Two- and three-dimensional echocardiography in primary antiphospholipid syndrome: misdiagnosis as rheumatic valve disease

This is a report of a woman in the fifth decade of life with primary antiphospholipid syndrome and involvement of a heart valve. Diagnosis was reached with echocardiography and serological studies.

The effect of kidney transplant on cardiac function: an echocardiographic perspective

Kidney transplant (KT) resolves many of the cardiac abnormalities associated with chronic kidney failure (CKF). This study analyzed cardiac alterations of kidney failure and their modification with transplant. Thirteen patients in CKF underwent conventional echocardiograms, dobutamine stress echocardiograms, and injection of contrast to examine perfusion before KT and 3 months after transplant. Nine patients had evidence of left ventricular hypertrophy and six had evidence of diastolic dysfunction. Wall thickness, left ventricular mass, and mass index diminished after KT; only two patients continued to manifest hypertrophy. Left ventricular systolic diameters and volumes diminished at 3 months, and diastolic diameters after 4 months. Left ventricular fractional shortening and ejection fraction increased 3 months after transplant. At the end of the study, only two patients continued to show diastolic dysfunction. Dobutamine echocardiograms showed no segmental wall-movement abnormalities. Myocardial perfusion was normal before and after transplant. The results suggest that KT diminishes hypertrophy and improves left ventricular systolic and diastolic function. Echocardiography provides valuable information for detection and follow-up of cardiac abnormalities in patients with kidney disease. Evaluation of segmental wall movement and myocardial perfusion aid in demonstrating that our studied patients with CKF had no indirect signs of coronary artery disease.

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.

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.

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.

Myocardial perfusion scintigraphy (SPECT) in the evaluation of patients in the emergency room with precordial pain and normal or doubtful ischemic ECG. Study 60 cases

OBJECTIVES

To evaluate the diagnostic utility of myocardial perfusion by SPECT and Gated-SPECT in the diagnosis of acute coronary syndrome in patients with precordial pain associated with normal or doubtful ischemic ECG within the first 6 hrs of the last episode of pain.

METHODS

Sixty such patients who sought attention in the Emergency room were included. Myocardial perfusion SPECT and Gated-SPECT (GSPECT) was performed in all patients using two distinct protocols. All patients underwent resting and pharmacological stress test. In 30 cases coronary angiogram were performed.

RESULTS

Resting myocardial perfusion was abnormal or positive in 25 patients (42%) and normal or negative in 35 patients (58%). In the latter group perfusion became abnormal in 15 patients (43%) under stress with dipyridamole, while it remained normal in 19 (54%). The last subgroup presented no coronary events during the 12 months following their hospital discharge. In the group of 25 patients with resting perfusion abnormalities acute myocardial infarction was diagnosed in 7 patients, ischemia in 12 and reverse-reversibility in 6. Myocardial perfusion scintigraphy showed in the resting phase a low sensitivity of 61% (95% CI 39-74%), and negative predictive value of 71% (95% CI, 58-82%). During the stress phase, the utility of the test increased significantly, with a sensitivity of 97% (95% CI, 83-99%), specificity of 79% (95% CI, 57-92%), positive predictive value of 87% (95% CI, 72-95%) and, most outstanding, a negative predictive value of 95% CI, 73-99%).

CONCLUSIONS

Myocardial perfusion studies have a sensitivity of 97% for identifying patients with acute coronary syndrome, with precordial pain and normal or doubtful ischemic ECG. For the intermediate or low risk patients with acute coronary syndrome the non-invasive diagnostic techniques of SPECT and GSPECT systems of evaluating myocardial perfusion achieve a high degree diagnostic accuracy, safety and reduces unnecessary admissions and costs.

Multiple recurring paragangliomas: a problem of diagnosis and location. Case report and review of the literature

RATIONALE

Paragangliomas constitute a particular diagnostic challenge because of the difficulties involved in identifying new lesions.

CASE REPORT

The findings in the case of a young woman with multiple recurring paragangliomas which reappeared eleven years after successful surgical treatment are presented.

DISCUSSION

This case illustrates the diagnostic difficulties of this pathologic entity and the lack of a technique of sufficient sensitivity to reveal the existence of one or more tumors with or without hormonal secretion, their location and rate of growth and the number of neoplasias to avoid as many surgical interventions as possible. Inasmuch as an ideal technique for diagnosis and localization of this type of tumor remains to be developed, non-invasive methods, particularly 131I MIBG scintigraphy, play a significant role in evaluation because of their high sensitivity for detecting chromaffin tissue, especially in extra-adrenal locations.

CONCLUSION

Periodic long-term radionuclide scanning should be recommended for all asymptomatic patients given the risk of residual and/or reactivating tumoral tissue with benign or metastatic behavior.

Echocardiographic, catheterization, and nuclear medicine findings of an aneurysm of the muscular interventricular septum associated with aneurysm of the interatrial septum

The unusual case of a young woman with an aneurysm of the muscular interventricular septum associated with an aneurysm of the interatrial septum and a muscular interventricular septal defect is presented. The echocardiographic, electrocardiographic, catheterization, and nuclear medicine findings are described.

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.

Diagnostic concordance in biopsies of deceptive prostatic carcinoma

OBJECTIVE

To explore the diagnostic concordancy of surgery pathologists in deceptive prostatic carcinoma biopsies (DPCs) purposely selected as of difficult interpretation.

SETTING

Ten experienced pathologists belonging to five tertiary care centers in Mexico City participated.

MATERIAL AND METHODS

A total of 25 slides (16 DPCs and 9 benign biopsies) were marked and circulated among the participants. They were asked to classify each slide in one of five categories ranging from carcinoma to benign hyperplasia using the criteria of Epstein. The 16 DPCs had been confirmed by immunohistochemistry studies and by review of two expert uropathologists from the MD Anderson Medical Center in Houston TX. A weighted kappa was use to evaluate the concordancy of the pathologists.

RESULTS

The concordancy with the experts opinion ranged from substantial in one pathologist (KW = 0.77) to bad in another (KW = -0.07) and the mean kappa was 0.32. In two of the three institutions with more than one pathologist, the intrainstitucional concordancy improved (KW of 0.57-0.64). The pathologists were unable to reach a consensus (7 or more agreeing) in 12 of the 25 slides. Overall, 12% of the diagnosis were considered uncertain, 29% were incorrect (45% of DPCs and 19% of benign) and only 59% were correct (55% of DPCs and 67% of benign).

CONCLUSION

Efforts should be made to improve the diagnostic accuracy of pathologists in DPCs.

Hepatitis C: a disease with a wide morphological spectrum?

We describe the pathological findings of 50 biopsies of Mexican (Mestizo, or mixed race, usually Indian and white heritage) patients with hepatitis C infection confirmed by a second generation test. Although half of the patients were asymptomatic, the histological examination revealed advanced stages of disease. Chronic active hepatitis was found in 26 cases, cirrhosis in 23, and acute hepatitis in one case. Common histological changes included steatosis, lymphoid aggregates, and apoptotic bodies, whereas indisputable bile duct damage was observed in only four cases. Comparison with other series in which different types of populations were analyzed revealed a wide morphological spectrum with respect to some histological changes and the type of hepatitis reported. The apparently contradictory results found in the literature indicate the need to apply universal histological criteria in biopsies of patients with hepatitis C.

Utility of transesophageal echocardiography in the examination of adult patients with patent ductus arteriosus

Thirteen patients with clinical suspicion of patent ductus arteriosus were evaluated by transthoracic and transesophageal echocardiographic studies. Findings were corroborated during corrective surgery in 8 patients and by cardiac catheterization in 5. Transthoracic echocardiography confirmed the diagnosis in 7 patients; in 2 of the patients endarteritis of the pulmonary artery was demonstrated, and in one infective vegetations in aortic and mitral valves. With transesophageal echocardiography, patent ductus arteriosus was established in all 8 patients and endarteritis of the pulmonary artery was shown in 3, including 1 not discovered by transthoracic technique. In 1 of these patients, vegetations were also found on the pulmonic valve. Both techniques demonstrated significant pulmonary hypertension in 5 cases; contrast studies showed the venoarterial shunt between the pulmonary artery and the aorta with particular clarity in transesophageal images. On the basis of these findings it may be concluded that transesophageal echocardiography complements the information provided by transthoracic recordings in adult patients with patent ductus arteriosus, especially when it is associated with pulmonary hypertension or pulmonary endarteritis.

Transesophageal echocardiographic diagnosis of an aneurysm and thrombosis of the left anterior descending coronary artery

An aneurysm of the left anterior descending coronary artery with thrombosis in its lumen in a 36-year-old woman who had an acute myocardial infarction is described. Although the aneurysm was detected by angiography, a transesophageal study provided new specific details of the exact site of origin of the aneurysm, as well as vascular thrombosis.

Transthoracic and transesophageal echocardiographic study of pulmonary autograft valve in aortic position

Eleven patients who underwent pulmonary valve autograft to aortic position with placement of bovine pericardial prosthesis in pulmonary position were studied with echocardiography. The etiology of aortic valvuloplasty as determined by anatomopathological examination was rheumatic in five, degenerative in four, and congenital in two. Important mitral stenosis coexisted in two patients, and during the same operation as the Ross surgery, a mitral valvuloplasty with Carpentier ring was practiced on one and an open mitral commissurotomy on the other. Transthoracic echocardiography, which helped to confirm the viability of the surgery by determining the diameters of the semilunar valve rings and quantifying the severity of the aortic valve lesions, was performed on all patients before surgery and repeated 3 months later. Transesophageal echocardiograms were practiced on nine patients during the surgical procedure and repeated after 6 months on seven. The latter technique aided in immediate postoperative evaluation, and repetition at 6 months served to explore the ventricular infundibuli and evaluate pulmonary valve performance in aortic position. In conclusion, transthoracic and transesophageal echocardiography provide a practical and valuable means of investigating the pre-, trans-, and postoperative conditions of patients undergoing Ross surgery.

[Usefulness of Doppler echocardiography in the analysis of left ventricular isometric relaxation time in an experimental model of myocardial reperfusion]

Modifications of left ventricular isometric relaxation time (LVIRT) were analyzed in an experimental model of myocardial reperfusion (MR). In a prospective study, 19 mongrel dogs were studied with open chest, mechanical ventilation and hemodynamic monitoring. A catheter was inserted in the middle third of the anterior descending artery (ADA) for registry of its pressure. The ADA was ligated distal to the first diagonal branch for 15 min and subsequently untied. Epicardial Echo/Doppler registries were obtained in basal conditions, at 5 and 15 min of ischemia and at 5, 15, 30 and 60 min after MR. Mobility and changes in thickness of the interventricular septum (IVS) were analyzed, and LVIRT was measured in all of the periods mentioned. There were no significant changes in the thickness of IVS. LVIRT increased in comparison to the basal registry at 5 and 15 min of ischemia (p < 0.0001) and returned to basal values with MR (p < 0.05).

CONCLUSIONS

Acute myocardial ischemia prolongs LVIRT, in this model, during MRLVIRT returned to normal. In the experimental model, measurement of LVIRT may be used as criterion for reperfusion.

Transesophageal echocardiography and right atrial infarction

Transesophageal echocardiographic findings in right atrial infarction are described. In three patients with myocardial infarction of one or both ventricles, the association of right atrial myocardial infarction was suspected because of anatomic (two-dimensional) and hemodynamic (Doppler) alterations obtained from transesophageal images. Transesophageal interrogation may prove widely applicable in the evaluation of patients with suspected right atrial infarction.

Diffuse lymphoplasmacytic infiltration of the small intestine with damage to nerve plexus. A cause of intestinal pseudo-obstruction

We describe the clinicopathologic characteristics of three patients with chronic intestinal pseudo-obstruction and malabsorption. The patients were young women (average age, 25 years) who presented with abdominal pain, nausea, vomiting, diarrhea, and weight loss that led to extreme inanition and death in two patients despite multiple treatment schemes. The evolution of the process averaged 8 years. No case manifested evidence of malignant lymphoproliferative progression. Histologically, a diffuse lymphoplasmacytic infiltrate that affected all the layers of the intestinal wall was observed in full-thickness biopsy specimens. The proliferating lymphocytes were small and mixed with mature plasma cells that proved to be polyclonal on immunohistochemical analysis. An outstanding finding in all three cases was extensive damage to submucosal and myenteric nerve plexus associated with a lymphoid infiltrate. Quantification of the myenteric plexus by using immunohistochemical and morphometric techniques also revealed a marked reduction in their number. We concluded that diffuse lymphoplasmacytic infiltration of the small intestine associated with damage to the intestinal nerve plexus constitutes a specific disorder that is different from other diseases that produce intestinal pseudo-obstruction.

Transesophageal echocardiography in adults with congenital cardiopathies

Eighty-seven adult patients with congenital cardiopathy were studied by using transesophageal echocardiography (TEE) over a period of 30 months. Transthoracic echocardiography was practiced on all patients, after which TEE with monoplanar and biplanar probes (74 and 15 patients, respectively) was used to confirm principal diagnoses and determine specific information. TEE findings were compared with those of cardiac catheterization in all 87 cases and with those of surgery in 15 cases. Dextrocardia was found in 11 cases and mesocardia in 2. Situs inversus was demonstrated in 6 and levoisomerism in 4. Intracardiac and extracardiac shunts were diagnosed in 20 cases, Ebstein's anomaly in 27, corrected transposition of great vessels in 15, univentricular atrioventricular connection in 7, cor triatriatum in 1, parachute mitral valve in 1, crisscross heart in 1, and double-outlet left atrium in 1. TEE was of particular value in evaluating total anomalous pulmonary venous connection, common atrioventricular canal, Ebstein's anomaly, corrected transposition of great vessels, and univentricular atrioventricular connection and in diagnosis of the rarer congenital cardiopathies.

Two dimensional and Doppler echocardiographic diagnosis of bicuspid pulmonary valve

The diagnosis of bicuspid pulmonary valve is usually established postmortem, occurring in 7% of patients with pulmonary stenosis and is usually associated to tetralogy of Fallot or ventricular septal defect. The authors report the case of a 14-year-old girl with patent ductus arteriosus in whom 2-D echocardiography disclosed a pulmonary valve formed of two slightly thickened leaflets that opened with the shape of a dome in systole, and moved under the valve ring plane during diastole. A Doppler examination showed a 21 mmHg transvalvar gradient. These characteristic features suggest that 2-D and Doppler echocardiography are the techniques of choice in the diagnosis of bicuspid pulmonary valve.

Ventriculoatrial shunts for hydrocephalus and cardiac valvulopathy: an echocardiographic evaluation

A group of 20 patients with ventriculoatrial shunts placed as surgical treatment for hydrocephalus were evaluated for cardiac lesions, particularly of the tricuspid valve. Patients with histories of septic or thromboembolic events were excluded. In each patient a clinical history, complete physical examination, electrocardiogram, chest x-ray film and M-mode, two-dimensional and pulsed continuous wave and color-coded Doppler echocardiography were performed. Eight patients were found to have cardiac abnormalities including tricuspid valve insufficiency, tricuspid stenosis and insufficiency, and the catheter passing through the foramen ovale into the left atrium. These findings demonstrate that tricuspid valvular lesions are frequent in patients with ventriculoatrial shunts, and that periodic echocardiographic evaluation should be performed routinely.

The role of the endoscopic biopsy in the diagnosis of gastric lymphoma: a morphologic and immunohistochemical reappraisal

Forty-three endoscopic biopsies from 29 patients with confirmed gastric lymphoma (GL) were analyzed retrospectively to establish the morphologic criteria of greatest diagnostic significance. An average of 10 tissue samples was obtained at each endoscopy. In 44% of the cases, lymphoma was discovered in only one or two of the tissue portions. Eighteen lymphomas were primary, six were probably primary, and five were generalized. The diagnosis of lymphoma was originally suspected or established in 46% of the biopsies. However, a review of the histologic sections indicated that the changes, either diagnostic of or compatible with lymphoma, were present in 75% and 18% of the sections, respectively. Most diagnostic errors consisted of confusion with diffuse lymphoid infiltrates in chronic gastritis and/or peptic ulcer, and less frequently with poorly differentiated carcinoma. In those cases confused with chronic gastritis or peptic ulcer, biopsies showed centrocyte-like cells of the standard type or small lymphocytes which produced: (1) a marked increase in density of the lymphoid infiltrate in the gastric mucosa, (2) massive substitution of gastric glands by lymphoid infiltration, and (3) a collection of lymphocytes infiltrating and partially destroying isolated glands (lymphoepithelial lesion). From 48 biopsies having intense benign lymphoid infiltrates, three were interpreted (by means of a blinded study) as compatible with GL. In poorly differentiated neoplasms (blastic and pleomorphic types), cytologic features were sufficient to diagnose GL or malignant neoplasms; immunohistochemical techniques were useful to define their lymphoid nature. It is concluded that many GLs can be suspected or correctly diagnosed by routine endoscopic biopsy.

Intracardiac extension of malignant uterine tumors. Echocardiographic detection and successful surgical resection

The echocardiographic findings of two unusual cases of malignant uterine tumors that invaded the heart are reported. A woman previously operated on for invasive cervical carcinoma had multiple embolic phenomena and evidence of obstruction to mitral flow. An echocardiogram showed a mass in the left atrium that reached the mitral valve ring. The tumor was implanted in a pulmonary vein and was removed with no complications. Cell type indicated metastatic carcinoma of the cervix. In the second case the patient had a large abdominal mass and precordial manifestations of obstruction and regurgitation of the tricuspid valve. An echocardiogram showed that a mass emanating from the inferior vena cava filled the right atrium and part of the right ventricle. The trajectory of the tumor was followed to its origin in an ovarian vein by tomography. The entire tumor was removed and identified as endometrial stromal sarcoma. An increase in operations with or without radiation therapy for malignant tumors has augmented the frequency of metastatic invasion of the heart; intracavitary extension tends to results from embolization or propagation along great veins. This is the first report of a uterine carcinoma reaching the heart by way of the pulmonary veins and of invasion of the heart by endometrial stromal sarcoma, both with successful excision.

[Diagnosis of constrictive pericarditis and restrictive cardiomyopathy by pulsed Doppler echocardiography]

Characteristics of flow through atrioventricular valves were analyzed by pulsed Doppler echocardiography (PDE) in 7 patients with either constrictive pericarditis or restrictive cardiomyopathy and 10 controls to determine the value of this technique in their differentiation. All patients were admitted with systemic venous congestion and underwent right and left heart catheterization. PDE variables considered included peak flow velocity (PV), acceleration time, peak velocity of the atrial component (PVA), PVA/PV quotient, duration of early diastolic fillings, deceleration of early diastolic filling, duration of diastolic flow and mean temporal velocity. Ventricular filling differed between patients and controls in that the former group was characterized by higher PV's, lower PVA's, higher deceleration and lower PVA/PV quotient. When we compared both patient groups we found a significant tendency toward higher PV's, faster deceleration and lower PVA/PV quotient in constrictive pericarditis.

Two-dimensional echocardiography and color Doppler imaging in patients with systolic-diastolic murmurs

Characteristics of color-coded Doppler imaging combined with two-dimensional and M-mode echocardiography in six patients with systolic-diastolic murmurs are reported. PDA, congenital absence of pulmonary valve leaflets, ventricular septal defect and aortic regurgitation, two ruptured aneurysms of sinus of Valsalva, and a coronary fistula were identified and findings were corroborated in cardiac catheterization and/or surgery. Color-coded Doppler imaging increases the information of the echocardiographic method in differential diagnosis of these entities by characterizing flow in cardiac chambers more completely and by facilitating detection of associated defects.

[Left ventricular hypertrophy simulating an intracavitary tumor. Echocardiographic diagnosis]

We report a case of a 14 month old infant with severe stenosis of the pulmonary valve in whom the angiographic image suggested the presence of a right ventricular (RV) tumor mass. The patient was admitted because of clinical manifestations of heart failure. Right heart catheterization demonstrated a transvalvular pulmonary gradient and filling defects in the infundibulum compatible with an intracavitary mass. Two dimensional and Doppler echocardiography confirmed pulmonary stenosis and showed that the mass corresponded to hypertrophy of the anterior RV wall. The combination of two dimensional and Doppler echocardiography are the indicated techniques in differential diagnosis of RV tumor masses and RV hypertrophy secondary to severe pulmonary valve stenosis.

[Initial phase of the left ventricular ejection (mesosystole) in coronary artery disease]

In patients with coronary artery disease (CAD), the ventricular ejection is altered specially the initial phase or the mid-systole. We studied such abnormalities through two-dimensional echocardiography and phonocardiography. We studied 40 patients with CAD and 11 normal subjects, we determined the times and volumes of total, initial and end of systole for to calculate the ejection fraction, integrated ejection and mean ejection rate. The measurements of total systole did not show important differences. In contrast, the initial ejection time (IET), the initial integrated ejection (IIE), the mid-systolic stroke volume (MSV), the mid-systolic ejection fraction (MEF) and the mean mid-systolic ejection rate (MMER) showed significant differences. The CAD group compared with normal subjects, had lower values of IET (P less than 0.05), MSV and MEF (P less than 0.01). The presence of myocardial infarction, the number of arteries with significant obstruction and the elevation of the left ventricular enddiastolic pressure had relationship with decrease in IIE (P less than 0.01) and with amount of MSV, MMER and MSV/end systolic stroke volume ratio (P less than 0.01). On the other hand, patients with angina, specially unstable and in those with ventricular aneurysm, the IIE showed higher values (P less than 0.01) and MSV, MMER, the percentage of mid-systolic ejection fraction and MSV/ESV ratio were lower (P less than 0.01). We conclude that in CAD, the mid-systolic changes are more sensitive than those of the whole systole. In presence of heart failure, the reduced stroke volume is ejected almost totally in the initial period or mid-systole. In patients with ventricular aneurysm or in those with unstable angina is the opposite behavior, the mid-systolic ejection is reduced and the small volume is ejected in the end last period or end systole. These observations could be useful to recognize the damage and the severity of it in CAD.