[Pulmonary hypertension associated with portal hypertension. Apropos of 2 cases]

The authors report the cases of two patients with pulmonary hypertension associated with portal hypertension. This is a rare association with a reported prevalence ranging from 0.25 to 0.73%. The diagnosis of portal hypertension preceded that of pulmonary hypertension by several years. The physiopathological mechanism of the latter is not well known although several hypotheses have been proposed. Treatment is only symptomatic. The prognosis is usually poor, the causes of death being related to complications of liver failure and/or portal hypertension or to those of pulmonary hypertension.

[Multidimensional transesophageal echocardiography in the determination of the orificial surface of aortic stenoses in adults. Apropos of 85 cases]

The objective of this study was to assess the validity of multidimensional transoesophageal echocardiography (TOE) in the determination of the orificial surface area of aortic stenosis (AS) in 85 patients, using as a reference the surface area calculated on transthoracic ultrasonography (TTU) by applying the continuity principle (n = 75) and/or by haemodynamic studies using Gorlin's formula (n = 40). Planimetry was able to be performed in 78 of the 85 patients (92%). Planimetry was impossible in 7 patients with massive calcification of the aortic orifice (n = 5) or posterior valve (n = 2). The mean value of the selected angle was 45 +/- 13 degrees (0 to 78 degrees). An excellent correlation was observed between aortic surface area (ASA) measured by multidimensional TOE and TTU (r = 0.94; y = 0.90x +/- 0.10; SEE = 0.10 cm2; p < 0.001). Similarly, the ASA on multidimensional TOE was also well correlated with the haemodynamic surface area (r = 0.90, y = 0.94x +/- 0.05; SEE = 0.09 cm2; p < 0.001). The correlations between multidimensional TOE and TTU measurements (n = 26; r = 0.96; y = 0.85 x +/- 0.11; SEE = 0.07 cm2; p < 0.001) and cardiac catheterization (n = 13; r = 0.92; y = 0.77 x +/- 0.7; SEE = 0.09 cm2; p < 0.001) remained satisfactory in patients with associated aortic incompetence. Multidimensional TOE identifies cases of AS with an ASA on TOE or haemodynamic studies less than or equal to 0.75 cm2 with sensitivities of 93% and 92%, respectively, and a specificity of 100%. Overall, multidimensional TOE allows a precise and reliable evaluation of ASA in the great majority of cases of AS.

[Transesophageal echocardiography in cardiac and paracardiac tumors. A multicenter study]

A multicentre study was undertaken to determine the diagnostic value of transoesophageal echocardiography (TOE) in tumours of the heart and pericardium. Forty-five cases were recensed: 24 myxomas, 1 fibroma, 1 hydatid cyst, 2 lymphomas, 3 sarcomas, 1 pleuropericardial cyst, 1 branchogenic cyst and 12 cardiac metastases. The diagnosis was made in all 45 cases by TOE but only in 35 cases by conventional transthoracic echocardiography which failed to recognise 2 myxomas, 1 hydatid cyst, 1 sarcoma, 2 paracardiac cysts and 4 cardiac metastases. The site of the tumour was identified 45 times by TOE compared with only 12 times by transthoracic echocardiography. However, the anatomical investigation of mediastinal tumours requires complementary computerised tomography. Moreover, TOE, like all other imaging techniques, is unable to predict the benign or malignant nature of the tumour, 1 leiomyosarcoma having been confused with a myxoma.

[Recording of pulmonary venous flow with Doppler echocardiography; normal and pathological aspects]

The appearances of pulmonary venous flow Doppler echocardiography have been the subject of many reports. The recording is obtained by transthoracic or transoesophageal pulsed Doppler examination. The value of this parameter in the study of left ventricular diastolic function has been clearly established. The transoesophageal approach is mainly useful for quantifying mitral regurgitation and for monitoring left atrial pressure during surgery. This review of the literature describes the methods of recording and the normal appearances of pulmonary venous flow, and then discusses the different variations encountered in pathological conditions.

[Does mitral insufficiency prevent spontaneous contrast phenomenon and formation of thrombi in the left atrium?]

The aim of this study was to assess the influence of mitral regurgitation on the prevalence of left atrial spontaneous echo contrast and thrombosis in 2,180 consecutive patients undergoing transthoracic and transoesophageal echocardiography. Two groups of patients were defined according to the absence (group I) or presence (group II) of grades 3 or 4 mitral regurgitation quantified by transoesophageal echocardiography. Group II was associated with a statistically significant lower frequency of spontaneous echo contrast (0.6 vs 11.2%; p < 0.0001), left atrial thrombosis (0.6 vs 4.2%; p < 0.03), ischaemic cerebrovascular accidents (1.2 vs 21%; p < 0.0001), transient ischaemic attacks (0 vs 12%; p < 0.0001) and systemic embolism (0 vs 4.6%; p < 0.01). Conversely, the prevalence of atrial fibrillation was higher in group II (28 vs 19%; p < 0.01) and there were more patients with left atrial dimensions > or = 5.5 cm (16 vs 6.7%; p < 0.0001). When mitral stenosis and valve prosthesis were excluded, there were no cases of spontaneous echo contrast (8.3 vs 0%; p < 0.001) or left atrial thrombosis (2.9 vs 0%; p < 0.05) in the group with grades 3 or 4 mitral regurgitation. The phenomenon of left atrial spontaneous echo contrast and/or thrombosis is rare in patients with grade 3 or 4 in native mitral valve regurgitation and explains the low incidence of systemic embolism in these cases.

[Paradoxical embolisms after pulmonary embolism. 6 cases]

Among a series of 6 patients who had paradoxical emboli after pulmonary embolus, thrombus was encrusted in the foramen ovale in 2 while contrast echocardiography showed a free foramen ovale in the 4 others. Surgical embolectomy was performed in 1 of the patients with a thrombus in the foramen ovale. This patient died in the post-operative period and the second patient died suddenly before the indication for surgery had been established. The 4 other patients were treated medically with anticoagulant therapy. After a follow-up of 37, 33, 32 and 3 months respectively none of these patients has developed recurrent emboli. The association of a thromboembolic disease and a systemic ischaemic event should strongly suggest the diagnosis of paradoxical embolus. Echocardiography is required to determine whether the foramen ovale is free or harbours a thrombus.

[Hemangioma of the interventricular septum simulating right obstructive cardiomyopathy. Apropos of a case and review of the literature]

The authors report a case of haemangioma of the interventricular septum, a rare cardiac tumour (2.8% of all primary cardiac tumours) simulating right obstructive cardiomyopathy. Based on a review of the literature, they emphasize the diversity of the clinical expression of this disease and the uncertain medium and long-term outcome of operated and nonoperated tumours.

[Valve ring abscesses: apropos of 59 cases. A multicenter study]

The authors report the results of a multicenter study which recensed 59 cases (46 men, 13 women, average age 59.8 +/- 14 years) of valve ring abscesses defined by echocardiographic criteria alone (20 cases) or by echocardiographic and/or operative criteria (39 cases). The site of abscess was aortic (53 cases), mitral (5 cases) and tricuspid (1 case). The abscess complicated a prosthetic valve in 34 cases, occurred with a non-pathological valve in 11 cases or a pathological valve in 14 cases. Taking the 39 operated patients as a reference, the diagnostic sensitivity of transthoracic echocardiography was 25% and that of transoesophageal echocardiography: 88%. Bacterial vegetations were diagnosed with a sensitivity of 55% for transthoracic and 88% for transoesophageal echocardiography. The mediocre results of transthoracic echocardiography make transoesophageal echocardiography mandatory when there is a clinical suspicion of abscess: transoesophageal echocardiography should be systematic in prosthetic valve endocarditis and widely employed in native aortic valve endocarditis. The clinical outcome of these cases was: 39 cases were operated: global mortality of 23%, and 18 cases were treated medically, surgery having been declined for various reasons: old age (2 patients), operative risk (1 patient), patient refusal (4 patients), general condition considered to be too good to justify surgery (11 cases, including 6 sterilised abscesses diagnosed some time after the acute infectious phase). The outcome of these 18 patients, who form the biggest non-operated series of valve ring abscesses to date, was studied in detail: 4 died (18% mortality), 1 was operated secondarily for progressive valve dehiscence and 13 had a favourable outcome with an average follow-up period of 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echocardiographic evaluation of left ventricular wall stress in aortic stenosis]

The measurement of wall stress allows study of morphological adaptation of the left ventricle, especially in conditions associated with symmetric hypertrophy (hypertension, aortic stenosis). The calculation is performed in hypertensive heart disease but not in aortic stenosis because of the ventriculo-aortic pressure gradient. In a preliminary study, the authors validated the peak systolic left ventricular pressure calculated by adding the systolic brachial artery pressure to the maximal transvalvular pressure gradient by comparing the value with that obtained by catheterization in 21 patients with aortic stenosis. The second phase of the study was to measure meridian and circumferential wall stress prospectively in 35 patients with aortic stenosis (29 symptomatic, 6 asymptomatic) and to compare the results with those observed in 21 normal subjects. In the latter group, the values were 151 +/- 22 and 311 +/- 37 10(3) dynes/cm2 respectively, whereas in asymptomatic aortic stenosis the stresses were 136 +/- 28 and 303 +/- 41 10(3) dynes/cm2 respectively (NS) and in symptomatic aortic stenosis 210 +/- 55 and 437 +/- 94 10(3) dynes/cm2 respectively (p < 0.0001). None of the cases of asymptomatic aortic stenosis had raised wall stress values whereas only 6 symptomatic aortic stenosis patients had normal wall stress. The values of wall stress obtained using the method proposed were comparable to those reported by other authors with invasive investigations. Non-invasive measurement of wall stress by Doppler echocardiography may be proposed as a method of evaluation of left ventricular adaptation, especially in severe stenosis and in patients with a patent geometric abnormality (abnormal dilatation or even an inadequately hypertrophied wall).

Mitral to aortic velocity-time integral ratio. A non-geometric pulsed-Doppler regurgitant index in isolated pure mitral regurgitation

To determine the clinical value of a simple and non-geometric pulsed Doppler regurgitant index, namely the mitral to aortic velocity-time integral (VTI) ratio in the semiquantitative assessment of severity of isolated pure mitral regurgitation (MR), 109 patients with isolated pure MR and sinus rhythm prospectively underwent Doppler echocardiography within 48 h of cardiac catheterization. The eccentricity of regurgitant jets was assessed by Doppler colour flow imaging and the mitral and aortic VTI and its ratio were derived from the pulsed Doppler method. Angiographic grade of MR was evaluated in all patients with MR, but haemodynamic regurgitant fraction was determined in only 91 patients. Fifty patients in sinus rhythm and without valvular disease served as controls. In the control group, the mitral VTI (16.2 +/- 2.5 cm) was lower than the aortic VTI (20.6 +/- 2.8 cm) (P < 0.001), resulting in a mitral to aortic VTI ratio of 0.79 +/- 0.08. In patients with MR, the mitral VTI was significantly greater than the aortic VTI (23.1 +/- 6.8 vs 16.9 +/- 4.7 cm, P < 0.001). There was a close relationship between the mitral to aortic VTI ratio and the angiographic grading of MR (n = 109, r = 0.74, P < 0.001). A ratio > or = 1.3 classified patients with severe MR (grade III or IV) with a sensitivity of 87%, a specificity of 91%, and positive and negative predictive values of 93% and 84%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitation of aortic valve area in aortic stenosis with multiplane transesophageal echocardiography: comparison with monoplane transesophageal approach

The accuracy and reliability of two-dimensional monoplane and multiplane transesophageal echocardiography (TEE) in the quantitation of aortic valve area were compared in 54 patients with aortic stenosis. Fifty patients had aortic valve area calculated by the continuity equation and transthoracic Doppler echocardiography (TTE); 25 underwent cardiac catheterization. Two-dimensional echocardiograms adequate for quantitation of aortic valve area were obtained in 21 (39%) patients with monoplane TEE and in 51 (94%) with multiplane TEE. The mean aortic valve area determined by both TEE methods did not differ significantly from that derived from TTE and catheterization. The mean difference of aortic valve area measurements between monoplane TEE and TTE was -0.045 +/- 0.11 cm2; that between multiplane TEE and TTE was 0.001 +/- 0.11 cm2. Multiplane TEE provided a better correlation of aortic valve area measurements with either TTE (y = 0.97 x + 0.03; r = 0.96; SEE = 0.11 cm2) or catheterization (y = 0.84 x + 0.11; r = 0.90; SEE = 0.12 cm2) than the monoplane TEE (y = 0.88 x + 0.13; r = 0.83; SEE = 0.15 cm2 and y = 0.41 x + 0.42; r = 0.81; SEE = 0.15 cm2). Severe aortic stenosis with valve orifice area of < or = 0.75 cm2 during TTE examination was found by multiplane TEE with a sensitivity of 96% and a specificity of 96%. Thus aortic valve area can be directly and reliably measured by two-dimensional multiplane TEE in majority of patients with aortic stenosis.

Noninvasive prediction of coronary artery disease by transesophageal echocardiographic detection of thoracic aortic plaque in valvular heart disease

Clinical and angiographic features and transesophageal echocardiographic (TEE) findings were retrospectively analyzed in 105 consecutive patients with valvular heart disease to assess the value of TEE detection of thoracic aortic plaque for predicting coronary artery disease. In 19 patients with significant coronary artery stenosis (> or = 70% narrowing of the luminal diameter in the left anterior descending, left circumflex, or right coronary arteries, or > or = 50% stenosis of the left main coronary artery), 18 had thoracic aortic plaque on TEE study. In contrast, aortic plaque existed in only 10 of the remaining 86 patients with normal coronary arteries or mildly atherosclerotic coronary lesions. The presence of aortic plaque on TEE study had a sensitivity of 95% and a specificity study had a sensitivity of 95% and a specificity of 88% for significant coronary stenosis at angiography. The positive and negative predictive values were 64% and 99%, respectively. There was a close relation between the degree of aortic intimal changes and the severity of coronary artery disease (r = 0.65; p < 0.001). Multivariate stepwise regression analysis of patient age, sex, risk factors of cardiovascular disease, angina, and TEE findings revealed that atherosclerotic aortic plaque was the most significant independent predictor of coronary artery disease. This study indicates that TEE detection of atherosclerotic plaque in the thoracic aorta is useful in the noninvasive prediction of the presence and severity of coronary artery disease in patients with valvular heart disease.

[Determination of the optimal atrioventricular timing by impedance plethysmography in patients with cardiac pacing; correlations with left ventricular filling]

The stroke volume (SV) was measured by the change in the impedance in thirteen patients with dual chamber pacemakers at different atrioventricular delay (AVD) intervals: 31 to 219 ms or 75 to 220 ms. The mitral inflow was also recorded by Doppler echocardiography at each AVD with measurement of the duration of mitral flow (MFD) and the velocity time integral (VTI). All thirteen patients were studied in the DDD mode; in addition, 5 patients were studied in the atrial sensing ventricular stimulation VDD mode. The SV measurement by impedance plethysmography was reproducible with an average variability of 3.5%: the optimal AVD was determined by this method in 11 patients with DDD and 4 patients with VDD pacing: in 3 patients (2 in DDD and 1 in VDD mode) 2 optimal AVD were obtained. The optimal AVD was 123 +/- 31 ms (63 to 156 ms) in DDD mode and 91 +/- 17 ms (63 to 110 ms) in VDD mode. The analysis of left ventricular filling showed that changes in AVD led to similar changes in mitral VTI. The MFD increased as the AVD was shortened to a constant value at the optimal AVD. In all patients, the optimal AVD was obtained when the MFD became maximal and constant. Measurement of MFD is a simple and rapid means of assessing optimal AVD at rest in patients with dual chamber pacing systems.

[Surgical treatment of leiomyosarcoma of the left atrium Report of a case and review of the literature]

The authors report a case of left atrial leiomyosarcoma presenting with systemic disturbances and retinal emboli diagnosed by echocardiography and surgery in a 59 year old woman. Surgical ablation was completed by a course of chemotherapy. Histopathological examination confirmed the diagnosis of sarcoma; although the patient remained generally well, severe mitral regurgitation appeared 21 months after surgery. Transoesophageal echocardiography revealed an abnormal, hyper-mobile, intra-atrial echo suggesting a ruptured chordae tendinae and the mitral valves appeared very thickened and retracted. The patient was reoperated and the mitral valve replaced with a bioprosthesis. After a total follow-up of 29 months, the patients is still alive and asymptomatic. The authors underline the importance of echocardiography in the diagnosis of intra-cardiac tumours in general and, in particular, of intra-cardiac sarcomas.

[Doppler echocardiography of tricuspid insufficiency. Methods of quantification]

Evaluation of tricuspid incompetence has benefitted considerably from the development of Doppler ultrasound. In addition to direct analysis of the valves, which provides information about the mechanism involved, this method is able to provide an accurate evaluation, mainly through use of the Doppler mode. In addition to new criteria being evaluated (mainly the convergence zone of the regurgitant jet), some indices are recognised as good quantitative parameters: extension of the regurgitant jet into the right atrium, anterograde tricuspid flow, laminar nature of the regurgitant flow, analysis of the flow in the supra-hepatic veins, this is only semi-quantitative, since the calculation of the regurgitation fraction from the pulsed Doppler does not seem to be reliable; This accurate semi-quantitative evaluation is made possible by careful and consistent use of all the criteria available. The authors set out to discuss the value of the various evaluation criteria mentioned in the literature and try to define a practical approach.

[Contribution of transesophageal ultrasonography in the etiologic evaluation of a systemic embolic accident. Apropos of 451 patients]

In order to compare the respective values of transoesophageal and transthoracic echocardiography in the investigation of systemic embolic events, 451 consecutive patients (average age 60 +/- 15 years) presenting either with a cerebral ischaemic event (n = 401) or a peripheral arterial embolism (n = 50), were examined. One hundred and ninety eight patients had documented cardiac disease and/or atrial fibrillation; 253 patients had no previous cardiovascular history. Transoesophageal echocardiography revealed a possible cardiac embolic lesion in 37% of patients compared with 11% by transthoracic echocardiography (p < 0.001). In those patients with previous cardiac disease, transoesophageal echocardiography was contributory in 50% of cases compared with 27% of cases in patients with no previous cardiac disease (p < 0.001), whereas transthoracic echocardiography was only contributory in 12% and 9.8% of cases, respectively. Transoesophageal echocardiography was more sensitive for the diagnosis of intracavitary thrombus (7.5% vs 2.2%, p < 0.001), prosthetic valve thrombosis (2.4% vs 0.6%, p < 0.01), spontaneous contrast in the left atrium (10.8% vs 0%, p < 0.001), interatrial septal aneurysm (6.4% vs 1.9%, p < 0.001), mitral valve prolapse (5.3% vs 2.8%, p < 0.01). Moreover, irregular atheromatous plaques in the thoracic aorta could only be visualised by transoesophageal echocardiography (9% of cases). This study underlines the superiority of transoesophageal echocardiography over transthoracic echocardiography in the investigation of systemic embolic events. Transoesophageal echocardiography is even more contributory in patients with a history of cardiac disease.

[Contribution of transesophageal and transthoracic echography in the evaluation of the mechanism and quantification of regurgitation in mitral and aortic bioprosthetic valves]

The respective values of transoesophageal (TOE) and transthoracic echocardiography (TTE) in the evaluation of the mechanism and the quantification of pathological regurgitation of bioprosthetic heart valves were analysed in 23 patients (14 mitral, 9 aortic; duration of implantation 108 +/- 43.2 months). Surgical or pathological correlations were available in all cases and catheter data in 18 of the 23 patients. With regards to mitral bioprostheses, the TOE evaluations of the mechanism and site of regurgitation corresponded in all cases with the operative or pathological findings and quantification of mitral regurgitation concorded with angiography. There was an underestimation of the severity of mitral regurgitation in 30% of cases by TTE compared with angiography; prolapse was diagnosed in 7 of the 10 cases with cusp tears. It was not possible to accurately determine the intra or perivalvular site of regurgitation by TEE. With regards to aortic bioprostheses, TOE and TTE were equally useful in determining the mechanism of regurgitation, showing cusp prolapse in 6 of the 9 cases with cusp tears. However, TTE quantified regurgitation accurately in all cases with respect to angiography, whereas TOE was only contributive in 50% of cases. These results show that single plane TOE is superior to TTE in the quantification and determination of the mechanism of regurgitation in mitral bioprostheses, but that TTE remains better for the quantification of regurgitation of aortic bioprostheses.

[Value and limits of single-plane transesophageal echocardiography in dysfunctions of aortic valve prosthesis]

The authors reviewed retrospectively the results of transoesophageal and transthoracic echocardiography in 26 patients with prosthetic aortic valve dysfunction in order to study the value and limitations of monoplane transoesophageal echocardiography in this condition. Surgical data was available in 14 of these cases. The diagnosis of abscess of the aortic ring was made on 7 occasions by transoesophageal echocardiography and on 3 occasions by transthoracic echocardiography Bacterial vegetations were visualised in 5 cases by transoesophageal echocardiography and in 1 case by transthoracic echocardiography. The diagnosis of thrombosis was made in 1 case by transoesophageal echocardiography and missed by transthoracic echocardiography; fibrous pannus (n = 1) was not recognised on transoesophageal and transthoracic echocardiography. In the latter two conditions, transthoracic Doppler showed signs of obstruction. The diagnosis of a stenotic bioprosthesis due to fibrocalcific degeneration was made in 1 case by transoesophageal and in 1 case by transthoracic echocardiography. Prolapse of cusp was diagnosed in 6 cases by transthoracic echocardiography. An intraprosthetic valve leak was visualised in 7 cases by transoesophageal echocardiography and in 9 cases by transthoracic echocardiography; periprosthetic leaks were diagnosed in 9 cases by transoesophageal and in 12 cases by transthoracic echocardiography. These results indicate that transoesophageal echocardiography is a major advance in the diagnosis of abscess of the aortic ring, bacterial vegetations and prosthetic valve thrombosis. On the other hand, transthoracic echocardiography remains superior for the quantification or regurgitation and enables evaluation of transprosthetic gradients of obstructive prostheses with continuous mode Doppler. Therefore, the two methods are complementary.

[Echocardiographic diagnosis of a thrombus trapped in a patent foramen ovale. Apropos of a case]

The authors report the case of a patient presenting with pulmonary embolism in which transthoracic echocardiography showed the presence of an intracardiac thrombus trapped in a patent foramen ovale; this was confirmed at surgery. It is rare to see this type of thrombus (which usually gives rise to paradoxical embolism) by transthoracic echocardiography. Previously, this used to be a postmortem diagnosis but the condition is often suspected nowadays when deep venous thrombosis and/or pulmonary embolism, an unexplained systemic embolism and a right-to-left interatrial shunt, are associated. However, the diagnosis can only be confirmed by the visualisation of the thrombus crossing the interatrial septum.

[Infectious endocarditis on permanent endocavitary pacemakers: value of echocardiography and review of the literature]

Infectious endocarditis around indwelling pacemakers is rare (0.15% of all implantations). They have a gloomy prognosis with a global mortality rate of nearly 34% as emerges from this review of the literature concerning 58 cases of infectious endocarditis published within the past 16 years. On the basis of the 6 cases which the authors report, they stress the importance and sometimes difficulty of using ultrasound in a positive diagnosis. Cardiographic ultrasound, which can determine the size and emboligenic nature of vegetations is capital in choosing how to remove the pacemakers. Percutaneous ablation by simply pulling or by catheterization currently gives the best results, but it may be necessary to resort to surgery involving right atriotomy if emboligenic vegetations are present. By combining antibiotic treatment and ablation of the intracavitary material, a cure is obtained in 92% of cases. These figures should be compared with the lack of success of using antibiotic treatment alone which results in a high level of mortality (84%).

[Delayed angioplasty for residual stenosis following thrombolyzed infarction: arterial permeability and left ventricular function after 6 months]

At medium term, the results of delayed angioplasty (DA) following intravenous thrombolysis (IVT) in terms of arterial permeability but particularly of left ventricular function (LVF) is still poorly understood and is the subject of this prospective study. Over 18 months, 76 patients underwent DA for the residual stenosis on day 8 +/- 5 with complete and partial success rates of 88.2% and 11.8% respectively. Rapid reocclusion (< 48 hours) was documented in 9.2% of cases. After 6 months, there had been no deaths and no recurrence of infarction but a recurrence of angina in 23.7% of cases. Angiographic monitoring, carried out in 56 cases (73.7%) after 6 +/- 2.4 months identified 21 restenosis (37.5%) and 6 re-occlusions (10.7%). 12 of the restenosis were successfully re-dilated. The effect on LV function was investigated in 50 patients. In the absence of reocclusion, the ejection fraction and the kinetics of the infarcted territory were improved; significant restenosis (> 60% by digital densitometry) did not appear to offset these improvements. In addition to the maintenance of arterial permeability, the possibility of functional recovery appears to be conditioned by the degree of contractile abnormality observed during the initial ventriculography. Despite the absence of restenosis after 6 months, the occurrence on day 6 of akinesia or above all of dyskinesia reduces the chances of contractile improvement with as a corollary more marked LV changes.

Prognostic importance of left ventricular diastolic filling velocity profiles in dilated cardiomyopathy

To determine the prognostic importance of pulsed Doppler-derived left ventricular diastolic filling velocity profiles and the relationship between Doppler variables and clinical functional status, the follow-up outcome of 58 patients with dilated cardiomyopathy and symptoms of left ventricular dysfunction was analysed. During a mean follow-up period of 31.2 +/- 12.8 months, 23 died of either progressive pump failure or sudden death. Peak early filling velocity (E) was higher and late atrial filling velocity (A) lower in nonsurvivors than in survivors. The E/A ratio was higher and the deceleration time (DT) of early diastole shorter in nonsurvivors. The mortality was significantly higher in patients with an E/A ratio > 2 or a DT < 150 ms than in those without. Repeated Doppler echocardiographic examinations in 31 of 35 survivors after intense treatment showed decreased E, increased A, reduced E/A ratio and prolonged DT in 18 patients with clinical functional improvement, whereas these measurements were unaltered in the remaining 13 patients whose functional status was unchanged or deteriorated. This study suggests that pulsed Doppler-derived left ventricular diastolic filling variables may be important predictors of outcome in dilated cardiomyopathy and provide useful measures in observing the effects of therapy during long-term follow-up of the patients.

[Contribution of transesophageal echocardiography in the diagnosis of intra- and para-cardiac masses]

The authors detected 59 thrombi and 7 intra- or paracardiac tumors in 58 patients in a series of 1,100 transesophageal echocardiography. Twenty-six of the 51 patients with a thrombus were in sinus rhythm; 25 had atrial fibrillation. In 44 cases, the thrombus was single and in 7 cases there were multiple thrombi. A phenomenon of spontaneous contrast in the left atrium was observed in 24 patients (47%). In 31 cases (53%) the thrombi were located in the left auricle, in 21 cases (36%) in the left atrium, in 4 cases in the left ventricle and in 3 cases in the right atrium. Transthoracic echocardiography only detected 25% of these thrombi. The superiority of transesophageal echocardiography was particularly evident for the detection of thrombi in the left auricle (31 by transesophageal echocardiography versus 2 by transthoracic echocardiography) and in the left atrium (13 by transesophageal echocardiography versus 7 by transthoracic echocardiography). Five myxomas were diagnosed by transesophageal echocardiography and 4 of them were identified by transthoracic echocardiography. The site of implantation of the tumor was located in all 5 cases by transesophageal echocardiography. Two right paracardiac tumours were only visible by transesophageal echocardiography. Transesophageal echocardiography is therefore very useful in the diagnosis of thrombi in the left atrium and auricle, of rare hypodense myxomas and paracardiac tumors. In addition, it enables precise localisation of the site of implantation of nearly all intracardiac tumors.

Doppler echocardiographic evaluation of valve regurgitation in healthy volunteers

OBJECTIVE

To study the prevalence and the characteristics of physiological valve regurgitation.

DESIGN

Pulsed wave Doppler echocardiography, continuous wave Doppler echocardiography and Doppler colour flow mapping were performed prospectively in healthy volunteers.

SETTING

Echocardiography laboratory in a city hospital.

PATIENTS

32 consecutive healthy volunteers (age 21-49 years, mean age 29.4).

MAIN OUTCOME MEASURES

Identification of regurgitation with colour Doppler flow mapping and measurement of the jet area, jet length, and maximal velocity of the regurgitation.

RESULTS

Regurgitation was recorded at the pulmonary (100%), tricuspid (100%), mitral (56%), and aortic valves (6%). The velocity of pulmonary and tricuspid regurgitation was similar to that predicted from the pressure gradient calculated from the Bernoulli equation. The jet area and jet length were generally small.

CONCLUSION

Trivial regurgitation from the pulmonary, tricuspid, and mitral valves is common in healthy people. It is important to take such regurgitation into account when valve disease is diagnosed.

[Aneurysm of the interatrial septum. Contribution of transesophageal echography. Relation with systemic embolic complications]

The aim of this study was to evaluate the contribution of transesophageal echocardiography to the diagnosis of aneurysms of the interatrial septum and to identify the role played by this condition in unexplained systemic embolic accidents. Thirty two aneurysms of the interatrial septum were discovered in a consecutive series of 751 transesophageal echocardiograms, i.e. an incidence of 4.2 per cent. The diagnosis was possible by transthoracic echocardiography in only 9 cases (28%). Search for a patent foramen ovale by a contrast test was positive in 87 per cent of cases of aneurysm of the interatrial septum as compared with 45 per cent for patients without an aneurysm (p < 0.01). In patients in whom transesophageal echocardiography was requested for etiological evaluation of an ischemic vascular accident of embolic origin (n = 191), an aneurysm of the interatrial septum was found in 8.3 per cent of cases. In patients with no history of a systemic embolic accident (n = 560), the incidence of septums of the interatrial septum was 2.8 per cent (p < 0.01). Furthermore, 50 per cent of patients with an aneurysm of the interatrial septum had a history of systemic embolism. Transesophageal echocardiography thus appears to be superior to transthoracic echocardiography in the positive diagnosis of aneurysms of the interatrial septum and our study is suggestive of their emboligenic nature.

Prognostic significance of Doppler-derived left ventricular diastolic filling variables in dilated cardiomyopathy

To determine the prognostic significance of pulsed wave Doppler-derived left ventricular diastolic filling velocity profiles and the relationship between Doppler variables and clinical functional status, the follow-up outcomes of 62 consecutive patients with dilated cardiomyopathy and symptoms of left ventricular dysfunction were analyzed. All patients had echocardiographic left ventricular end-diastolic dimension > or = 6.0 cm, fractional shortening < 25%, increased E pointseptal separation, and diffuse hypokinesia or akinesia. During a mean follow-up period of 30.5 +/- 13.9 months, 27 patients experienced cardiac events: 23 died of either progressive pump failure or an episode of sudden death and four required cardiac transplantation because of refractory heart failure. Peak early filling velocity (78 +/- 23 cm/sec vs 65 +/- 25 cm/sec; p < 0.03) was higher and late atrial filing velocity (34 +/- 13 cm/sec vs 55 +/- 19 cm/sec; p < 0.001) was lower in patients with cardiac events than in cardiac event-free survivors. The ratio of early to late transmitral filling velocities was higher (2.6 +/- 1.2 vs 1.5 +/- 1.3; p < 0.001), and the deceleration time of early diastole was shorter (133 +/- 48 msec vs 175 +/- 71 msec; p < 0.001) in patients with cardiac events. The cardiac event rate was significantly higher in patients with an early to late filling velocity ratio greater than 2 (77% vs 19%; p < 0.001) or a deceleration time less than 150 msec (58% vs 23%; p < 0.05) than in those without. Stepwise multivariate regression analysis revealed that the pattern of transmitral early to late filling velocity ratio was the only significant independent Doppler echocardiographic predictor of outcome for these patients. Repeat Doppler echocardiographic examinations, which were performed in 31 survivors after intensive treatment (mean, 38.6 +/- 6.5 months), showed that early filling velocity was decreased (55 +/- 20 cm/sec vs 75 +/- 25 cm/sec; p < 0.02), late atrial filling velocity was increased (74 +/- 27 cm/sec vs 57 +/- 21 cm/sec; p < 0.01), early to late filling velocity ratio was reduced (0.8 +/- 0.3 vs 1.7 +/- 1.3; p < 0.001), and deceleration time was prolonged (227 +/- 60 msec vs 167 +/- 82 msec; p < 0.01) in 18 patients with clinical functional improvement, whereas these measurements were unaltered in the remaining 13 patients whose functional status was unchanged or had deteriorated.(ABSTRACT TRUNCATED AT 400 WORDS)

Left ventricular flow propagation during early filling is related to wall relaxation: a color M-mode Doppler analysis

OBJECTIVES

This study was designed to evaluate the relation between the velocity of flow propagation and left ventricular relaxation by using color M-mode Doppler echocardiography to analyze flow propagation in the left ventricle.

BACKGROUND

Noninvasive attempts to identify alterations in left ventricular relaxation have been hampered because both the relaxation rate and left atrial filling pressure are the determinants of peak early velocity and filling rate.

METHODS

Color M-mode velocity data were transferred to a microcomputer and compared with conventional pulsed Doppler data to assess the ability of color M-mode echocardiography to analyze velocity field properties. The velocity of flow propagation was measured as the slope of the flow wave front during early filling in normal subjects (n = 29) and in patients with disease that alters relaxation (dilated cardiomyopathy [n = 31], ischemic cardiomyopathy [n = 8], hypertrophic cardiomyopathy [n = 5], systemic hypertension [n = 22] and aortic valve disease [n = 25]). In nine patients with end-stage dilated cardiomyopathy, echocardiographic and left heart catheterization data were obtained at baseline and during intracoronary dobutamine infusion.

RESULTS

Color M-mode and pulsed Doppler echocardiographic data were highly correlated (n = 217, r = 0.94, p less than 0.0001, velocity range 0.2 to 1.5 m/s). The velocity of flow propagation was lower in patients than in normal subjects (0.46 +/- 0.15 vs. 0.84 +/- 0.11 m/s, p less than 0.0001). The decrease was significant in all disease forms with or without left ventricular dilation. The velocity of flow propagation was related to peak early velocity in normal subjects (p less than 0.001) but not in patients. It varied inversely with the isovolumetric relaxation time constant during dobutamine infusion and the two variables were highly correlated (p less than 0.0001).

CONCLUSIONS

The velocity of flow propagation during early filling seems to be highly dependent on the left ventricular relaxation rate and could be an important tool in studying diastolic function.

[Determination of aortic and pulmonary flow by Doppler ultrasonography]

Numerous studies have demonstrated the reliability of ultrasound Doppler in measuring aortic flow. It is generally agreed that aortic surface area and flow rate should be measured at the arch. In contrast, determination of the pulmonary flow by ultrasound Doppler, validated in children and infants, is difficult in adults due to problems encountered in measuring the diameter of the pulmonary arch.

Assessment of severity of mitral regurgitation by measuring regurgitant jet width at its origin with transesophageal Doppler color flow imaging

BACKGROUND

The ability of transesophageal color Doppler echocardiography to provide high-resolution images of both cardiac structure and blood flow in real time is advantageous for many clinical purposes. This study was performed to determine the utility of the regurgitant jet width at its origin measured by transesophageal Doppler color flow imaging in the assessment of severity of mitral regurgitation.

METHODS AND RESULTS

Sixty-three consecutive patients with mitral regurgitation underwent transesophageal color Doppler examination, and the diameter of regurgitant jet at its origin was measured. Both right and left cardiac catheterizations were performed within 24 hours of Doppler studies, and angiographic grading of mitral regurgitation and regurgitant stroke volume were evaluated. There was a close relation between the jet diameter at its origin measured by transesophageal Doppler color flow imaging and the angiographic grade of mitral regurgitation (r = 0.86, p less than 0.001). A jet diameter of 5.5 mm or more identified severe mitral regurgitation (grade III or IV) with a sensitivity of 92%, specificity of 92%, and positive and negative predictive values of 88% and 95%, respectively. In 31 patients with isolated mitral regurgitation, the jet diameter correlated well with the regurgitant stroke volume determined by a combined hemodynamic-angiographic method (r = 0.85, p less than 0.001). A jet diameter of 5.5 mm or more identified a regurgitant stroke volume of 60 ml or more with a sensitivity of 88%, specificity of 93%, and positive and negative predictive values of 94% and 87%, respectively.

CONCLUSIONS

The regurgitant jet width at its origin measured by transesophageal Doppler color flow imaging provides a simple and useful method of measuring the severity of mitral regurgitation, and it may allow differentiation between mild and severe mitral regurgitation.

[Non-invasive methods in the study of the elastic properties of the thoracic aorta. Effect of isosorbide dinitrate]

The role of the great arteries is to distribute and stock blood. Pulsatile discontinuous flow is transformed to a continuous flow system. The elastic properties of the aorta play a major role in these functions. It is generally agreed that changes in these elastic properties may lead to the development of left ventricular hypertrophy. The evaluation of the aorta has, until recently, depended on invasive hemodynamic and angiographic techniques. In addition, the measurement of pulse wave velocity, though useful, is a global and only an approximate method. Transoesophageal echocardiography (TEE) enables accurate measurement of the aortic diameter and its systolo-diastolic variations. The accuracy of these measurements has been validated in vitro and the reproducibility is much better than with previously used techniques. Previous studies have shown an improvement of the elastic properties of the great arteries with nitrate derivatives. In recent studies using TEE, isosorbide dinitrate caused dilatation of the descending thoracic aorta and thereby improved its elastic properties. The development of tonometry techniques in our department has resulted in the finding of excellent correlations between carotid and aortic pulse pressures measured non-invasively. The association of TEE and tonometry thereby provides a direct approach to the evaluation of aortic compliance. It has then become possible to study the effects of nitrate derivatives on the aortic compliance of elderly patients in whom it is the most reduced.

[Value and limits of the determination of aortic output by Doppler echocardiography in the quantification of aortic valve insufficiencies]

The aim of this study was to assess the value and limitations of Doppler echocardiographic measurement of aortic flow in the quantification of aortic regurgitation. Sixty-one patients were examined by Doppler echocardiography within 48 hours of cardiac catheterisation. There were 9 Grade I, 18 Grade II, 18 Grade III and 16 Grade IV angiographic aortic regurgitations. The mean aortic blood flow in angiographic Grades I and II (p less than 0.01). A correlation was observed between Doppler aortic flow and the angiographic grade of regurgitation (r = 0.66, p less than 0.001) and between aortic flow and regurgitant fraction (r = 0.68, p less than 0.001). Aortic flow greater than 10 l/mn identified angiographic Grades III or IV regurgitation with a sensitivity and specificity of 73.5% and 92.5% respectively and a positive and negative predictive values of 92.5% and 73.5% respectively. Aortic regurgitation with a regurgitant fraction greater than 40% was identified by a pulsed Doppler aortic blood flow greater than 10 l/mn with a sensitivity and specificity of 70% and 93% respectively, and positive and negative predictive values of 95% and 61% respectively. The sensitivity of this criterion is relatively poor as some severe aortic regurgitations have aortic flows of less than 10 l/mn: these patients have low outputs because of left ventricular dysfunction which is apparent from measurement of left ventricular fractional shortening.

Left ventricular aneurysm and prognosis in patients with first acute transmural anterior myocardial infarction and isolated left anterior descending artery disease

To determine the clinical and angiographic factors responsible for left ventricular aneurysm formation and the prognosis of patients with aneurysm, 79 patients with a first acute transmural anterior myocardial infarction and angiographically documented isolated left anterior descending artery disease were retrospectively evaluated. Presence of large infarct size and left ventricular volumes, reduced left ventricular function, and evidence of clinical functional impairment were more common in patients with aneurysm (n = 31) than in those without (n = 48). Patients with aneurysm often had total occlusion of the proximal left anterior descending artery without collateral vessels on angiography. During a mean follow-up of 53 months, 10 patients with and three without aneurysm died (P less than 0.01). Compared to survivors with or without aneurysm, the nonsurvivors were older, had significantly larger infarct size and left ventricular volumes and poor systolic function. The incidence of total occlusion of the left anterior descending artery without collaterals was higher in nonsurvivors. In patients with aneurysm, stepwise multivariate analysis revealed that left ventricular ejection fraction and the status of left anterior descending artery obstruction and collaterals were independent predictors of mortality. The study indicates that in patients with a first acute transmural anterior myocardial infarction and isolated anterior descending artery disease, left ventricular aneurysm often results from a large infarct caused by total occlusion of the proximal left anterior descending artery without collateral supply to the infarct region. The reduced survival rate for patients with aneurysm is primarily related to severe global left ventricular dysfunction which may be determined by assessing the residual flow to the infarct region.

[Quantification of mitral valve diseases by Doppler]

Echo Doppler makes a fundamental contribution to the non-invasive quantification of mitral valve disease. It enables calculation of gradients and of orifice surface area in mitral stenosis. The quantification of mitral insufficiency is also possible though more difficult: it is based upon the combination of semi-quantitative and quantitative methods, in particular the calculation of regurgitation fraction obtained by comparison of flow rates at different orifices in cases of pure regurgitation. Finally, the calculation of pulmonary artery pressures from a Doppler record in tricuspid and pulmonary insufficiency can be used to assess the effects of mitral valve disease on the pulmonary circulation. Echo Doppler thus provides a reliable non-invasive hemodynamic assessment of mitral valve disease and should lead to a reduction in the number of invasive investigations in this type of valve disease.

Non-invasive measurement of the regurgitant fraction by pulsed Doppler echocardiography in isolated pure mitral regurgitation

OBJECTIVE

To assess the usefulness of pulsed Doppler echocardiography as a method of measuring the regurgitant fraction in patients with mitral regurgitation.

PATIENTS AND METHODS

Twenty controls and 27 patients with isolated mitral regurgitation underwent Doppler studies. In the patients the study was performed within 48 hours of cardiac catheterisation. Aortic outflow was measured in the centre of the aortic annulus, and mitral inflow was derived from the flow velocity at the tip of the leaflets and the area of the elliptical mitral opening. The regurgitant fraction was calculated as the difference between the two flows divided by the mtiral inflow.

RESULTS

In the 20 controls the two flows were almost identical (mitral inflow, 4.44 (SD 0.88) l/min; aortic outflow, 4.58 (SD 0.84) l/min), with a mean regurgitant fraction of 4.2 (SD 8.4)%. In patients with mitral regurgitation, the mitral inflow was significantly higher than the aortic outflow (8.8 (3.6) v 4.3 (1.1) l/min). In most patients the Doppler-derived regurgitant fraction (45.8 (19.2)%) accorded closely with the regurgitant fraction (41.3 (SD 17.8)%) determined by the haemodynamic technique.

CONCLUSION

Pulsed Doppler echocardiography, with an instantaneous velocity-valve area method for calculating mitral inflow, reliably measured the severity of regurgitation in patients with mitral regurgitation.

[Determination of cardiac output by Doppler ultrasonics. Principle, techniques and limitations]

The development of quantitative applications of Doppler ultrasound for the measurement of cardiac output was a lengthy and difficult process. These applications call for rigor of the part of the ultrasound cardiographer and a sufficiently echoic patient. Numerous studies have demonstrated the reliability of Doppler ultrasound in determining aortic flow. A high degree of consensus has emerged for measuring aortic areas and velocities at the ring. Doppler ultrasound quantification of the pulmonary flow has been validated in children. In adults, measurement of the pulmonary ring is often difficult and may lead to major errors in the estimation of the flow rates. The determination of mitral flow is also possible, either at the ring or at the tip of the mitral funnel. A few publications highlight the value of Doppler ultrasound in evaluation of tricuspid flow, however, these results require confirmation.

Relationship between electrocardiographic patterns and angiographic features in isolated left circumflex coronary artery disease

The relation of electrocardiographic (ECG) patterns to clinical and angiographic features was assessed in 89 patients with isolated left circumflex coronary artery (LCx) disease (46 with and 43 without myocardial infarction). ECG abnormalities were present in 75 patients; there were isolated Q waves in 20, an abnormal R wave in lead V1 with or without inferior and/or lateral Q waves in 21, and isolated ST-T wave changes in 34 cases. Inferior abnormalities on the electrocardiogram were similar in patients with proximal or distal stenoses of the LCx, but an abnormal R wave in lead V1 correlated with proximal LCx stenosis (p less than 0.01). Lateral abnormalities were more common in stenoses of the obtuse marginal branch and proximal LCx than in distal stenosis (all p less than 0.01). Compared with patients without myocardial infarction with or without ST-T-wave changes and those with infarction without an abnormal R wave in lead V1, patients with LCx-related infarction and an abnormal R wave in lead V1 associated with inferior and/or lateral Q waves had larger left ventricular end-diastolic and end-systolic volumes, lower ejection fraction, higher incidence of total occlusion of proximal LCx without collateral vessels, and more cardiac events during follow-up. This study suggests that an abnormal R wave in lead V1 associated with lateral abnormalities on the standard electrocardiogram may be clinically useful in predicting proximal LCx stenosis and identifying a subset of postinfarction patients with left ventricular dysfunction due to a large infarct size.

[Pulsed echo-Doppler evaluation of regurgitant fraction in mitral valve insufficiency]

The aim of this study was to evaluate the validity of Doppler echocardiographic evaluation of the regurgitant fraction in pure mitral insufficiency. The Doppler echocardiographic measurement of systemic flow was made at the level of the aortic ring, and the mitral flow by the method of integration of instantaneous flow proposed by Touche. In a preliminary study, we demonstrated a close correlation between forward aortic and mitral flow in 20 normal subjects (r = 0.94; SD = 0.31 l/mn; y = 0.98 x -0.004). We then studied a group of 38 patients with pure isolated mitral regurgitation. Five patients were excluded because of the poor quality of the echocardiographic documents. The hemodynamic regurgitant fraction was determined by measuring pulmonary flow by thermodilution and the left ventricular outflow by digitised angiography. The average Doppler and hemodynamic regurgitant fractions were 46.6 +/- 18% and 42 +/- 17% respectively. There was a close correlation between the Doppler and hemodynamic values (r = 0.91; SD = 7.8%; y = 0.97 x + 5.7). The correlations were also good between Doppler regurgitant fraction and the four angiographic grades of regurgitation (r = 0.88). A statistically significant difference was observed between the Doppler regurgitant fractions of Grades I and II and of Grades III and IV (p less than 0.001). In addition, the ratio of mitral VTI/aortic VTI gave a useful index of regurgitation in pure mitral insufficiency. When the ratio was greater than 1.3 the regurgitant fraction was over 40% with a sensitivity of 79% and a specificity of 86%. Finally, this study shows that pure, isolated mitral regurgitation can be evaluated by Doppler echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Echo-Doppler quantitative assessment of non-ischaemic mitral regurgitation

The reliability of non-invasive quantification of mitral regurgitation (MR) was assessed in 76 patients with angiographically demonstrated MR by comparing the results of different echo-Doppler (ED) indices with angiographic grade and MR fraction (MRF). Echo-Doppler studies were performed within 72h of right and left heart catheterizations in all patients. The following results were obtained: Transthoracic maximal relative jet area (RJA) is disappointing and differentiates only grade 1 from grade 4MR. RJA correlates better with haemodynamic data when obtained by transoesophageal echo: r = 0.78 versus r = 0.62, P less than 0.001. With the transoesophageal approach, a relative jet area greater than 50% and/or a jet width greater than 6 mm measured at the origin of the jet are strong indicators of severe MR. The ratio of mitral velocity time integral (VTI) to aortic VTI correlates with MRF: r = 0.77, P less than 0.001, n = 37. A VTI ratio greater than 1.3 identifies RF greater than 40% with a sensitivity of 80% and a specificity of 87%. A total inversion of the systolic wave of pulmonary venous flow is specific for grade 4 MR. The Doppler-derived MRF, correlates well with haemodynamic RF (r = 0.92, P less than 0.001, SEE: 7.5%).

[Determination of transmitral blood flow by pulsed echodoppler. Correlation with aortic blood flow in 30 patients]

The aim of this study was to assess the validity of mitral valve blood flow measured by pulsed Doppler echocardiography (PDE) with the sample volume positioned at the tips of the mitral leaflets. Thirty patients with a mean age of 38.4 years underwent calculation of transmitral blood flow: by Touche's method (A) in which the mitral orifice is assumed to be an ellipse with a constant long axis equal to the diameter of the mitral annulus and a variable short axis equal to the distance between the mitral leaflets measured on the M mode recording. The velocities are recorded by PDE with the sample volume at the tips of the mitral leaflets. The instantaneous cardiac output is equal to the surface multiplied by the instantaneous velocity. The integration of the instantaneous outputs throughout the whole of diastole by a computer programme provides the stroke volume; by a simplification of this method (B) which considers the short axis of the mitral ellipse to be constant and equal to the mean mitral valve leaflet separation measured from the M mode recording, and; by Hoit's method (C) which calculates mitral valve surface area from the M mode recording alone. The transmitral blood flow was calculated by these three methods and compared to the classical PDE aortic cardiac output measurement during the same examination, the accuracy of which has been previously demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of severity of aortic regurgitation by M-mode colour Doppler flow imaging

To assess the value of measuring the aortic regurgitant jet diameter at its origin by M-mode colour Doppler imaging, 82 patients with aortic regurgitation underwent, within 72 h of each other, colour Doppler examination and angiography. After excluding one patient without colour Doppler aortic regurgitation and five with a highly eccentric regurgitant jet, we found a close relationship between the jet diameter at its origin measured by M-mode colour Doppler and the angiographic grade of aortic regurgitation (r = 0.88). A jet diameter greater than or equal to 12 mm identified severe aortic regurgitation (grade III or IV) with a sensitivity of 86.4% and a specificity of 94.4%. In 38 patients, the jet diameter correlated well with the regurgitant fraction measured by a combined haemodynamic-angiographic method (r = 0.88). A jet diameter greater than or equal to 12 mm identified a regurgitant fraction greater than or equal to 40% with a sensitivity of 88.2% and a specificity of 95.2%. This study indicates that the size of the regurgitant jet diameter at its origin measured by M-mode colour Doppler provides a simple and useful measure of the severity of aortic regurgitation. It may allow differentiation between mild or moderate and severe aortic regurgitation and evaluation of regurgitant fraction.

[Postoperative iatrogenic left coronaroventricular fistula. Demonstration by color two-dimensional Doppler]

The authors report the case of an asymptomatic 67 year old patient, in whom, 6 years after aortic valve replacement, Doppler color flow mapping showed the presence of a coronary artery--left ventricular fistula. The normality of preoperative coronary angiography suggested that this fistula was created during peroperative left ventricular purging: the implantation of a needle through the right ventricle and interventricular septum. A iatrogenic lesion of a septal branch probably caused the communication between the left anterior descending artery and the left ventricle. Postoperative normalisation of the left ventricular end diastolic dimension, the absence of dilatation of the left main coronary on 2D echocardiography, the narrowness of the Doppler color jet and the absence of a significant end diastolic Doppler signal in the aortic isthmus indicated a fistula of small size and simple Doppler echocardiographic follow-up was decided upon.

End diastolic flow velocity just beneath the aortic isthmus assessed by pulsed Doppler echocardiography: a new predictor of the aortic regurgitant fraction

End diastolic flow velocity just beneath the aortic isthmus was measured within 72 hours of cardiac catheterisation by pulsed Doppler echocardiography in 30 controls and 61 patients with aortic regurgitation. The end diastolic flow velocity was determined at the peak R wave on a simultaneously recorded electrocardiogram. In all controls there was no reverse flow at the end diastole beneath the aortic isthmus. In patients with aortic regurgitation the end diastolic flow velocity correlated well with the angiographic grade of regurgitation (r = 0.81) and regurgitant fraction (r = 0.82). The mean (SD) values were 6.3 (5.2), 12.2 (4.3), 22.1 (5.7), and 34.3 (9.3) cm/s for patients with regurgitant fraction of less than 20%, between 20% and 40%, between 41% and 60%, and greater than 60%, respectively. An end diastolic flow velocity of greater than 18 cm/s predicted a regurgitant fraction of greater than or equal to 40% with a sensitivity of 88.5% and a specificity of 96%. The study suggests that the pulsed Doppler derived end diastolic flow velocity is a useful index in the routine non-invasive assessment of the severity of aortic regurgitation.

Determination of left ventricular inflow by pulsed Doppler echocardiography: influence of mitral orifice area and blood velocity measurements

Pulsed Doppler echocardiography was performed in 30 patients to assess the influence of mitral orifice area and velocity on the determination of mitral stroke volume and inflow. Aortic forward stroke volume and outflow were measured at the centre of the aortic annulus, and compared with mitral flow measurements calculated by three methods. Both mitral stroke volume and inflow derived from an instantaneous velocity-area method showed an excellent correlation with aortic flow measurements. The other two methods, which determined mitral stroke volume and inflow based on a mean mitral valve area and diastolic velocity integral, significantly underestimated mitral flow measurements. This study indicates that the instantaneous velocity-area method offers a reliable means for quantitating left ventricular inflow.

[Doppler echocardiographic study of mitral and aortic flow at various rates and atrioventricular intervals in patients with dual chamber pacemakers]

The aim of this study was to measure the changes in mitral and aortic blood flow induced by rate changes and different atrioventricular intervals in dual chamber pacemaker patients. Ten totally pacemaker dependant patients were studied under basal conditions, in double atrial and ventricular stimulation mode, by pulsed Doppler recordings of mitral and aortic flow, at three different pacing rates (80, 100 and 120/mn) and with three different atrioventricular intervals at each rate (short, 90 or 115 ms; medium, 165 or 190 ms; and long, 240 ms). The increase in pacing rate and prolongation of the atrioventricular interval significantly shortened the duration of mitral flow. Increasing the pacing rate induced a significant fall in stroke volume measured from the aortic flow. The optimal atrioventricular interval tended to shorten when the pacing rate was increased; a long atrioventricular interval had a deleterious effect on stroke volume compared with medium and short atrioventricular intervals; however, the difference between the short and medium atrioventricular intervals was not statistically significant even at 120 mn. These observations emphasise the hemodynamic advantages of shortening of the atrioventricular interval of dual chamber pacemakers when the pacing rate increases.

[Echodoppler evaluation of the normally functioning Saint-Jude's aortic valve prosthesis]

The aims of this study were: to define Doppler echocardiographic criteria of normality of aortic St Jude Medical (SJM) valve prostheses with respect to their size and to verify the validity of the continuity equation in the determination of prosthetic valve functional surface area. Forty patients with apparently normally functioning SJM prostheses without other cardiac disease were investigated at least one month after surgery. The group consisted in 1 n. 19, 6 n. 21, 9 n. 23, 12 n. 25 and 12 n. 27 SJM prostheses. The following parameters were measured: the maximum transprosthetic velocity, maximum and mean transprosthetic pressure gradients, permeability index and the Doppler surface area calculated by the continuity equation using the method proposed by Skjaerpe. The global results were as follows: maximum velocity = 2.5 +/- 0.4 m/s (1.8-3.7 m/s); maximum gradient = 26.9 +/- 9.8 mmHg (14-53 mmHg); mean gradient = 13.7 +/- 5.6 mmHg (7-30 mmHg); permeability index = 0.41 +/- 0.09 (0.23-0.57); Doppler surface area = 1.89 +/- 0.66 cm2 (0.73-3.23 cm2). When the prostheses were considered according to their sizes a weak negative correlation was observed between the mean pressure gradients and the size of the prostheses: r = -0.43, p less than 0.05 and a positive correlation between Doppler surface area and the theoretical prosthetic surface area: r = 0.71, p less than 0.005; SD = 0.45 cm2. No significant differences were observed between the pressure gradients and velocities of each size of prosthesis except when sizes 21 + 23 were compared with the large sizes (n. 25 + 27).(ABSTRACT TRUNCATED AT 250 WORDS)

[EPIM. Survey of myocardial infarction in Picardie]

The aim of this prospective study carried out in picardy (Aisne, Oise and Somme Departments) between October 1st 1985 and September 30th 1986, was to determine the incidence and outcome of recent myocardial infarction (less than 1 month) hospitalised in the region, to assess the time delay before hospital admission, the mode of management, treatment in the acute phase and at discharge, and the attitudes to exercise stress testing and coronary angiography. All public and private hospitals of the 3 departments who admitted patients with acute myocardial infarction accepted to fill out the questionnaire. A total of 1260 infarcts in patients with an average age of 66.7 +/- 12.6 years were collected. Nearly 3 out of 4 patients were male, and the men generally 10 years younger (64 +/- 12.6 years) than the women (73.4 +/- 10 years). The time delay to hospital admission was very long: 16.6 +/- 47.5 hours. Two thirds of patients were transferred by non medicalised transport; 82 per cent of patients were directed to the casualty department which redirected 71 per cent to the cardiology department. Myocardial infarction was inaugural in 46.5 per cent of cases. The incidence of anterior and inferior infarction was almost identical (44 ans 45.5 per cent respectively). Treatment in the acute phase included Heparin (94 per cent), nitrate derivatives (93.7 per cent) and calcium inhibitors (78 per cent). Thrombolytic and betablocker therapy was only prescribed in 8.3 and 23.5 per cent of cases respectively. During the hospital period, average 17 +/- 9 days, the mortality rate was 22.3 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echocardiographic study of hemodynamic changes of double stimulation mode and atrial detection in patients with dual chamber pacemaker. Value of hysteresis of the atrioventricular delay]

This Doppler echocardiographic study of patients with a dual chamber pacemaker was undertaken to assess the changes in mitral and aortic flow induced by passing from the double stimulation to the atrial detection mode. Thirteen patients totally dependent on ventricular pacing were examined and mitral and aortic blood flow recorded by pulsed wave Doppler. The chronology of left atrial contraction as assessed by the Doppler mitral A wave was measured with respect to the ventricular stimulation. The A wave was recorded on average 177 ms after the right atrial stimulation artefact. For an average AV delay of 168.8 ms and an identical pacing frequency, the passage from the double stimulation to the atrial detection mode led to left atrial contraction occurring on average 70 ms earlier with respect to ventricular stimulation, reflecting prolongation of the programmed AV delay related to the delay in detection of the sinus atrial wave. This earlier atrial systole shortened the total duration of mitral flow from 363 to 317 ms, decreased the early diastolic mitral flow and increased the atrial end diastolic flow; the stroke volume and cardiac output calculated from the aortic velocity time integral decreased significantly from 73 +/- 11 ml to 67 +/- 10 ml and 5.4 +/- 1.11/mn to 4.9 +/- 1.01/mn respectively. The initial parameters were restored (average 74 +/- 9 ml and 5.5 +/- 1.11/mn respectively) when the AV delay in the atrial detection mode was reduced by a value close to that of the calculated increase.(ABSTRACT TRUNCATED AT 250 WORDS)

[Quantification of valvular stenosis by Doppler echography]

Doppler echocardiography has made decisive advances in the non-invasive quantification of valvular stenosis. The simplified Bernoulli formula gives access to the maximum and mean transvalvular pressure gradients which correlate very well with the gradients measured at catheterisation. In addition, it is possible to calculate valve surface area in aortic and mitral stenosis from the continuity equation providing its conditions of application are respected. The Doppler surface area of mitral stenosis can also be estimated with some reservations by measuring pressure half time. Doppler echocardiography provides a reliable non-invasive hemodynamic study of valvular stenosis and should lead to a reduction in the number of indications of cardiac catheterisation, especially as pulmonary artery pressures can be determined from Doppler recordings of tricuspid and pulmonary regurgitation.

[Mid-term results of 50 percutaneous aortic valvuloplasties. Follow-up studies using Doppler echocardiography]

The aim of this study was to assess the results of percutaneous aortic valvuloplasty in 50 patients (29 men and 21 women, mean age 74 years) at 6 months by Doppler echocardiography performed 24 hours before, 24 hours, 3 and 6 months after the procedure. The following parameters were compared: maximum instantaneous transaortic pressure gradient; mean gradient; aortic valve area and index of valve patency. The initial results of catheterisation and valvuloplasty were very satisfactory as the peak-to-peak and mean pressure gradients decreased by 50 per cent and the aortic valve area increased from 0.55 +/- 0.2 to 0.83 +/- 0.30 cm2 and the success rate defined as a final surface area greater than 0.75 cm2 was 84 per cent. Unfortunately, these favourable results were not sustained in most cases: restenosis, defined as a valve area of less than 0.7 cm2, was observed in 18 per cent of patients at Day 1 and 71 per cent of patients at the 6th month; the natural history of disease was little affected with a global mortality rate at 6 months of 18 per cent through cardiac failure and sudden death; only 18 per cent of patients maintained an aortic valve area of over 0.75 cm2 at 6 months. These results suggest that percutaneous aortic valvuloplasty should be reserved for patients in whom surgery is formally contra-indicated.

[Noninvasive measurement of cardiac output by pulsed Doppler echocardiography. Correlation with thermodilution]

Cardiac output was measured simultaneously by pulsed Doppler echocardiography and thermodilution in 22 patients, 18 of whom also underwent atrial pacing at different rates to give a total of 42 different measurements. The aortic diameter was measured firstly at the aortic ring at the level of insertion of the aortic cusps and then at the point of maximum separation of the valve cups in the left parasternal long-axis view. The aortic velocities were recorded in the apical 5-chamber view immediately below the level of the aortic valve. The correlations obtained at the aortic ring (R1) and at the point of maximum separation of the valve cusps (R2) were 0.77 (y = 0.67x + 1.17: standard error = 0.81 l/m) and 0.64 (y = 0.56x + 0.87; standard error = 1.01 l/mn) respectively. The correlations were much better when 7 technically unsatisfactory measurements were excluded (R2 = 0.76: y = 0.59x + 0.74: standard error = 0.79 l/mn) (R1 = 0.87: y = 0.72x + 1.04: standard error = 0.65 l/mn). THe correlations of stroke volume measured at aortic ring level also improved from r = 0.82 (y = 0.75x + 7.29: standard error = 8.9 ml) to r = 0.89 (y = 0.78x + 7.38: standard error = 7.3 ml). The measurement of cardiac output by pulsed Doppler echocardiography in the aortic root seems to be reliable. The correlations of the values of stroke volume and cardiac output with the thermodilution method are good, allowing detection of beat-to-beat variations of cardiac output, in suitable patients in the hands of experienced operators.