Anatomic correlation of left atrial appendage by 3-dimensional echocardiography

The adequate study of the left atrial appendage is an echocardiographic challenge. The purpose of this study was to assess the ability of 3-dimensional echocardiography in reconstructing this potentially complex structure.

Echocardiographic study of patients with congenital heart disease and infective endocarditis

BACKGROUND

Infective endocarditis (IE) occurs with significant frequency in patients with congenital heart disease. The complications leading to increased morbidity and mortality may be detected by echocardiographic examination. This study was undertaken in order to identify echocardiographic findings that influence the outcome of patients with congenital heart disease and IE.

METHODS

Twenty-five patients with an average age of 28 years were selected and divided into two groups according to evolution. Group I included patients who survived the infectious process, while Group II included patients who died during hospitalization or after release.

RESULTS

Aortic valve disease was the most frequent anomaly. The clinical finding of most relevance for evolution during hospitalization was heart failure. Acute kidney failure and multiple organ failure from sepsis were the most common complications in patients who died. Echocardiograms established the diagnosis in all cases. Transesophageal studies revealed all periaortic abscesses.

CONCLUSIONS

Echocardiography makes it possible to identify and evaluate complications associated with elevated morbidity and mortality in patients with congenital heart disease and IE.

Evaluation of the response to pharmacological stress in chronic aortic regurgitation

We evaluated the hemodynamic response of patients with chronic aortic regurgitation and decreased ejection fraction (EF), mean value +/- SD (37 +/- 9), to dobutamine stress echocardiography (DSE). Eleven patients were studied with DSE. Nine patients were in New York Heart Association (NYHA) Class II and two in NYHA Class III. Ten patients received medical treatment in the only other periodic evaluation. With DSE in nine patients, a significant decrease in left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD) as well as LV end-diastolic and end-systolic volumes (LVEDV and LVESV) was documented in comparison to resting values. EF and fractional shortening (FS) improved significantly with DSE. Systolic wall stress (SWS) and pulmonary arterial systolic pressure (PASP) did not change. Average follow-up was 6.7 months. Three patients underwent valve replacement with mechanical prostheses. Two of them are in NYHA Class I and the other died of LV failure 3 days after surgery. One patient deteriorated beyond surgical treatment and was in NYHA Class II. The other seven patients remain in NYHA Class II and await valve replacement. In patients with chronic aortic regurgitation and depressed EF, the variables relevant to myocardial reserve appear to be EF, FS, LVEDD, LVESD, LVEDV, and LVESV.

Two- and three-dimensional echocardiographic unroofed coronary sinus

We present the 2-dimensional findings and 3-dimensional reconstruction of images from an 18-year-old patient with unroofed coronary sinus, persistent left superior vena cava, a common atrium with levoisomerism, ventricular septal defect, and double-outlet right ventricle. The left superior vena cava showed continuity with the floor of the coronary sinus. Diagnosis of the constellation of anomalies established by transesophageal reconstruction clarified the continuity of the coronary sinus with left superior vena cava and atrial wall.

Cor triatriatum dexter: transesophageal echocardiographic diagnosis and 3-dimensional reconstruction

Cor triatriatum dexter is an unusual cardiac abnormality with division between the sinus and primitive atrial portions of the right atrium. Three-dimensional echocardiography is a novel technique that defines this entity.

Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction

The echocardiographic findings of an intramyocardial dissecting hematoma that formed after an extensive acute myocardial infarction of the anterior wall of a 42-year- old man are described. Serial transesophageal studies were used to construct 3-dimensional images that clarified the participation of various myocardial layers that surrounded the dissecting hematoma. The patient was successfully treated with intra-aortic balloon counterpulsation and subsequently coronary artery bypass grafting. Intramyocardial dissecting hematoma is a rare complication of acute infarction; differential diagnosis must be made with pseudoaneurysm by establishing integrity of epicardium and with intracavitary thrombosis by identifying the endomyocardial layer surrounding the neoformation and associated wall movement.

[Utility of echo enhancers in the study of pulmonary circulation time]

Pulmonary circulation time (PCT) varies under different clinical conditions. To evaluate the PCT, the persistence of contrast in both ventricles and the digital arterial saturation of oxygen with peripheral intravenous injection of microbubbles, were examined 14 patients. Groups: I normals, II left ventricular hypertrophy (EF > 50%), III with mitral stenosis and IV in congestive heart failure. In seven patients, isosorbide S/L was administered after the first injection. The transpulmonary transit in beats was 7.3 in normals, and larger in the others. The persistence of echo contrast in right chambers was 31 beats in group I, and larger in the other groups. In left chambers it was 20.6 beats in group I, and larger in others. There were no alterations with regards to peripheral arterial saturation of oxygen. AII patients with isosorbide presented shorter PCT and persistence of contrast in right chambers.

CONCLUSIONS

There are differences in PCT among normals, patients with mitral stenosis and those with congestive heart failure. Prolonged persistence contrast in right chambers indicates abnormally slow transpulmonary transit. Patients with congestive heart failure and ventricular damage, have longer persistence of echo contrast. PCT studied with contrast is an easy means of evaluating some aspects of pulmonary circulation.

[Safety and efficiency of Echogen. Transthoracic echocardiography study]

This study was performed to determine the safety and efficacy of intravenous dodecafluoropentane emulsion (Echo Gen), to determine the efficacy and duration of contrast agent in left cavities by transthoracic echocardiography and to evaluate the clinical impact of Echogen. Fifteen patients were studied, by transthoracic echocardiography. Duration of contrast intensity of left ventricular cavity opacification and endocardial border definition were studied. The adverse effects were assessed immediately, 24 hours and 7 days after Echogen. Both the vital signs and electrocardiogram did not show any significant changes. Minimal changes in hepatic function in one patient and in renal function in other one were observed. The mean duration of left ventricular opacification was 4 minutes 47 seconds and full or intermediate opacification was more frequently observed after Echogen. Endocardial border delineation was poor in one patient, intermediate in five and excellent in nine. In 86.7% the diagnostic information obtained was sufficiently and allowed other studies.

CONCLUSIONS

This study demonstrates that Echogen is effective for Left ventricular cavity opacification, endocardial border definition and assessment of left ventricular volume and ejection fraction 2) The obtained information with the use of Echogen allowed other studies. 3) The intravenous administration of Echogen is safe in doses of 0.05 ml/Kg.

Prognostic implications of right atrial ischemic dysfunction in patients with biventricular inferior infarction: transesophageal echocardiographic analysis

In order to determine the effect of right atrial dysfunction on clinical outcome, six patients with inferior myocardial infarction with extension to right ventricle and right atrium involving only obstructions of the right coronary artery were examined with transesophageal echocardiography (TEE) at the time of the event. Five of the patients were reexamined 15 to 55 months later. Two patients underwent thrombolysis and maintained ratios of right-to-left ventricular diameters of less than 1, as well as normal convexity of the interatrial septum. One patient had spontaneous reperfusion of the right coronary artery, reduction in right ventricular diameter, and normalization of interatrial septum. Another patient underwent delayed angioplasty and manifested a diminished wall movement score (WMS) in the follow-up echocardiogram. One patient died during his first hospitalization with significant right ventricular dilatation, inverted convexity of the interatrial septum, and right atrial thrombosis. The last patient died during follow-up with right ventricular dilatation, increased WMS, right atrial akinesis, and inverted interatrial convexity. Serial TEE examination of patients with infarction of the left ventricular inferior wall is a safe technique for determining the degree of the extension of the ischemic process to the right chambers.

Nonobstructive asymmetrical septal hypertrophy and ostium secundum-type atrial septal defect

We report a 36-year-old woman with hypertrophic cardiomyopathy with asymmetric septal hypertrophy without outflow tract obstruction associated with an ostium secundum-type atrial septal defect with significant hemodynamic repercussion. Diagnosis was established with transesophageal echocardiography. This is the second case of this rare association reported in the literature and the first evaluated by transesophageal echocardiography.

Transesophageal echocardiographic diagnosis of thrombus in accessory lobes of the left atrial appendage

Fifty-four percent of left atrial appendages have two lobes. The number ranges from one to four lobes. We describe three patients with accessory lobes of the left atrial appendage studied with multiplanar transesophageal echocardiography (TEE). In one patient there was evidence of thrombi in the accessory lobe.

Recurrent myxoma implanted in the left atrial appendage

We present the case of a young woman who developed myxomas in multiple cardiac chambers for the third time. One of the tumors was found in the left atrial appendage with the use of transesophageal echocardiography, indicating that this technique is the method of choice for the follow-up of multiple myxomas.

Left atrial thrombosis after percutaneous mitral valvuloplasty: resolution with conservative management

We report the detection of a thrombus 72 hours after mitral valvuloplasty through the use of the technique of Inoue. Images obtained by transesophageal echocardiography revealed its localization on the interatrial septum at the level of the transseptal puncture. Although the patient subsequently underwent surgery for the placement of a prosthetic valve in mitral position due to failure of the valvuloplasty, the thrombus resolved with conservative management.

[Valvulopathy in primary antiphospholipid syndrome. Prospective echocardiography study]

Echocardiographic studies have demonstrated a high prevalence of valvular disease in patients with primary antiphospholipid syndrome (PAPS). However, there are no studies assessing changes over time in valvular abnormalities. We conducted a study to determine whether there are changes over time in valvular lesions as detected by serial transesophageal echocardiography (TEE). Twelve patients with a first TEE had a second evaluation after a mean period of 13.5 months. There were 10 women and two men with a mean age of 38 years. Two patients had normal TEE on both initial and follow-up studies. Ten patients (83%) had valvular abnormalities, predominantly of the mitral and aortic valves in both studies. Abnormalities consisted of thickening, nodules, regurgitation, regurgitation and stenosis, and calcification. The type and frequency of lesions changed over time. As an example, one mitral valve nodule disappeared on follow up but three new aortic nodules developed even though all patients were receiving anticoagulant therapy. Two patients with mitral and aortic nodules presented cerebral ischemia. Mitral valvuloplasty was performed in one case. These results show that valvular abnormalities in patients with PAPS resolve, appear, or persist irrespective of anticoagulant therapy. Regurgitation is often mild or moderate, but stenosis may appear.

Severe dynamic obstruction of the left ventricular outflow tract induced by dobutamine

We present the case of a 63-year-old man who developed a subaortic gradient of 182 mmHg during an echocardiographic pharmacological stress study with dobutamine.

Echocardiographic evaluation of patients with primary antiphospholipid syndrome

BACKGROUND

A third to half of the patients with primary antiphospholipid syndrome have valve disease.

METHODS AND RESULTS

The echocardiographic characteristics of primary antiphospholipid syndrome were analyzed, and the utility of treatment with anticoagulants and/or antiplatelet agents (acetylsalicylic acid) is examined with the use of transesophageal echocardiography in the evaluation of valvular lesions after 1 year of therapy. Twenty-nine patients, 22 women and 7 men with average age of 35.4 years, were studied. Transesophageal echocardiography was performed on all patients before beginning anticoagulant and/or antiplatelet treatment. Valve lesions were found in 22 (75.9%) patients. Of these, other cardiac abnormalities were found in 3 cases, myocardial infarction in 2, and atrial septal defect in 1. In 7 (24.1%) cases, no valvular abnormality was detected, although in 1 of these, alterations in left ventricular segmental wall movement secondary to myocardial infarction were found. One year after initiation of anticoagulant and/or antiplatelet therapy, it was possible to perform transesophageal echocardiograms on 13 patients. No modification of valve lesions was found in 6 (46.2%) cases; new lesions had appeared in the remaining 7 (53.8%) as well as left ventricular apical akinesis in 1 case.

CONCLUSIONS

These results indicate that the predominant heart lesion in primary antiphospholipid syndrome is valvular; anticoagulant and/or antiplatelet treatment does not diminish the noninfective valve lesions, and on occasion this entity may be associated with myocardial infarction despite angiographically normal coronary arteries.

Infectious endocarditis in pacemaker endocardial leads: report of three cases

Three cases of endocarditis affecting endocardial leads of permanent pacemakers are presented with a review of the literature. Vegetations were identified using transesophageal echocardiography. Infection of pacemaker leads is far less common than infection at the site of the pulse generator with greater morbidity and mortality and generally requiring surgical removal of both electrodes and power source. The most frequent infective agents are stahylococcus varieties.

Tetralogy of Fallot with absent pulmonary valve and total anomalous pulmonary venous connection

It has been shown that congenital absence of the pulmonary valve rarely occurs by itself but tends to be associated with other heart defects, especially tetralogy of Fallot. Other malformations and other complex cardiac malformations also have been described in patients with absent pulmonary valve. In this report we describe the findings of a patient with this combination of cardiac defects who survived spontaneously to adulthood.

Myocardial contrast and transesophageal echocardiographic study of the left coronary artery from the main pulmonary artery

A case of a 26-year-old woman with thoracic pain and anomalous origin of the left coronary artery from the main pulmonary artery is described. The diagnosis was by coronary angiography and complemented with Doppler and transesophageal myocardial contrast.

[Effect of acute myocardial ischemia on pulmonary venous flow pattern. Experimental study with transesophageal echocardiography]

Pulmonary venous flow (PVF) has been analyzed by Doppler echocardiography in various cardiopathies, but up to now no studies of its behavior in acute myocardial ischemia have been reported. The purpose of this study is to describe the changes observed in the normal pattern of PVF with myocardial ischemia in an experimental model. Thoracotomy and pericardiectomy with exposure of the heart were performed on 19 mongrel dogs, weighing between 18 and 25 kg anesthetized with intravenous sodium pentobarbital. Pulmonary venous and mitral flows were analyzed by transesophageal echocardiography with pulsed Doppler and simultaneous recording of intracavitary pressures in left atrium (LA) and left ventricle (LV) before and after 30 minutes of partial occlusion of the middle portion of the anterior descending coronary artery distal to the first diagonal branch. The variables examined included maximal velocities and time-velocity integrals of antegrade systolic(s) and diastolic (D) PVF, mitral rapid filling flow (E) and left ventricular isovolumic relaxation time (LVIRT). The pressures directly measured were mean left atrial pressure (MLAP), systolic and diastolic pressures of the LV. Results included a decrease in peak velocities and time-velocity integrals of PVF (S and D) with myocardial ischemia, S velocity from 70.1 +/- 14.8 to 49.5 +/- 13.8 cm/sec (p < 0.001) and D from 41.4 +/- 16.5 to 29.5 +/- 11.4 cm/sec (p = 0.001), with an increase in LVIRT from 65.8 +/- 8.6 to 76.0 +/- 12.6 msec (p < 0.006) and elevation of the mean pressure of the LA from 4.3 +/- 1.0 to 6.4 +/- 1.5 mmHg (p < 0.001). This findings suggest that acute myocardial ischemia alters the normal pattern of PVF, producing a significant decrease in peak velocities and time-velocity integrals of antegrade systolic and diastolic flows as well as an increase in LVIRT and MLAP, which taken together may reflect altered diastolic function of the LV.

[Diagnosis of thoracic aorta dissection using transesophageal echocardiography]

During a 36 month period there were 20 patients in our hospital with aortic dissection suspected clinically. All of them were examined with transesophageal echocardiography (TEE); 17 were examined with transthoracic echocardiography (TTE); six with computed tomography (CT) and seven with aortography. Twelve patients required surgery: eight with proximal aortic dissection (Type-A), two with distal dissection (Type-B) and two with aortic aneurysm without dissection. With the goal of investigating the utility of TEE for the diagnosis of aortic dissection in our hospital, we compared this and other available methods to the surgery findings. The sensitivity to TEE was 100% and the specificity 92%, with test accuracy at 92%. The sensitivity of the other tests was low: 66% with TTE; 50% with TAC; 57%, with aortography. The specificity was 90% with TTE, and higher with CT and aortography (100%). The ultrasound tests reveal additional information about complications like aortic regurgitation. Transesophageal echocardiography is the best test to examine patients with aortic dissection in our hospital. Computed tomography, aortography and magnetic resonance imaging have indication only to answer specific doubts.

[The usefulness of transesophageal echocardiography in the diagnosis of intracardiac and extracardiac tumors]

We studied 18 patients with suspected intrathoracic mass from january 1990 to august 1993. In all patients electrocardiogram, X-ray, transthoracic and transesophageal echocardiography were performed. Accordingly, the patients were divided into two groups: I) 8 patients with intracardiac myxoma, and II) 10 patients with no myxomatous tumor. The histopathologic identification of the intracardiac or extracardiac tumor was corroborated in all patients of group I and in only 8 patients of group II. In group I the mean age was 39 years and the female sex was more frequently (75%); with transthoracic and transesophageal approaches the myxoma was found in right atrium in four patients, in left atrium in three, and in the last patient the four chambers were occupied. In group II the mean age was 36 years, and the male sex was predominant (60%). In three patients cardiac tumors were detected by echocardiography, two of them were found in the right cavities (leiomyoma and leiomyosarcoma), in the rest the histologic lineage of the left atrial tumors was not possible to recognize. In the other seven patients with mediastinal tumor the heart was not infiltrated. On the basis of the obtained results we conclude that transthoracic echocardiography permits the identification of the intracardiac tumor; in these patients transesophageal studies give us an additional valuable information about the valves, the site of tumoral implantation and the wall infiltration. Transesophageal approach provides more information about its potential cardiac compression.

[Dynamic intracavitary echoes studied by transthoracic and transesophageal echocardiography]

One hundred consecutive echocardiograms performed on adults using transthoracic and transesophageal (TEE) transducers were analyzed in order to determine the prevalence of spontaneous contrast (SC) and the factors associated with it. Indications for study included complex congenital cardiopathy, evaluation of valve lesions or prosthetic valves, dissecting aortic aneurysm, cardiac masses and evaluation of ventricular function. SC was observed only with TEE and appeared in 25% of cases, most frequently in left atrium. Factors associated with contrast included mitral valve disease and replacement, ventricular dysfunction, left atrial dilatation and atrial fibrillation. An important relationship existed between SC and presence of thrombi. Atrioventricular valvular regurgitation was not associated with SC. Results are compared with those of previous series.

[Transesophageal echocardiography in the study of intracardiac thrombosis, tumors and vegetations]

Of 200 consecutive patients, studied with transesophageal echocardiography the findings were analyzed with respect to the presence of thrombi, tumors or vegetations. Thrombus formation was detected in 18 patients; their location and associated pathology are described. Tumors were present in 9 cases and in 10 patients endocarditis in native or prosthetic valves. The information obtained by transesophageal echocardiography was compared with transthoracic echocardiographic data. Transoesophageal echocardiography was demonstrated to be more sensitive, especially in the detection of intracavitary masses in the posterior structures of the heart.

[Doppler color transesophageal echocardiography. Report of the first 110 studies carried out at the Ignacio Chávez National Institute of Cardiology]

Transesophageal echocardiography allows views of the posterior structures of the heart. This approach provides additional and complementary information to the transthoracic study, it is also an alternative in those patients with technical limitations for optimal precordial imaging. This study analysis the first 110 cases studied with transesophageal echocardiography in the National Institute of Cardiology Ignacio Chávez. They correspond to patients with valvular heart disease, prosthesis, acute and chronic ischemic heart disease, dissecting aortic aneurysm, cardiomyopathies, thrombus, tumors and masses. As well as paediatric and adult with complex congenital heart disease. The advantages of the transesophageal technique compared with the precordial approach are described.