Transesophageal echocardiography

The size distribution of the agitated saline microbubbles for contrast transcranial Doppler generated using standard manual methods

Agitated saline microbubbles (MBs) are a common contrast agent for determining right-to-left shunt (RLS) by the contrast transcranial Doppler (c-TCD). The size of the generated bubbles is not standardized in clinical practice. MBs were generated using the recommended manual method by reciprocating motion through two syringes. The bubble size distributions (BSD) were measured using the microscopic shadow imaging technique. The results show that the diameter of MBs is mainly distributed between 10 and 100 μm, the mean bubble size is between 21 and 34 μm, the Sauter mean diameter (D32) is primarily between 50 and 300 μm, and the standard deviation (SD) is between 6 and 17 μm in 80 experiments. It provides a more accurate basis for the recommended manual method instability. The high variance values of the BSD indicate that the manual method has low stability and repeatability. The results of this study can be useful for further improvement of the reliability of c-TCD in detecting RLS. RESEARCH HIGHLIGHTS: This study provided the first detailed descriptions of the MBs size distribution in a flowing contrast agent by the microscopic shadow imaging technique. It reveals significant differences in the bubble size of manual foaming during repeated manipulations for each individual and between individuals.

Extensive myocardial calcifications in a dialysis patient: A porcelain heart manifesting with abdominal pain

This case report describes a 41-year-old male patient with chronic kidney disease on peritoneal dialysis presenting with upper abdominal pain and mild thigh numbness. CT chest demonstrated extensive myocardial calcifications and left atrial thrombus. This case emphasizes the clinical relevance of myocardial calcifications, especially in patients with end-stage renal disease. It also highlights the potential association between these calcifications and complications such as atrial fibrillation and thromboembolic events. The findings emphasize the need for diagnostic vigilance and an improved understanding of the pathophysiology of myocardial calcifications in the context of renal disease.

Oropharynx pain, discomfort, and economic impact of transesophageal echocardiography for planned radio-frequency catheter ablation in patients with atrial fibrillation: A cross-sectional survey study

Background

To survey the unmet medical needs associated with atrium thrombus screening in Chinese patients with atrial fibrillation (AF) who underwent transesophageal echocardiography (TEE) for planned radio-frequency catheter ablation (RFCA).

Methods

This cross-sectional survey study interviewed 300 patients who underwent their first TEE for planned RFCA. The surveyed information included patients' anxiety, oropharynx pain and discomfort, time expense, and patient satisfaction related to TEE examination. Patient preference for a new atrium thrombus screening technology, hospital length of stay (LOS) of RFCA, and hospital costs of RFCA in these surveyed patients were collected as well. Descriptive statistical methods were used to summarize the collected survey information.

Results

Of the 300 interviewed patients, 36.3% reported anxiety before TEE examination, 58.6% reported oropharynx pain related to TEE, and 76.2% reported oropharynx discomforts, mainly including foreign body sensation (54.3%), dry heaves (33.8%), nausea (31.9%), and bleeding (22.9%). Even though 62.3% were satisfied with TEE, 84.3% preferred a new technology to replace TEE. Conducting outpatient TEE took more wait time (4.4 days vs. 0.1 days, p = 0.016) but led to significantly shorter hospital LOS (3.8 days vs. 6.4 days, p < 0.001) and significant lower hospital costs for RFCA (¥74,097 vs. ¥85,843, p < 0.001) than conducting inpatient TEE.

Conclusions

Most AF patients experienced oropharynx pain and discomfort during or after TEE. Although more than half of AF patients were satisfied with TEE, most AF patients preferred a new technology to replace TEE for atrium thrombus screening. TEE was associated with economic impact on RFCA irrespective of TEE conducting settings.

The 2022 FASEB Virtual Catalyst Conference on the Cardiac Interatrial Septum and Stroke Risk, December 7, 2022

There is emerging evidence that the cardiac interatrial septum has an important role as a thromboembolic source for ischemic strokes. There is little consensus on treatment of patients with different cardiac interatrial morphologies or pathologies who have had stroke. In this paper, we summarize the important background, diagnostic, and treatment considerations for this patient population as presented during the Federation of American Societies for Experimental Biology (FASEB) Virtual Catalytic Conference on the Cardiac Interatrial Septum and Stroke Risk, held on December 7, 2022. During this conference, many aspects of the cardiac interatrial septum were discussed. Among these were the embryogenesis of the interatrial septum and development of anatomic variants such as patent foramen ovale and left atrial septal pouch. Also addressed were various mechanisms of injury such as shunting physiologies and the consequences that can result from anatomic variants, as well as imaging considerations in echocardiography, computed tomography, and magnetic resonance imaging. Treatment options including anticoagulation and closure were addressed, as well as an in-depth discussion on whether the left atrial septal pouch is a stroke risk factor. These issues were discussed and debated by multiple experts from neurology, cardiology, and radiology.

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces.

Spontaneous Echo Contrast in the Left Atrium and Aortic-Arch Atheroma, Detected by Transesophageal Echocardiography, Was Negatively Correlated with Cognitive Function

BACKGROUND

The relationship between transesophageal echocardiography findings and cognitive function.

OBJECTIVE

This study aimed to establish an association between transesophageal echocardiography findings and cognitive function in stroke survivors.

METHODS

A single-center study was conducted between April 1, 2017 and March 31, 2022. All subjects that were included had a past history of ischemic stroke and were admitted after >21 days from onset. The participants underwent cognitive function tests including a Mini-Mental State Examination, Revised Hasegawa Dementia Scale, Frontal Assessment Battery, and transesophageal echocardiography.

RESULTS

The results of 126 participants were analyzed. The cognitive function of participants with a spontaneous echo contrast (+) in the left atrium including appendage or of those with an aorta-arch plaque with a maximum thickness ≥4 mm significantly worse while neither the patent foramen ovale nor the branch extending plaque influenced cognitive function (The median cognitive scores of the spontaneous echo contrast (-) versus (+) were 26 versus 22, p < 0.01**, 26 versus 21, p < 0.001***, and 14 versus 11, p < 0.01**. Those of the aortic-arch plaque max thickness (<4 mm) versus (≥4 mm) were 26 versus 25, p < 0.05*, 27 versus 24, p < 0.05*, and 15 versus 13, p < 0.05*).

CONCLUSION

Our findings show that spontaneous echo contrast in the left atrium and aortic-arch atheroma detected by transesophageal echocardiography, were negatively associated with cognitive function.

Myocardial Cut-off Sign is a Sensitive and Specific Cardiac Computed Tomography and Magnetic Resonance Imaging Sign to Distinguish Left Ventricular Pseudoaneurysms From True Aneurysms

PURPOSE

The purpose of this study was to describe the myocardial cut-off sign, assess its ability to distinguish left ventricular pseudoaneurysms (LV PSAs) from true aneurysms (LVAs), and compare its performance with other imaging findings and quantitative measurements used to differentiate LV PSAs from LVAs.

MATERIALS AND METHODS

This retrospective single-center study identified patients with preoperative cardiac computed tomography (CT) or magnetic resonance imaging (MRI) and surgically confirmed LVAs or LV PSAs over a 10-year period. Seventeen LV PSAs (11 MRI, 6 CT) and 18 LVAs (10 MRI, 8 CT) were included. The myocardial cut-off sign was objectively a >50% decrease in aneurysm sac wall thickness measured at 1 cm from the aneurysmal neck (measurements at 2 cm were also assessed) and subjectively an abrupt "cut-off" of myocardium for the aneurysm sac for PSA compared with a gradual tapering of sac wall thickness for LVA. Two radiologists independently evaluated images for the subjective presence of this sign.

RESULTS

The myocardial cut-off sign was 91% sensitive and 97% specific when measured 1 cm from the aneurysm neck. When measured at 2 cm from the neck, the sign was 100% sensitive and 69% specific. Subjective analysis of whether the myocardium appeared "cut-off" was 94% to 100% sensitive and 78% to 94% specific with excellent agreement for both PSA (κ=0.94) and LVA (κ=0.83).

CONCLUSIONS

The myocardial cut-off sign on cardiac CT and MRI is a sensitive and specific finding of LV PSA. Specificity is improved with objective measurements compared with subjective assessment (97% vs. 78% to 94%). This sign may help radiologists distinguish between LV PSAs and LVAs.

Imaging of left heart intracardiac thrombus: clinical needs, current imaging, and emerging cardiac magnetic resonance techniques

Intracardiac thrombus in the left atrium and atrial appendage (LA/LAA) and left ventricle (LV) increases the risk of systemic thromboembolism and causes potentially devastating diseases such as ischemic stroke and acute ischemia in abdominal organs and lower extremities. Detecting the presence and monitoring the resolution of left heart intracardiac thrombus are of vital importance for stratifying patients and guiding treatment decisions. Currently, echocardiography is the most frequently used method for the above clinical needs, followed by computed tomography. An increasing number of studies have been performed to investigate the value of cardiac magnetic resonance (CMR) as an alternative imaging modality given its several unique strengths. This article provides an overview of the clinical relevance of the LA/LAA and LV thrombus as well as the diagnostic performance of the current imaging modalities and emerging CMR techniques.

Atypical imaging presentation of a massive intracavitary cardiac thrombus: A case report and brief review of the literature

Intracavitary cardiac thrombi, uncommonly found in the right chambers, have been shown to form secondary to endocardial and myocardial diseases. The differential diagnosis for an intracavitary cardiac mass is broad, including primary cardiac tumors, cardiac metastases, anatomic variants, vegetations, and thrombi. Here we present a unique case with a large calcified intracavitary cardiac thrombus in a 26-year-old woman with obesity, immune thrombocytopenic purpura, and a new diagnosis of systemic lupus erythematosus. Initial imaging presentation in this case masqueraded as a tumor, delaying the true diagnosis. A combination of cardiac imaging techniques, including transthoracic and transesophageal echocardiograms, cardiac CT, and cardiac MRI were required to correctly diagnose this calcified bland thrombus.

[Value of dual-energy computed tomography for detection of left atrial appendage thrombus]

OBJECTIVE

Contrast-enhanced computed tomography (CT) is a convenient method to visualize left atrial appendage (LAA) thrombi. We determined whether diagnostic accuracy improves by including dual-energy as compared to transesophageal echocardiography (TEE). Furthermore, the influence of protocol parameters on radiation dose were quantified.

METHODS

Patients were assigned to the different CT protocols. All CTs were assessed qualitatively for presence of LAA thrombi and dual-energy CT scans quantitatively for iodine concentration. TEE was assessed qualitatively for the presence of thrombi.

RESULTS

Of 32 enrolled patients, 6 had a thrombus in TEE. Qualitative CT assessment yielded 83% sensitivity and 88% specificity. In the 26 patients who underwent dual-energy CT, median iodine concentration was 8.6 mg/cm³ and significantly lower in patients with than without LAA thrombi ; furthermore, it provided value for detecting LAA thrombi (AUC: 0.950 vs 0.867 for combined vs. only qualitative assessment, p = 0.04). The median radiation dose was 1.83 mSv; independently lower in scanning only LAA and with prospective gating , while arrhythmia and dual-energy did not contribute independently.

CONCLUSION

CT provides good diagnostic accuracy for detecting LAA thrombi, which can further be improved if iodine density measurements by dual-energy are incorporated. With an optimized protocol, reasonably low radiation dose can be achieved.

Transoesophageal echocardiography current practice in France: A multicentre study

BACKGROUND

Few data are available on the application of transoesophageal echocardiography (TOE) recommendations in daily practice.

AIMS

To evaluate TOE practice based on echocardiography societies' guidelines, and to determine complication rates and factors associated with patient feelings.

METHODS

Between April and June 2017, we prospectively included all consecutive patients referred to 14 French hospitals for a transoesophageal echocardiogram (TOE). A survey was taken just after the examination, which included questions about pre-procedural anxiety, and any pain, unpleasant feeling or breathing difficulties experienced during the examination.

RESULTS

Overall, 1718 TOEs were performed, mainly for stroke evaluation. A standardized operating procedure checklist was completed in half of the patients before the examination. TOE was unpleasant for 62.4% of patients, but was stopped for agitation or intolerance in 3.5 and 1.4% of cases, respectively. We observed one severe complication (pulmonary oedema). The mean TOE duration was short (9.2±4.6minutes), but was longer with residents than with more experienced physicians (11±4.7 vs. 8.8±4.7minutes for junior physicians [P=0.0027]; vs. 8.9±4.8minutes for senior physicians [P=0.0013]; and vs. 7.5±4.1minutes for associate professors/professors [P<0.0001]). The visual analogue scale (VAS) score after TOE was good (8.3±1.7 out of 10), and was better in patients with general anaesthesia (GA) than in those without GA (9.3±0.9 vs. 8.1±1.7; P<0.0001). In patients without GA, the VAS score was similar with and without local anaesthesia (8.1±1.7 vs. 8.2±1.6; P=0.19). After multivariable adjustment, absence of anxiety before TOE and greater operator experience were consistently associated with a higher VAS score.

CONCLUSIONS

TOE is safe, with a low rate of complications and few stops for intolerance. A shorter TOE duration and better patient feelings were observed for experienced operators, highlighting the importance of the learning curve, and paving the way for teaching on a TOE simulator.

Aortic valve papillary fibroelastoma causing embolic strokes: a case report and review

Papillary fibroelastomas (PFEs) are the second most common benign neoplasms of the cardiac valves and are being recognized more frequently because of higher resolution imaging technology. PFEs are associated with substantial complications that are secondary to systemic embolism. Surgical resection should be offered to all patients who have symptoms and to asymptomatic patients who have pedunculated lesions or tumors larger than 1 cm in diameter. Herein, we present a patient who presented for a second time in 2 months with stroke symptoms. During his first admission, a transthoracic echocardiogram was performed and he was sent home after resolution of his symptoms and a grossly negative workup. During his second admission, a transesophageal echocardiogram was performed and the PFE was found and later excised. While this discussion reviews the literature with regard to detection and management, it will hopefully serve as a reminder to keep this on the differential when the workup has remained without an obvious source.

The Standard TEE Examination: Procedure, Safety, Typical Cross-Sections and Anatomic Correlations, and Systematic Analysis

Multiplane transesophageal echocardiography (TEE) is a semiinvasive, very low-risk imaging procedure utilizing the upper gastric and esophageal echo windows to image the heart with the use of high-frequency transducers. It allows for high spatial resolution and access to structures that are routinely not well seen by transthoracic echocardiography, such as the left atrial appendage, the thoracic aorta, and the pulmonary veins, or where transthoracic imaging may be insufficient to answer a specific question, such as the presence of small vegetations, endocarditic abscesses, abnormalities of the interatrial septum, and others. Another important indication is the ventilated patient or the patient in the operating room, where transthoracic echocardiography is unrewarding or impossible. A particular role has emerged for TEE for identifying candidates for mitral valve repair by providing detailed functional and morphologic information on the diseased valve and by checking intraoperatively the results of surgery. A set of cross-sections, defined by anatomic landmarks, has been compiled, which can be systematically sought, evaluated, and modified according to the clinical question in order to extract the maximal information from TEE.

Infective endocarditis and mannose-binding lectin deficiency – A case report

We present the case of a 40-year-old woman diagnosed with Austrian syndrome, an association of endocarditis, meningitis and pneumonia caused by Streptococcus pneumonia. She had none of the risk factors previously described in the literature but on immunological assay was found to have low serum levels of mannose-binding lectin, a protein required for complement activation. The clinical manifestation and treatment of this condition are discussed, and we emphasize the importance of early recognition of cardiac involvement and prompt surgical management.

Cardiac involvement in antiphospholipid syndrome: The diagnostic role of noninvasive cardiac imaging

OBJECTIVES

The antiphospholipid syndrome (APS) is an autoimmune disorder of acquired hypercoagulability characterized by vascular thrombosis, increased pregnancy morbidity, and elevated levels of antiphospholipid antibodies. Cardiac involvement in APS may be presented as heart valve disease affecting approximately a third of patients or less frequently as intracardial thombosis, pulmonary hypertension, right or left ventricular dysfunction, micro-vascular thrombosis, coronary artery, or micro-vascular disease with overt or silent clinical presentation.

METHODS

Noninvasive cardiovascular imaging plays a crucial role in the evaluation of heart involvement in APS. Transthoracic or transoesophageal echocardiography enable early, accurate diagnosis and severity assessment of HVD as well as of ventricular dysfunction and pulmonary hypertension. Studies by echocardiography and nuclear imaging have detected abnormalities in myocardial perfusion in approximately 30% of primary APS. CT scan is the technique of choice for the assessment of pulmonary embolism and can effectively detect intracardiac thrombi. Myocardial perfusion defects have been detected by 13N-ammonia PET in 40% of APS. Cardiovascular magnetic resonance (CMR) has identified an unexpectedly high prevalence of occult myocardial scarring and endomyocardial fibrosis in APS, and is the technique of choice, if quantification of heart valve disease and stress myocardial perfusion-fibrosis is needed.

RESULTS

Noninvasive, nonradiating imaging techniques, such as echocardiography and CMR are superior to CT or nuclear techniques and are of great value for the diagnosis and follow-up of both clinically overt and silent cardiac disease in APS.

CONCLUSIONS

The high incidence of cardiac involvement in APS demands early diagnosis/treatment and multimodality cardiovascular imaging is of great importance.

Predictors of Recurrent Stroke in Patients with Ischemic Stroke: Comparison Study between Transesophageal Echocardiography and Cardiac CT

PURPOSE

To investigate cardiac computed tomographic (CT) findings predictive of recurrent stroke in patients with ischemic stroke and determine the incremental risk stratification benefit of cardiac CT findings compared with transesophageal echocardiography (TEE) findings in patients with ischemic stroke.

MATERIALS AND METHODS

This single-center prospective study protocol was approved by the institutional review boards, and written informed consent was obtained from all patients. Among 548 consecutive patients, 374 patients with ischemic stroke (254 men and 120 women, with a mean age of 63.1 years) who underwent TEE and cardiac CT were prospectively enrolled in this study. TEE and cardiac CT images were assessed for cardioembolic sources, including thrombus, tumor, spontaneous echo contrast, valvular vegetation, atrial septal aneurysm, patent foramen ovale, and aortic plaque. The primary end point was stroke recurrence. Prognostic factors were assessed with Cox univariate and multivariate analysis. The integrated area under the receiver operating characteristic curve was calculated to compare the prognostic abilities of CT and TEE parameters.

RESULTS

During a median follow-up period of 433 days, there were a total of 28 recurrent stroke events. The TEE parameter of plaque complexity (hazard ratio, 13.512; 95% confidence interval: 3.668, 49.778; P < .001) and CT parameter of plaque complexity (hazard ratio, 32.538; 95% confidence interval: 7.544, 140.347; P < .001) were predictors of recurrent stroke. The time-dependent receiver operating characteristic curve analysis demonstrated no significant differences in prediction of recurrent stroke between TEE and CT parameters (integrated area under the receiver operating characteristic curve, 0.812 vs 0.840, respectively).

CONCLUSION

Complex aortic plaque evaluated with cardiac CT and TEE was associated with an increased risk of stroke recurrence in patients with ischemic stroke.

Transesophageal echocardiography: a complementary view of the heart

Transesophageal echocardiography has been widely used as a diagnostic tool during the past two decades to detect cardiac abnormalities that are not visible or poorly visible with transthoracic echocardiography. At present, transesophageal echocardiography is a cornerstone of modern diagnosis of several cardiac diseases, providing diagnostic, prognostic and therapeutic information. In this review, the present status of transesophageal echocardiography not only as a diagnostic tool, underlining its effects on clinical decision making, but also as a monitoring adjunct for many interventional cardiac procedures is examined.

Measurement science in the circulatory system

The dynamics of the cellular and molecular constituents of the circulatory system are regulated by the biophysical properties of the heart, vasculature and blood cells and proteins. In this review, we discuss measurement techniques that have been developed to characterize the physical and mechanical parameters of the circulatory system across length scales ranging from the tissue scale (centimeter) to the molecular scale (nanometer) and time scales of years to milliseconds. We compare the utility of measurement techniques as a function of spatial resolution and penetration depth from both a diagnostic and research perspective. Together, this review provides an overview of the utility of measurement science techniques to study the spatial systems of the circulatory system in health and disease.

Formal infectious diseases consultation is associated with decreased mortality in Staphylococcus aureus bacteraemia

To determine the impact of infectious diseases consultation (IDC) in Staphylococcus aureus bacteraemia. All MRSA bacteraemia and a random subset of MSSA bacteraemia were retrospectively analysed. Out of 599 SAB episodes, 162 (27%) were followed by an IDC. Patients with IDC were younger and more frequently intravenous drug users, but fewer resided in a long-term care facility or were indigenous. Hospital length of stay was longer (29.5 vs 17 days, p < 0.001), and endocarditis (19.1% vs 7.3%, p < 0.001) and metastatic seeding (22.2% vs 10.1%, p < 0.001) were more frequent in the IDC group; however, SAPS II scores were lower in the IDC group (27 vs 37, p < 0.001). ICU admission rates in the two groups were similar. The isolate tested susceptible to empirical therapy more frequently in the IDC group (88.9% vs 78.0%, p = 0.003). Seven-day (3.1 vs 16.5%), 30-day (8.0% vs 27.0%) and 1-year mortality (22.2% vs 44.9%) were all lower in the IDC group (all p < 0.001). Multivariate analysis showed that effective initial therapy was the only variable associated with the protective effect of IDC. In patients with SAB, all-cause mortality was significantly lower in patients who had an IDC, because of the higher proportion of patients receiving effective initial antibiotics.

Austrian syndrome

The authors present a case of Austrian syndrome, the triad of pneumococcal pneumonia, endocarditis and meningitis, in a 49-year-old woman, who developed severe acute heart failure due to aortic valve destruction. The patient required imminent valve surgery, but eventually recovered.

Permanent pacemaker and implantable cardioverter defibrillator infections: seven years of diagnostic and therapeutic experience of a single center

BACKGROUND

Increasing evidence-based indications for the implantation of permanent pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) have led to an increase in the rate of device infections. The aim of the present study was to evaluate infection frequency, clinical characteristics, risk factors, and microbiologic and therapeutic features in patients with PM/ICD infections.

HYPOTHESIS

Clinical and demographic characteristics of the patients can affect the PM/ICD infections.

METHODS

The PM/ICD infection group consisted of 57 patients diagnosed and treated with PM/ICD infections in our hospital. The control group in this case-control study consisted of 833 patients in whom a PM or ICD had been implanted and no infections were noted.

RESULTS

Patients with PM/ICD infections (median age 65 years; range, 18-104 years) were older than those without PM/ICD infections (median age 58 years; range, 18-86 years; P = 0.005). The percentage of generator replacement was higher in the PM/ICD infection group compared with the control group (16% vs 8%, P = 0.003). Independent predictors of PM/ICD infections were advanced age (>60 years; odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.2-4.0, P = 0.021) and device revision (OR: 3.8, 95% CI: 1.5-5.5, P = 0.002). Primary antibiotic prophylaxis during the procedure reduced the risk for PM/ICD infection (OR: 0.5, 95% CI: 0.4-0.8, P = 0.011).

CONCLUSIONS

PM/ICD infections occur in a significant number of patients. It is important to be aware of the risk factors for PM/ICD infections so that patients with an increased risk can be identified and preventive measures can be implemented.

[Value of cardiac MRI for intraventricular thrombi's diagnosis]

BACKGROUND

Intraventricular thrombosis is a serious event, generally complicating a wide myocardial infarction. It requires an adapted therapy, based on the oral anticoagulants. The diagnosis is generally carried out by trans-thoracic echocardiography but with an insufficient sensitivity and a specificity. In this context, the place of cardiac MRI remains to be explored.

PATIENTS AND METHOD

We carried out a retrospective registry of all cardiac MRI done in our hospital since 2003, for assessment of an intracardiac mass or an cerebral stroke. The aim was to compare the results of cardiac MRI with those of echocardiography and contrast ventriculography.

RESULTS

Our registry includes 26 cases of intraventricular thrombi, confirmed by cardiac MRI. Our results confirm the lack of sensitivity of echocardiography and the ventriculography. The Kappa correlation coefficient of echocardiography and ventriculography, with respect to the MRI, are very weak, respectively of -0.08 and 0.16.

CONCLUSIONS

The values of echocardiography and contrast ventriculography seem limited. The realization of a complementary cardiac MRI must be recommended as often as possible in case of doubt or high risk disease.

[Cryptogenic cerebral infarction: from classification to concept]

Since the foundations laid by Sacco and Mohr in 1989, from the Stroke data bank, cryptogenic infarctions have had a predominant place among the causes of ischemic strokes. In that study, they accounted for approximately 40% of the stroke causes. Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up; they differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. The size of this group will probably shrink as knowledge advances. Patent foramen ovale (PFO), with or without a septal aneurysm, is more frequent in patients with a cryptogenic infarction. Transesophageal echocardiography is the reference examination for screening for these abnormalities. A meta-analysis of several case-control studies showed a significant association between PFO and stroke in subjects younger than 55 years. For now, these septal abnormalities constitute a risk factor but not a cause. Complex aortic atheroma affecting area upstream of the left subclavian artery may be a source of cerebral embolisms in some conditions. The prevalence of this disease increases with age. It is identified most frequently in patients older than 60 years with a cryptogenic infarction. The thickness of the atheromatous plaque determines whether it is a risk factor or a cause. Recent stroke classifications do not consider carotid atheromatous lesions less than 50% to be a source of ischemic stroke. Nonetheless some studies identify moderate stenosis of the carotid artery more frequently in infarctions of unknown causes than in other categories. The increased risk of cerebral infarction when parents and homozygous twins have a history of stroke suggests that there may be genetic causes that have not yet been detected. An unknown genetic cause would thus be included in the infarctions of unknown causes. A recent study tested for Fabry disease in young patients with a cryptogenic infarction: 4.9% of the men and 2.4% of the women had a functional mutation of the alpha-galactosidase gene. These findings must be confirmed. Some studies suggest an association between cryptogenic infarction and hereditary thrombophilias. Nonetheless the risk attributable to these thrombophilic disorders is slight and the discovery may be only a coincidence. The work described above shows the importance of stratification in the identification of stroke causes: age older or younger than 55/60 years, type of interatrial abnormality (PFO and aneurysms of the interatrial septum), type of atheroma of the aortic arch (more or less than 4mm). They also show the difficulty involved in attributing cause to an identified abnormality: is carotid stenosis of less than 50% a marker of atherosclerosis or also a cause of stroke? To continue improving our understanding of the mechanisms of strokes, new investigational techniques are under evaluation. They include magnetic resonance imaging (MRI), computed tomographic angiography (CT), positron emission tomography (PET) of carotid plaque and of the aortic arch, transcranial Doppler, cardiac recording by telemetry, and even new biological assays.

Presence Of Left Atrial Appendage Thrombus In Patients Presenting For Left Atrial Ablation Of Atrial Fibrillation Despite Pre-Operative Anticoagulation

Background: One of the recognised complications of left atrial ablation for atrial fibrillation (AF) is stroke. Left atrial (LA) thrombus, which may be dislodged by catheter manipulation, is an absolute contraindication to ablation. It is unclear whether imaging of the left atrial appendage (LAA) by transesophageal echo (TEE) is mandatory to exclude LA clot prior to ablation, particularly in "low-risk" patients with paroxysmal AF and normal left ventricular (LV) function. Methods and Results: We carried out a retrospective analysis of pre-ablation TEE in patients presenting for ablation of AF. Images from 244 ablation procedures carried out in 148 patients were examined, including 106 patients with paroxysmal AF and normal LV function. Despite at least 4 weeks of pre-operative therapeutic anticoagulation with Warfarin (INR>2.0), LAA thrombus was identified in 4 patients (2.7% (0.1-5.3%)). These included 2 patients with paroxysmal AF and normal LV function, although both had a high arrhythmia burden. The thrombi regressed with intensification of anticoagulation. Conclusions: Pre-operative imaging of the LAA remains advisable to exclude thrombus prior to ablation for AF even in patients with paroxysmal AF and normal LV function, especially if there is a high AF burden.

MDCT features of cardiothoracic sources of stroke

Multidetector computed tomography (MDCT) is widely used in the assessment of cardiothoracic disease and provides high-resolution images of the heart, great vessels, and lungs. A range of cardiothoracic conditions can precipitate stroke, including intracardiac thrombus, right-to-left shunts, and diseases of the thoracic aorta. Many of these conditions may be identified on non-electrocardiogram (ECG)-gated studies, but the advent of high temporal resolution ECG-gated MDCT provides superior anatomical delineation. Radiologists should be familiar with the pathogenesis and CT features of cardiothoracic conditions that can precipitate stroke as their early identification to enables appropriate management and prognostic decisions.

Endocarditis caused by Staphylococcus aureus: A reappraisal of the epidemiologic, clinical, and pathologic manifestations with analysis of factors determining outcome

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Acute aortic dissection in children and adolescents: diagnostic and after-event follow-up obligation to the patient and family

Acute aortic dissection in childhood and adolescence is a rare but life-threatening condition with many known risk factors, most of which are heritable. The importance of determining the presence of any predisposing disorders is stressed, since all close relatives can then be screened for any such inherited trait that would make them at risk for a similar catastrophic event. Even with no obvious predisposing disorder, it may still be prudent to evaluate close kin for the presence of aortic root dilatation, since some genetic disorders have no manifestation other than acute aortic dissection secondary to aortic medial pathology. Close monitoring for at-risk family members, including the index patient, may need to be a life-long process.

Various findings of cardiac thrombi on MDCT and MRI

Cardiac thrombus accompanies risk for peripheral embolization, either into the systemic circulation (from the left heart) or into the pulmonary arteries (right heart). In fact, the presence of peripheral emboli should prompt the search for a source within the heart. Echocardiography is the present technique of choice. Also, computed tomography and magnetic resonance imaging may provide additional information. In this article, we will demonstrate various features of cardiac thrombus on computed tomography and magnetic resonance imaging such as mural thrombus after myocardial infarction, thrombus at left atrial appendage in patients with mitral stenosis, thrombus mimicking tumor, organized thrombus containing calcification at left atrium, and compact moderator band mimicking thrombus.

Papel do forame oval patente e da válvula de Eustáquio nos eventos tromboenbólicos

A associação entre forame oval patente (FOP) e embolia paradoxal é assunto já descrito na literatura médica. Quando não existe associação com aneurisma de septo atrial, surgem dúvidas quanto à origem do trombo devido à dificuldade que se tem de documentar a passagem de êmbolos vindos da circulação venosa pelo shunt direita-esquerda. Descrevemos quatro casos de eventos vasculares, cujos ecocardiogramas transesofágicos demonstraram a presença de trombo aderido ao FOP associado à válvula de Eustáquio proeminente na ausência de aneurisma de septo. Esse artigo visa ilustrar e chamar atenção para o potencial papel do FOP e da válvula de Eustáquio na ocorrência da embolia paradoxal

Yield of transesophageal echocardiography for nonbacterial thrombotic endocarditis and other cardiac sources of embolism in cancer patients with cerebral ischemia

Cerebrovascular events occur frequently in patients who succumb to cancer, and nonbacterial thrombotic endocarditis (NBTE) is a frequent postmortem finding in these patients. Despite the excellent diagnostic accuracy of transesophageal echocardiography (TEE) for cardiac sources of cerebral embolism, however, the prevalence of NBTE and other cardioembolic sources in patients with cancer and cerebral ischemia has not been investigated using this modality. This study examined the frequency of cardioembolic findings in consecutive patients with cancer referred to our institution for TEE evaluation of cerebrovascular events. The study cohort comprised 51 patients, of whom 18% had marantic vegetations, and 47% and 55% of whom had definite and definite or probable cardiac sources of embolism, respectively. The present study documents, for the first time, a high frequency of marantic endocarditis and other cardioembolic sources in patients with cancer and cerebrovascular events selected for TEE. This finding has important implications for evaluation and management in this patient population.

A novel method of measuring cardiac output in infants following extracorporeal procedures: preliminary validation in a swine model

In infants, technologies for obtaining rapid, quantified measurements of cardiac output (CO) following weaning from cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation are not readily available. A new technique to measure CO based on ultrasound velocity dilution is described. It utilizes reusable probes placed on the extracorporeal circuit that permits convenient measurement of CO prior to decannulation. This report provides preliminary validation data in an animal model. Three Yorkshire pigs (11-14 kg) were fully heparinized and cannulated via the right common carotid artery (cannula advanced to the aortic arch) and right atrium. Both the venous and arterial lines were instrumented with ultrasonic probes connected to a computer-monitoring system. A 'stopcock bridge' between the arterial and venous cannulas provided the access for saline injection and a controlled AV-shunt. For comparison, a vascular flow probe was fitted directly to the pulmonary artery (PA) in both animals and, for the larger animal, a PA catheter was inserted to obtain standard thermodilution measurements. Linear regression analysis revealed a correlation between the CO by ultrasound dilution (CO UD) technique and the vascular probe and PA thermodilution techniques to be R2 =0.94 and 0.81. This pilot study demonstrated that the CO UD technique correlates to other benchmarks of CO measurements. This novel technology has specific application in the field of pediatric open heart surgery in that it would allow the surgeon to accurately and inexpensively measure the CO of neonatal and pediatric patients before and after surgical manipulation of the heart without the need for placement of additional catheters or probes.

Clinical features remain important for the diagnosis of infective endocarditis in the modern era

BACKGROUND

Infective endocarditis (IE) can be difficult to diagnose, due to multiple (often non-specific) presenting features.

AIM

To assess the predictive accuracy of classical clinical features and blood investigations readily available at the time of presentation.

DESIGN

Cross-sectional analysis.

METHODS

We studied 29 IE cases and 79 controls (clinically suspicious contemporaneous cases where IE was subsequently excluded) from a hospital-based group of patients referred to a cardiac department with possible infective endocarditis. Patients were identified from the echocardiography database. Cases were defined by final diagnosis. Symptoms, signs, risk factors for IE and blood investigations were recorded from case notes and examined by univariate and multivariate analyses.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of transthoracic echocardiography (TTE) for detection of IE in clinically suspected cases were 71%, 98%, 57% and 99%, respectively. Univariate analyses revealed a significant association between IE and several clinical features. Under multivariate analysis, previous heart valve surgery (OR 13.3, 90%CI 3.2-55.6), positive blood cultures (OR 17.2, 90%CI 4.9-58.8), signs of embolism (OR 11.4, 90%CI 3.0-43.5), a new, altered or changing murmur (OR 10.3, 90%CI 2.8-38.5) and splenomegaly (OR 18.2, 90%CI 3.6-90.9) were independent predictors for IE.

DISCUSSION

Clinical features at presentation continue to be important for the diagnosis of IE. Features such as positive blood cultures, signs of embolism and a changing heart murmur should be used to guide investigation and treatment of IE prior to echocardiography, or when TTE is negative.

Thrombus Detection in the Left Atrial Appendage Using Contrast-Enhanced MRI: A Pilot Study

OBJECTIVE

Left atrial thrombi are an important cause for embolism-related morbidity and mortality. Transesophageal echocardiography (TEE), the clinical reference, is semiinvasive; thus, we aimed to assess the value of contrast-enhanced cardiovascular MRI for the detection of thrombus in the left atrial appendage.

CONCLUSION

The image quality was good for both 2D perfusion (grade 4 +/- 1) and 3D turbo fast low-angle shot (FLASH) (grade 4 +/- 1, n.s.). Compared with TEE, 2D perfusion, 3D turboFLASH, and the combination of both techniques yielded sensitivities of 47/35/44%, specificities of 50/67/67%, positive predictive values of 73/75/80%, and negative predictive values of 25/27/29%, respectively. The size of the thrombus was overestimated by 2D perfusion (66%) and by 3D turboFLASH (25%) and agreement for location and shape of thrombus was 50% and 75% for 2D perfusion and 75% and 50% for 3D turboFLASH, respectively. The TEE thrombus size was significantly larger in patients with true-positive diagnoses by 2D perfusion (148%) and by 3D turboFLASH (151%) when compared with patients with false-negative diagnoses (p < 0.05 for both). No such difference was found for image quality, time delay between TEE and MRI examination, and location and shape of thrombi. Contrast-enhanced MRI lacks diagnostic accuracy for the detection of thrombi in the left atrial appendage. Future technical improvements are essential to establish this technique as a noninvasive alternative to TEE.

Defeitos de septo atrial como fator de risco para migrânea: um estudo de caso controle

Para determinar a magnitude da associação entre defeitos de septo atrial (DSA) e migrânea avaliamos 101 indivíduos submetidos ao ecocardiograma transesofágico (ETE). Eles foram questionados sobre a presença de cefaléia. Migrânea foi diagnosticada segundo os critérios da Sociedade Internacional para Estudo das Cefaléias segunda edição. Pareamos 1:1 em portadores de DSA (casos) e indivíduos com septo atrial normal (controles). Calculamos frequência de migrânea e de aura e a ocorrência de mais de três crises no último mês. Analisamos as diferenças pelo teste do qui-quadrado. Pareamos 34 casos e controles. Média etária 38,7(±11,2) e 38,9(±11,17) sendo 82,4% mulheres. Migrânea ocorreu em 79,4% dos casos e 55,9% dos controles (or= 4,3 ic 95% = 1,048 - 8,89) (p= 0,038). Aura ocorreu em 65,1%(casos) e 40%(controles). Em 76,7% casos e 60% dos controles ocorreram mais de três crises no último mês. DSA se constituiu fator de risco para migrânea com aura na amostra estudada. DSA parece aumentar a freqüência de crises de migrânea.

Transesophageal echocardiographic recognition of infiltrative cardiac sarcoma mimicking mitral stenosis

Primary cardiac sarcomas are very rare. Infiltrative cardiac tumors may be difficult to diagnose by transthoracic echocardiography (TTE) only. Herein, we report a case of primary unclassified cardiac sarcoma with clinical and echocardiographic manifestations of mitral stenosis (MS). The tumor was not identified by TTE preoperatively because of its diffuse infiltration of the left atrial wall and both mitral leaflets without protruding mass, and was only discovered by intraoperative transesophageal echocardiography (TEE). This report alerts clinicians that TEE is a necessary adjunctive tool to facilitate the correct diagnosis in patients with obscure etiologies of mitral valve diseases especially when they will receive surgical intervention.

True versus false left ventricular aneurysm: differentiation with MR imaging--initial experience

PURPOSE

To assess the usefulness of cardiac magnetic resonance (MR) imaging for differentiation of true from false left ventricular aneurysm in patients after myocardial infarction.

MATERIALS AND METHODS

Cardiac MR images obtained in 22 sequential patients (20 men, two women; mean age, 63 years; age range, 45-75 years) with pathologically proved left ventricular true aneurysm (n = 18) or false aneurysm (n = 4) after myocardial infarction were retrospectively analyzed. The MR imaging protocol included steady-state cine imaging followed by perfusion measurement and delayed contrast-enhanced imaging with delays of 15 and 20 minutes. Differences between true and false aneurysms with regard to maximal internal width of orifice, maximal parallel internal diameter, ratio of maximal orifice to maximal internal diameter, presence of mural thrombus and delayed enhancement of pericardium, left ventricular end-diastolic volume, and left ventricular ejection fraction were analyzed by using the Mann-Whitney U test or Fisher exact test, as appropriate.

RESULTS

Inferior wall location was noted in two of four patients with false aneurysm and in none of 18 patients with true aneurysm (P = .03). The remaining aneurysms were apicoanterior (two false, 10 true) or apical (eight true). False aneurysms had a ratio of maximal internal width of the orifice to maximal parallel internal diameter that was significantly lower than that of true aneurysms (0.73 vs 1.00, P < .001) and had a significantly higher left ventricular end-diastolic volume (median, 202 vs 136 mL/m(2); P = .001), as well as a nonsignificant tendency toward lower left ventricular ejection fraction (17% vs 28%, P = .15). Mural thrombus was identified in all four patients with false aneurysm and in seven of 18 patients with true aneurysm (P = .09). Delayed enhancement of pericardium was noted in all four patients with false aneurysm and in three of 18 patients with true aneurysm. Resultant sensitivity of MR imaging for the detection of false left ventricular aneurysm was four of four, specificity was 15 of 18, accuracy was 19 of 22, and positive and negative predictive values were four of seven and 15 of 15 patients, respectively.

CONCLUSION

Initial experience with a small number of patients suggests that marked delayed enhancement of the pericardium is a characteristic feature of false aneurysm. Study with a larger patient sample is required to further assess this feature.