.05). Sensitivity of dipyridamole testing decreased from 93 to 61% (p = 0.002) if patients were receiving antianginal treatment but sensitivity of dobutamine-atropine testing was not affected (77% in patients receiving and not receiving treatment). When results were considered as positive-negative, agreement between dipyridamole and dobutamine-atropine echocardiography was 85% (kappa = 0.70). With regards to regional analysis, concordance was good (93% for segments, kappa = 0.76; and 95% for coronary arteries, kappa = 0.92). Major complications were more frequent during dobutamine-atropine (n = 7) than during dipyridamole infusion (n = 2) (p = 0.06).

CONCLUSIONS

Dobutamine-atropine and dipyridamole echocardiography have a similar sensitivity and a higher specificity than that obtained by exercise ECG for the diagnosis of coronary artery disease. Similar information is obtained with dipyridamole and dobutamine-atropine echocardiography. It is our thought that pharmacologic stress echocardiography should be used as a first-step test to rule out coronary artery disease in patients not capable of exercising.

[Echocardiography with dobutamine in hypertensive patients with chest pain]

INTRODUCTION

The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease.

PURPOSE

Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients.

MATERIAL AND METHODS

Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease.

RESULTS

Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005).

CONCLUSIONS

Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.

Transesophageal echocardiographic assessment of papillary muscle rupture

BACKGROUND

In some patients with papillary muscle rupture, the ruptured head may not prolapse into the left atrium, which makes diagnosis by transthoracic or transesophageal echocardiography difficult.

METHODS AND RESULTS

In an attempt to find additional or more definite diagnostic echocardiographic features, we analyzed intraoperative transesophageal echocardiograms of 21 consecutive patients with papillary muscle rupture (20 involved the left ventricle and 1 involved the right ventricle) confirmed at surgery. In 7 (35%) of 20 patients with left ventricular papillary muscle rupture, the ruptured head was not seen to prolapse into the left atrium. In these patients, examination of the left ventricle proved most useful. Abnormal, large-amplitude erratic motion (1 to 5 cm in 17 patients; 0.5 cm in 1 patient) of a large echo density in the left ventricle consistent with the ruptured head was noted in 18 (90%) of these 20 patients. This included all 7 patients with non-prolapse of the ruptured papillary muscle head into the left atrium. Less prominent erratic motion or flutter of the papillary muscle still attached to the left ventricular wall was also noted but was less sensitive in the diagnosis of papillary muscle rupture. The single patient with right ventricular papillary muscle rupture showed erratic motion as well as prolapse of the ruptured head into the right atrium.

CONCLUSIONS

Transesophageal echocardiographic examination of the left ventricle is useful in the diagnosis of papillary muscle rupture, especially in those patients in whom the ruptured head does not prolapse into the left atrium. The left ventricle should be scrutinized thoroughly during transesophageal echocardiographic examination for erratic papillary muscle motion in all patients with suspected rupture.

Myocardial Stunning and Unique ECG Changes Associated with Dobutamine Stress Echocardiography

The clinical, electrocardiographic, and echocardiographic changes associated with myocardial stunning during dobutamine stress echocardiography in a patient with severe left main coronary artery disease are presented. (ECHOCARDIOGRAPHY, Volume 13, July 1996)

Impact of Beta Blockers on Dobutamine-Atropine Stress Echocardiography

Dobutamine increases oxygen demand in the myocardium and is used in conjunction with echocardiography to detect coronary artery disease. Beta blockers (BB) are partial antagonists of dobutamine and, therefore, offset dobutamine effects. Still, the impact of BB therapy on dobutamine stress echocardiography is not clear. One hundred forty-one dobutamine-atropine echocardiographic studies have retrospectively been analyzed: 27 patients were on BB (19%; group I); and 114 off BB (81%; group II). Coronary angiography was performed in a similar percentage of patients (97% and 85%, respectively; P = NS). No differences in clinical and angiographic profile were found between the groups. Sensitivity (83% vs 71%; P = NS) and specificity (100% vs 95%; P = NS) for coronary artery disease were similar in both groups. Atropine was infused more frequently to patients from group I (67% vs 46%; P = 0.04). Limiting side effects and prolonged ischemia presented with the same frequency in both groups. When the dobutamine test was positive, severe extent of ischemia appeared more often in patients from group I than in patients from group II (66% vs 33%; P = 0.03). The majority of patients from group I (55%) with severe extent of ischemia and only 12% from group II received atropine (P = 0.02). No differences were found in dobutamine time and extent of ischemia in patients from group I who had a positive response to dobutamine. On the contrary, patients from group II with one vessel disease had a dobutamine time longer (10.5 +/- 3.8 vs 7.8 +/- 3.7 min; P < 0.05) and extent of ischemia smaller (1.8 +/- 0.4 vs 2.6 +/- 0.5 segments; P < 0.05) than patients from group II with multivessel disease. We conclude that: 1) sensitivity of dobutamine-atropine echocardiography for diagnosis of coronary artery disease remains even if patients are on BB; 2) patients with significant coronary artery disease who are taking BB often develop severe myocardial ischemia during dobutamine-atropine stress echocardiography; and 3) BB therapy precludes stratification of a positive echocardiographic response. These conclusions should be confirmed in a prospective study to be considered as definitive. (ECHOCARDIOGRAPHY, Volume 13, July 1996)

[Identification of intramural aortic hematoma by transesophageal echocardiography]

BACKGROUND AND AIM

The usefulness of transesophageal echocardiography in the diagnosis and assessment of patients with aortic dissection has been widely demonstrated. The aim of this study was to evaluate the role of this technique in the detection of intramural aortic hematoma and in the follow-up of these patients.

METHODS

The records of 51 patients with aortic dissection by transesophageal echocardiography diagnosed between May 1990 and May 1994 were reviewed.

RESULTS

The diagnosis of intramural aortic hematoma was established in 6 patients by transesophageal echocardiography (11%). This diagnosis was confirmed either anatomically (3 patients) or with an additional diagnostic technique (computed tomography or magnetic resonance imaging) and on the basis of echocardiographic follow-up changes (3 patients).

CONCLUSIONS

Intramural aortic hematoma represents an infrequent variant of aortic dissection that can be detected by transesophageal echocardiography and is usually unrecognized by aortography.

[Aortic intramural hematoma and penetrating aortic ulcer]

Two poor-defined acute aortic syndromes (intramural aortic hematoma and penetrating aortic ulcer) that must be distinguished from the classic dissection are reviewed in this article. Based on the literature and our own experience we describe the clinical characteristics, diagnostic aspects and treatment.

[Echocardiography and aortic dissection]

Echocardiography is the technique most used in the diagnosis of aortic dissection. In this article the echocardiographic signs of aortic dissection are described. The following issues regarding the usefulness of echocardiography in aortic dissection are reviewed as well: detection of entry site, distinction between false and true lumen, assessment of aortic regurgitation, ventricular function, aortic branches involvement, pericardial effusion and follow-up.

[Aortic dissection: clinical evaluation, comparison of diagnostic techniques and treatment election]

Aortic dissection is a life-threatening disease with a high mortality in the first hours. The diagnosis must be established as promptly as possible and a high index of suspicion is needed. Then, a thorough evaluation of the patient is necessary for an adequate clinical decision making. In this article, the definition, classification, predisposing factors, clinical signs and symptoms, diagnostic methods and treatment are reviewed.

Role of transesophageal echocardiography in right-sided endocarditis

Investigations performed over the last few years support the invaluable usefulness of transesophageal echocardiography in the diagnosis of left-sided endocarditis. Whether this can be applied to right-sided endocarditis remains speculative. Patients at risk of having right-sided endocarditis can be classified into three different and well-defined groups: (1) intravenous drug abusers; (2) patients with pacemakers; and (3) patients with congenital heart diseases. In this article, we review the different value of transesophageal echocardiography in right-sided endocarditis depending on the subset of patients considered.

Complementary role of MRI in infectious endocarditis

The usefulness of magnetic resonance for imaging of cardiac structures is well established. In this study, we evaluated the role of this technique in the diagnosis of perivalvular extension of infectious endocarditis. Our initial experience and the few case reports in the literature show that magnetic resonance imaging can complement echocardiography in the assessment of periannular extension of infectious endocarditis.

[Echocardiography and MIBI-SPECT scintigraphy during dobutamine infusion in the diagnosis of coronary disease]

BACKGROUND AND PURPOSE

Dobutamine, an adrenergic agonist, has been combined with echocardiography and scintigraphy with MIBI-SPECT to detect coronary artery disease. Our purpose has been to compare echocardiography and MIBI-SPECT scintigraphy during dobutamine infusion for diagnosing coronary artery disease.

METHODS

Both tests and coronary angiography have been performed on 72 consecutive patients with chest pain and no previous history of coronary artery disease. Dobutamine had administered up to 40 micrograms/kg/min. Atropine was given when necessary. MIBI was injected at peak stress. Echocardiographic continuous monitoring and SPECT images were carried out. Positivity was defined as: 1) echocardiographic: wall motion abnormalities of new onset, and 2) scintigraphic: dobutamine-induced perfusion abnormalities.

RESULTS

Coronary artery disease was demonstrated in 49 patients. Echocardiography was positive in 37 of them (sensitivity of 75%) and MIBI-SPECT in 43 (sensitivity of 88%; p = NS). Specificity was higher with echocardiography (22/23, 96%) than with scintigraphy (16/23, 69%, p = 0.02). Accuracy was 82% for both tests. More patients with multivessel disease were detected by scintigraphy (61% versus 35%; p = 0.09). Agreement between tests was as follows: 1) results: 77% (kappa = 0.53); 2) segments: 86% (kappa = 0.65), and 3) artery diseased: 90% (kappa = 0.84).

CONCLUSIONS

Echocardiography and MIBI-SPECT in combination with doubtamine are useful techniques to detect coronary artery disease. Diagnostic accuracy is similar with both tests.

[Cardiac tamponade with the absence of a paradoxical pulse. The practical utility of echocardiography]

A patient with cardiac tamponade but without hypotension and pulsus paradoxus is reported. In this patient, echocardiography confirmed the diagnosis of cardiac tamponade, showing diastolic collapse of the right ventricle and also the presence of an atrial septal defect (ostium secundum) that explains the absence of pulsus paradoxus. The role of echocardiography in those rare clinical situations that in the presence of cardiac tamponade showed no pulsus paradoxus are discussed.

Tuberculous cardiac tamponade and AIDS

Tuberculosis, usually extrapulmonary, is often associated with AIDS but tuberculous pericarditis is a rare manifestation in this group. We report three patients with tuberculous pericarditis as the first manifestation of AIDS.

New echo-anatomical correlations in aortic dissection

Acute dissection of the aorta is a life-threatening condition requiring immediate diagnosis and definitive treatment. Transoesophageal echocardiography may be considered the diagnostic procedure of choice in the assessment of patients with aortic dissection. A detailed morphological and functional study of the aorta must be obtained quickly. This report summarizes the echo-anatomical correlation of two distinct echocardiographic images of patients with aortic dissection.

[The evaluation of the mechanism of mitral bioprosthesis malfunction by transesophageal echocardiography]

OBJECTIVES

The aim of this study was to assess the usefulness of transesophageal echocardiography for detection of the mechanism of dysfunction in bioprosthetic valves in the mitral position.

METHODS

Transthoracic and transesophageal echocardiograms were performed in 40 patients (mean age 61 +/- 12 years) with a dysfunctional bioprosthetic mitral valve. Echocardiographic results were compared to surgical findings in all except 1 patient.

RESULTS

All 9 patients with stenotic degenerated bioprosthesis were diagnosed by transthoracic and transesophageal echocardiography. Mechanism of dysfunction in the remaining patients were as follows: cusp tear or rupture in 18, dehiscence in 4 and endocarditis in 6. Transthoracic and transesophageal echocardiography visualized respectively: 8 (44%) and 15 (83%; p < 0.05) with cusp tears or ruptures; 3 (75%) and 3 (75%) with dehiscence; 3 (50%) and 6 (100%; p < 0.1) with endocarditis. One patient with pannus formation and 1 of 2 bioprosthetic thrombosis were not correctly identified by either echocardiographic technique.

CONCLUSIONS

Transesophageal echocardiography is suited for the assessment of mechanism of mitral regurgitation and for the diagnosis of vegetations in most of patients with bioprosthetic mitral valves. Transesophageal echocardiography adds little information to the transthoracic study in the evaluation of patients with stenotic bioprosthetic mitral valves, particularly in calcified degeneration.

Usefulness of transesophageal echocardiography for diagnosis of infected transvenous permanent pacemakers

BACKGROUND

Transesophageal echocardiography is superior to transthoracic echocardiography in detecting left-sided valvular vegetations. There are no data on the value of transesophageal echocardiography in the diagnosis of infected transvenous permanent pacemakers.

METHODS AND RESULTS

Transthoracic and transesophageal echocardiography was performed in 10 patients for whom there was clinical suspicion of infected permanent transvenous pacemakers. Transthoracic echocardiography detected pacemaker lead vegetations in 2 patients, whereas transesophageal echocardiography visualized pacemaker lead vegetations in 7 patients. Surgical confirmation was obtained in 6 of these 7 patients. Most patients had more than one pacemaker electrode in place. Local complications at the generator pocket were present in 6 patients. Staphylococcus was the predominant causative organism.

CONCLUSIONS

Transesophageal echocardiography is superior to transthoracic echocardiography in the detection of pacemaker lead vegetations.