Left atrial myxoma. Evaluation with transoesophageal echocardiographic and real time three-dimensional imaging

Myxoma is the most common benign cardiac neoplasm. A 66-year-old woman presented with a large left atrial myxoma, which was detected by a real-time three-dimensional echocardiography (RT3DE) and a real-time three-dimensional transoesophageal echocardiography (RT3D-TEE) approach. RT3DE and RT3D-TEE proved to be techniques that can provide additional contributions to the diagnostic investigation of structural heart diseases.

[Tissue doppler for the assessment of LV function--what makes sense?]

Tissue Doppler based velocity and deformation measurements allow the quantitative and thus objective assessment of myocardial function. So far, many techniques and parameters have been developed, most of which require an explanation for the clinical user. This article reviews relevant tissue Doppler parameters and gives examples of the current clinical usage of this technique.

Doppler myocardial imaging in the assessment of regional myocardial function in longitudinal direction pre- and post-PTCA

AIMS

Doppler myocardial imaging is potentially a sensitive tool to assess regional myocardial velocities pre- and post-percutaneous transluminal coronary angioplasty (PTCA) as a marker of contractility to evaluate short- to medium-term information on functional myocardial recovery following the release of ischaemia.

METHODS

Thirty patients with single vessel disease were studied to assess regional myocardial peak systolic velocity, systolic velocity time integral and mitral valve plane excursion in longitudinal direction one day pre-, one day post- and 3 months post-PTCA. The patients were assigned to group A with coronary stenoses >70% and group B with stenoses < 70%.

RESULTS

In group A pre-PTCA the ischaemic segments showed a significantly lower peak systolic velocity and velocity time integral compared with the values one day after PTCA (5.8 +/- 1.4 vs 7.7 +/- 1.4cm.s(-1); 1.06 +/- 0.22 vs 1.23 +/-0.28cm;P< 0.03). In contrast, mitral valve plane excursion in this group remained unchanged after PTCA for both the ischaemic and non-ischaemic left ventricular wall. In group B no changes of these parameters and no differences in mitral valve plane excursion of the ischaemic and the non-ischaemic left ventricular wall could be seen.

CONCLUSION

With Doppler myocardial imaging it was possible to quantify a number of indices which changed due to the successful release of ischaemia.

Changes in ocular blood flow velocities during external counterpulsation in healthy volunteers and patients with atherosclerosis

BACKGROUND

External counterpulsation (ECP) is a new noninvasive means of augmenting organ perfusion by applying ECG-triggered diastolic pressure to the vascular bed of the lower limbs. In this study, effects of ECP on changes of ocular blood flow velocities were studied.

METHOD

Mean, systolic and diastolic flow velocities of the ophthalmic artery were measured by Doppler sonography before and during ECP. Twelve healthy volunteers (age 31.3+/-4.3 years) and 12 patients with severe atherosclerosis (inclusion criteria: two atherosclerotic risk factors, at least one severe coronary stenosis, age 62.1+/-5.3 years) were included in the study.

RESULTS

In healthy subjects, ECP changed diastolic flow velocity of the ophthalmic artery nonsignificantly from 21.6+/-7.7 to 23.7+/-10.5 cm/s. Systolic flow velocity decreased significantly from 36.1+/-13.6 to 28.9+/-10.2 cm/s (P<0.01). Mean flow velocity changed nonsignificantly from 28.1+/-9.4 to 26.5+/-9.9 cm/s. In atherosclerotic patients, mean flow velocity increased significantly from 26.3+/-11.4 to 29.3+/-11.2 cm/s (P<0.001), which was caused by significant diastolic flow augmentation from 19.7+/-9.1 to 23.9+/-9.7 cm/s (P<0.001). Systolic flow velocity was not changed significantly (from 34.2+/-12.8 to 32.6+/-11.8 cm/s).

CONCLUSION

No significant change of mean blood flow velocity in the ophthalmic artery was found in young healthy subjects. In elderly patients with atherosclerosis, ECP significantly increased blood flow velocity in the ophthalmic artery by 11.4%. This may indicate an ocular perfusion benefit in these patients as a result of ECP and could also explain the increase of perfusion found in patients with retinal ischemia after ECP.

Does atrioventricular ring motion always distinguish constriction from restriction? A Doppler myocardial imaging study

Constrictive pericarditis and restrictive cardiomyopathy can be difficult to differentiate on clinical examination. Cardiac ultrasonography is increasingly being used as the noninvasive method of choice for confirming the specific morphologic and hemodynamic abnormalities associated with either condition. Interrogation of atrioventricular valve plane motion by Doppler myocardial imaging (DMI) has been suggested as a valuable new approach that can help differentiate one from the other. We report the color DMI, pulsed DMI, and strain rate findings in 2 cases of constrictive pericarditis in which consideration of the annular motion pattern alone would not have allowed such differentiation.

A comparison of regional myocardial velocity information derived by pulsed and color Doppler techniques: an in vitro and in vivo study

The objective was to compare velocity information derived from either a tissue mimicking phantom or normal contracting myocardium by both pulsed wave and color Doppler myocardial imaging (PWDMI and CDMI). Both CDMI and PWDMI allow quantitative assessment of regional myocardial contraction and relaxation velocities, but their potential clinical applications have not yet been investigated. Moreover, no information is available as to whether they can be used interchangeably for regional velocity assessment. For the in vitro study, a rotating, circular-shaped, tissue-mimicking sponge driven by a motor at speeds of 15, 30, 60, 90 rpm was used to derive velocity data from the same eight points of interest by using PWDMI or CDMI techniques. For the in vivo study, 25 normal subjects were examined at rest using parasternal and apical approaches. Velocity profiles were derived from the same 26 areas of interest (18 left ventricular segments, 3 right ventricular segments, and 5 measurement points for the tricuspid and mitral annuli) for each technique. Peak maximal velocities were detected by PWDMI and peak mean velocities were measured using CDMI. The results of the in vitro study phantom showed excellent correlation (r = 0.99, P < 0. 001) and satisfactory agreement (0.04 cm/sec; 3.3 cm/sec) between both Doppler techniques. PWDMI velocities were higher than CDMI velocities by up to 20% and overestimated the real velocity value (0. 37 +/- 0.29 cm/sec) while CDMI underestimated predicted velocity by 1.35 +/- 0.36 cm/sec. Good correlation (r = 0.87, P < 0.001), but poor agreement (-2.1 cm/sec; 5.4 cm/sec) was shown in vivo for all segments with regard to peak systolic and diastolic velocities. Both Doppler techniques cannot be used interchangeably for comparing peak velocities in the clinical situation. However, with adequate temporal resolution, they can be used interchangeably for velocity profile recording and for timing of events.

[New techniques for the quantification of myocardial function: acoustic quantification, color kinesis, tissue Doppler and "strain rate imaging"]

In this article, the authors discuss different semi-quantitative methods for the analysis of global and regional myocardial function. Analysis of endocardial motion and direct measurements of myocardial velocities are the basic principles. The former is a two-dimensional technique which, however, requires good image quality and which is influenced by motion artefacts. The latter technique has a better signal to noise ratio and offers the opportunity to sufficiently quantify diastole. Strain rate imaging is a new and interesting way to display and evaluate regional myocardial deformation.

[Contrast echocardiography]

The intravenous application of an ultrasound contrast agent induces enhanced display of blood in all its pathways. Within cardiology, this principle is mainly utilized for signal enhancement of color Doppler and spectral Doppler in order to improve quantification of congenital and acquired valvular lesions and also for improved endocardial delineation during stress tests and in the evaluation of LV function. The new domaine of myocardial perfusion imaging by contrast echocardiography, however, needed profound technical developments before realization of the clinical potential could even be conceived. These are based on the complex reactions of microbubbbles in the acoustic field in order to allow the sensitive and bubble specific display of intramyocardial contrast effects. The presently available acquisition techniques, second harmonic imaging and harmonic power Doppler, demonstrate significant improvements if compared to traditional fundamental 2-d echocardiography; however, they are still subjected to important limitations. There are many anatomical, physiological, and technical reasons for insufficient display of intramyocardial microbubbles, the most important one being attenuation. It is hoped that the most recently developed imaging modality, pulse inversion technique, allows the necessary diagnostic accuracy and reproducibility in myocardial perfusion imaging.

The effect of pacing-induced heart rate variation on longitudinal and circumferential regional myocardial function after acute beta-blockade--a cardiac ultrasound study

AIMS

To evaluate the effect of acute beta-blockade in combination with differing heart rates on longitudinal and circumferential regional myocardial function using Doppler myocardial imaging and two-dimensional-echocardiography.

METHODS AND RESULTS

In seven pigs the following echocardiographic indices were measured at baseline, after beta-blockade both without and with atrial pacing: wall thickening fraction, fractional shortening, myocardial peak systolic velocity, transmyocardial velocity gradient and systolic velocity time integral of the posterolateral wall in short-axis view; mitral valve plane excursion, myocardial peak systolic velocity and systolic velocity time integral of the posterolateral wall in an apical five-chamber view. Peak systolic velocities and velocity gradients decreased significantly following acute beta-blockade but no further decay occurred at high heart rate due to pacing. The velocity time integrals and mitral valve plane excursion showed a tendency to decrease following beta-blockade but only after pacing were they significantly reduced. The wall thickening fraction and fractional shortening showed a significant reduction after beta-blockade but no further decay after pacing.

CONCLUSION

Changes in systolic velocities and velocity gradients were independent of heart rate reduction under high dosage beta-blockade, whereas wall thickening fraction, mitral valve plane excursion and velocity time integrals changed due to pacing.

Assessment of regional longitudinal myocardial strain rate derived from doppler myocardial imaging indexes in normal and infarcted myocardium

Myocardial deformation properties may be characterized by regional strain rates (SRs) calculated from Doppler myocardial velocity data. In 10 control subjects and 12 patients with established transmural infarcts, longitudinal median segmental SR, strain, and myocardial velocity were analyzed and compared with the corresponding wall motion score. All segments in control subjects and normal segments in infarct patients showed no significant difference in either systolic or diastolic SR (systolic: -1.27+/-0.39 s(-1) versus -1.23+/-0.24 s(-1), not significant [NS]; and isovolumic relaxation [IVR]: 1.23+/-0.38 s(-1) versus 1.95+/-0.62 s(-1), NS; respectively) and strain (-0.21+/-0.06 versus -0.19+/-0.06, NS). In infarcted segments, peak systolic SR, systolic strain, and early diastolic SR showed the most pronounced reduction (hypokinetic and akinetic) or even inversion (dyskinetic segments: 0.10+/-0.26 s(-1), 0.00+/-0.03, and -1.78+/-0.67 s(-1), respectively; P<.001). In this study, new myocardial deformation indexes were shown to quantitatively describe the function of normal and chronically infarcted regions.

[Endovascular stent in spontaneous arteriovenous fistula of the common iliac artery]

In a 64 years old patient with increasing oedema of the legs and massive untreatable ascites, colour coded duplex sonography and angiography revealed a wide arteriovenous fistula (AVF) of unknown origin between right common iliac artery and vein. Avoiding surgical intervention, the AVF was eliminated by applying an endovascular stent covering the site of the fistula. After intervention oedema and ascites disappeared, and colour doppler half a year later showed a good long term result.