Acute aortic syndrome: CT findings

Acute aortic syndrome (AAS) is a constellation of potentially life-threatening acute aortic diseases. The spectrum includes penetrating atherosclerotic ulcer, intramural haematoma, dissection, and unstable thoracic aneurysm. AAS cannot be reliably diagnosed clinically and multidetector computed tomography (MDCT) has revolutionized the diagnosis and management of this group of conditions in the acute setting due to its availability, speed, and accuracy. The purpose of this review is to illustrate key MDCT findings of AAS. Imaging techniques, radiological findings, and common pitfalls are also discussed.

Penetrating atherosclerotic ulcer of the aorta: a continuing debate

Aortic penetrating atherosclerotic ulcer (PAU) is a relatively common incidental finding on thoracic computed tomography (CT) examinations. This is likely to relate to the steady increase in the number of CT examinations performed and also due, in part, to the increasing age of the general population. There is as yet no consensus on the management of incidental PAUs in asymptomatic patients. This article aims to review the literature and discuss the natural history, prognosis, and management of incidental PAU.

Patterns of renal angiomyolipoma regression post embolisation on medium- to long-term follow-up

OBJECTIVE

To assess the patterns of regression of renal angiomyolipoma (AML) post embolisation and report the outcomes related to the use of different embolic materials.

METHODS

A retrospective review of all patients who underwent embolisation for renal AML at our institution between January 2004 and April 2012.

RESULTS

13 patients underwent 16 episodes of embolisation. Coils were used as the primary embolisation material in 10 episodes and microspheres in 6 episodes. The size reduction rate highly correlated on CT follow-up between the two groups, with 25.6% vs 22.7% reduction at 12 months, 27.5% vs 25.1% at 24 months, 35.0% vs 33.0% at 36 months and 35.0% vs 36.8% at 48 months. During follow-up, all tumours reduced in size with one patient requiring subsequent embolisation whose tumour reduced by only 6.5% after 1 year and subsequently exhibited regrowth after 4 years. Two patients presented with rebleeding and underwent repeat embolisation. Our overall retreatment rate (23%) is well within the literature range (up to 37%). None of the patients underwent surgery.

CONCLUSION

The majority of AML shrinkage occurs within the first year following embolisation and appears to plateau after 3 years, which could have an impact on follow-up strategy. The percentage reduction at 1 year may reflect the long-term effect of embolisation with tumours demonstrating minor size reduction more likely to relapse at long-term follow-up. Embolisation of renal AML produces durable long-term results regardless of the choice of embolic agent.

ADVANCES IN KNOWLEDGE

These findings provide information to guide CT follow-up of renal AML post embolisation.

Primary infrarenal aortic stenting with or without iliac stenting for isolated and aortoiliac stenoses: single-centre experience with long-term follow-up

PURPOSE

The purpose of this study was to evaluate the technical success, complications, long-term clinical outcome, and patency after primary infrarenal aortic stenting for aortic and aortoiliac stenosis. Between January 1999 and January 2006, 22 consecutive patients underwent endovascular treatment because of infrarenal aortic stenosis with and without common iliac stenosis (10 men; mean age 64 ± 14 years). Eleven (11 of 22) patients had an isolated aortic stenosis, whereas 11 of 22 had aortic stenosis that extended into the common iliac arteries (CIAs). Thirteen patients were Rutherford classification type 3, and 9 patients were type 4. Statistical analysis included paired Student t test and Kaplan-Meier life table analysis; p < 0.05 was considered significant. Technical and initial clinical success was achieved in all patients. There were three (14 %) procedure-related complications, which included two access-point pseudoaneurysms and one non-flow-limiting left external iliac dissection. Patients were followed-up for a mean period of 88 months (range 60-132). Mean preprocedure ankle brachial pressure indexes (ABPI) were 0.60 ± -0.15 (right) and 0.61 ± -0.16 (left). After the procedure they were 0.86 ± -0.07 (right) and 0.90 ± -0.09 (left). The increase in ABPI was significant (p < 0.05), and this continued throughout follow-up. Four (18 %) patients had recurrence of symptoms during follow-up. These occurred at 36, 48, 48, and 50 months after the original procedure. All four patients were successfully treated with repeat angioplasty procedures. There was a significant difference in primary patency between isolated aortic stenosis (100 %) and aortoiliac stenosis (60 %) (p = 0.031). Cumulative follow-up was 1920 months yielding a reintervention rate of 0.025/events/year.

CONCLUSION

Primary stenting of infrarenal stenosis is safe and successful with a low reintervention rate. It should be considered as first-line treatment for patients with infrarenal aortic stenotic disease.

Patient experience, pain, and quality of life after lower limb angioplasty: a multisite prospective cohort study

PURPOSE

To explore the experience of patients undergoing endovascular lower limb angioplasty and evaluate the improvements in quality of life and disease-related symptoms after the procedure.

METHODS

Patients completed a questionnaire before treatment and three questionnaires after the procedure (immediately after the procedure, and again 4 weeks and 3 months later). Anxiety, patient understanding, procedure-related pain, and disease-related pain were assessed by a visual analog score (VAS). Complications, analgesic requirements, and satisfaction were recorded. Changes to quality of life were assessed by the validated SF36 questionnaire.

RESULTS

A total of 88 patients (41%) responded. Overall, disease-related pain decreased over 3 months after the procedure. Smokers had more pain both before and after the procedure (P < 0.05). Explanation was considered better if provided by radiologist (P < 0.05). Sixty-nine percent of patients found the procedures less painful (mean VAS 2.5) than they had anticipated (VAS 5.5). Fifty percent of patients experienced adverse effects related to their puncture site, but this was highest among patients who had undergone the procedure before and smokers. The greatest quality-of-life improvements were in emotional and general health. Higher levels of disease-related pain were associated with worse general, emotional, and physical health (P < 0.05).

CONCLUSION

Lower limb angioplasty provides symptomatic and quality-of-life improvements. Implementation of simple measures could improve patient satisfaction-for example, treatment should be explained by the radiologist in advance. Routine prescription of analgesics with particular attention to smokers and those undergoing repeat interventions is suggested.

Staged coil embolisation for the management of persistent aneurysmal right subclavian artery

A 70-year-old patient, who had previously undergone open surgical repair of an aneurysmal aberrant right subclavian artery (ARSA), presented with recurrent symptoms and reperfusion of the aneurysm at the site of proximal ligation. This was successfully treated by a staged endovascular procedure.

Long term follow-up of transcatheter coil embolotherapy for major colonic haemorrhage

AIM

Therapeutic angiography with embolization is fast becoming the preferred treatment modality for major bleeding in the lower gastrointestinal (LGI) tract. The aim of this study was to determine the long term outcome and complications of percutaneous coil embolization (PCE) and its efficacy as definitive therapy in patients with major LGI bleeding.

METHODS

All patients presenting to our institution with a haemodynamically significant LGI tract bleed between 1995 and 2001 that were unresponsive to conservative measures were considered for emergency angiography and coil embolization where appropriate. The outcome of these individuals was determined by case note review and telephone interview.

RESULTS

There were 20 patients (11 females) with a mean follow-up period 72 months, mean age was 67 years. All underwent PCE following positive angiogram. The most common site of bleeding was the right colon (40%); haemostasis was successfully achieved in 16 (80%) patients. Five of the 20 patients died within 30 days of the intervention, three following PCE and two following surgery. None of the mortality following PCE was considered procedure related. On long term follow-up four patients required readmission to hospital for further LGI bleeds at 1, 2, 12 and 16 months respectively. Ischaemic complications occurred in 23%.

CONCLUSION

Superselective embolization as the primary technique for the treatment of haemodynamically significant LGI bleeding is an effective, feasible and safe technique. Long term follow-up in our series up to 72 months has shown that it should be considered as both a primary and potentially definitive treatment for life threatening LGI bleeds.

Chronic haematoma or soft-tissue neoplasm? A diagnostic dilemma

Chronic soft-tissue haematomas are infrequently reported in the literature. We present a case of a slowly expanding post-traumatic chronic soft-tissue haematoma located anterior to the knee and leg, occurring in a region previously unreported. Both clinically and radiologically, it was impossible to distinguish the haematoma from an aggressive soft-tissue neoplasm. We review the literature and discuss the diagnostic problems related to this uncommon presentation.

Subclavian vein compression in anaplastic carcinoma of the thyroid

Anaplastic thyroid cancer is a condition with a dismal prognosis in most cases. We present a case of subclavian vein compression in a case of anaplastic thyroid carcinoma treated with subclavian venous stenting. Subclavian vein compression is a recognized complication in disseminated carcinomatosis particularly in carcinoma of the breast and bronchus. It has never been described in anaplastic thyroid carcinoma.

Fibroid calcification after uterine artery embolization: ultrasonographic appearance and pathology

PURPOSE

To describe the ultrasonographic (US) appearance of fibroid calcification occurring after uterine artery embolization (UAE) and discuss its etiology and pathology.

MATERIALS AND METHODS

Twenty-seven of a total of 38 patients were followed up clinically and with duplex US for longer than 6 months after UAE for uterine fibroids. At US, changes in uterine size, fibroid vascularity, and morphology have been recorded. Pathologic studies were performed by one of the authors on resected specimens from a different cohort of patients, at intervals ranging from 4 months to 1 year after UAE.

RESULTS

Twenty patients reported complete resolution of symptoms. In 16 of these, a reduction in fibroid volume of 70%-85% was recorded and, at US, the development of a peripheral hyperechoic rim around an increasingly hypoechoic fibroid was noted. Computed tomography in two patients revealed it to be a rim of calcium. Histologic studies in a different cohort of patients who had undergone hysterectomy at variable intervals after UAE demonstrated early aggregation of polyvinyl alcohol (PVA) particles, an intermediate giant cell inflammatory reaction, and calcification in the periphery of the infarcted fibroid at 6-12 months.

CONCLUSION

Calcification is the end stage of hyaline degeneration. However, its peripheral location is unlike that of natural fibroid involution and hyaline necrosis. Pathologic studies in resected human fibroids after embolization suggest that its development is the end result of aggregation of PVA particles in peripheral fibroid arteries.

Recurrent superior vena caval obstruction due to invasion by malignant thymoma: treatment using a stent-graft

A stent-graft was used to palliate superior vena caval obstruction in a 50-year-old patient with histologically proven ingrowth of malignant thymoma through three previously inserted non-covered stents. The stent-graft is still patent 12 months later. This is the first report of such a procedure where histological evidence of tumour ingrowth is available and long-term patency is verified.

Vascular imaging and intervention in peripheral arteries in the diabetic patient

Diabetic patients are four times more likely to develop peripheral vascular disease than the general population. This disease is likely to be more aggressive, with five times more patients developing critical limb ischaemia. Early diagnosis and treatment allows up to 80% of these patients to have some form of surgical or endovascular re-vascularisation. The primary imaging modalities to be used should be duplex ultrasound followed by angiography. Magnetic resonance angiography, however, holds out promise for the future as being a good method of non-invasive imaging. Endovascular (interventional radiological) procedures have a major role to play in treatment of vascular stenoses and occlusions. Thrombolytic agents can be used to dissolve thrombus within occluded vessels and so restore patency. Percutaneous transluminal angioplasty is of value in dilating the stenotic lesions within the vessels and so restoring normal blood flow. Endovascular stents may be inserted to ensure longer term patency. There is indirect evidence to suggest that the outcomes of endovascular procedures in the diabetic patient are less good than those in the general population, but nevertheless such procedures may save the diabetic patient from primary amputation and allow healing of ischaemic ulcers.

Long-term follow-Up of percutaneous balloon angioplasty in adult aortic coarctation

PURPOSE

To assess long-term outcomes following percutaneous transluminal angioplasty (PTA) of congenital aortic coarctation in adults.

METHODS

Seventeen patients underwent PTA for symptomatic adult coarctation of the aorta. Sixteen patients, with a mean age of 28 years (range 15-60 years), were reviewed at a mean interval after angioplasty of 7.3 years (range 1.5-11 years). Assessment included magnetic resonance imaging (MRI), Doppler echocardiography, and clinical examination. Current clinical measurements were compared with pre- and immediate post-angioplasty measurements.

RESULTS

At follow-up 16 patients were alive and well. The patient not included in follow-up had undergone surgical repair and excision of the coarctation segment following PTA. Mean brachial systolic blood pressure for the group decreased from 174 mmHg before angioplasty to 130 mmHg at follow-up (p = 0.0001). The mean gradient had fallen significantly from 50.9 to 17.8 at follow-up (p = 0.001). The average number of antihypertensive drugs required per patient decreased from 0.56 to 0.31 (p = 0.234). No significant residual stenoses or restenoses were seen at MRI. Small but clinically insignificant residual pressure gradients were recorded in all patients using Doppler echocardiography. Complications included one transient ischemic attack at 5 days, one external iliac dissection requiring stent insertion, and a further patient who developed a false aneurysm close to the coarctation site at 12 months which subsequently required surgical excision.

CONCLUSION

PTA of adult coarctation is safe and effective in the long term. Although primary stenting has recently been advocated in the treatment of this condition, our results suggest that PTA remains the treatment of choice.

Mechanical properties of metallic stents: how do these properties influence the choice of stent for specific lesions?

PURPOSE

To assess selected balloon-expandable and self-expanding stents for radial force, flexibility, radio-opacity, and trackability, and to relate these physical characteristics to potential indications for placement.

METHODS

Force-strain curves were plotted for each stent and the force required to produce 50% luminal narrowing was recorded. The ability of the stent to show elastic recoil following deformation was also noted. Flexibility was measured by bending the stents against a force transducer and recording the force required per degree of flexion. Radio-opacity was measured by comparing each stent against a standard aluminum step wedge. Trackability was measured by testing the ability of the stent on its delivery system to track over angles of 90 degrees and 60 degrees.

RESULTS

The balloon-expandable stents showed greater radial strength and radio-opacity but, apart from the AVE Iliac Bridge stent, showed poorer flexibility and trackability. The self-expanding stents showed less radial force but were able to re-expand following deformity. They were generally more flexible and had better trackability but lower radio-opacity.

CONCLUSION

There is no stent which exhibits all the ideal properties required and therefore the interventionist will need to keep a range of stents available if all lesions are to be addressed.

Long-term follow-up of the Bird's Nest IVC Filter

AIM

This study is a long-term clinical follow-up of the Bird's Nest Filter which addresses issues such as caval patency, filter integrity, morbidity and mortality.

MATERIALS AND METHODS

78 consecutive patients with Bird's Nest Filters inserted between 1989 and 1994 were recalled for clinical assessment and imaging follow-up. Pre- and post-filter medical histories were obtained from the patients and their medical records. They were examined for clinical signs of inferior vena cava occlusion. Imaging follow-up was by plain abdominal radiography, colour duplex ultrasound and computed tomography.

RESULTS

52 patients were alive and well at 4-6 years. Thirty-day mortality was 5.1%. Three-year mortality was 19.2%. Recurrent pulmonary embolus occurred in 1.3%. IVC occlusion was demonstrated in 4.7%. No evidence of filter migration was seen. Wire prolapse occurred in 70% on abdominal X-ray and asymptomatic performation of the caval wall in 85.3% on CT. Morbidity and mortality were the same whether the patient was anticoagulated or not.

CONCLUSION

The Bird's Nest Filter is safe and effective in both the short and long term.

Directional atherectomy in iliac stent failure: clinical technique and histopathologic correlation

PURPOSE

To assess the feasibility and efficacy of directional atherectomy in the treatment of iliac stent stenosis or occlusion and to evaluate the histologic composition of excised atherectomy specimens.

METHODS

Directional atherectomy of six occluded and 10 severely stenosed iliac stents was undertaken in 12 patients at a mean interval of 28 months (range 3-69 months) after stent insertion for occlusive aortoiliac disease. In cases of stent occlusion, atherectomy was preceded by low-dose thrombolysis. In all patients stent clearance with return of femoral pulses was achieved within 24 hr and there were no significant complications. All excised specimens were sent for histologic examination.

RESULTS

Eleven patients (92%) remain symptom free with unlimited walking distance at a mean follow-up interval of 11.5 months (range 3-31 months) after treatment. Histologic examination revealed typical myointimal hyperplasia at three excision sites, intimal fibrosis at three sites, atheroma at four sites and organized thrombus at six sites.

CONCLUSION

Atherectomy offers an effective treatment in iliac stent occlusion and restenosis with no significant adverse effects. Debulking of these lesions seems to offer a more logical approach than simple balloon angioplasty. Clinical and duplex follow-up confirms satisfactory outcome within the first year but longer-term results are not yet known. The histologic data obtained demonstrate that stent restenosis and occlusion are likely to be multifactorial, and challenge the assumption that myointimal hyperplasia is the sole cause of iliac stent occlusion.

Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage

BACKGROUND

The management of major colonic bleeding is problematic. A proportion of patients require emergency surgery which is associated with high morbidity and mortality. Percutaneous embolotherapy, previously considered a high risk procedure in the colon, may provide an alternative treatment in this group of patients.

AIMS

To assess the safety and efficacy of embolotherapy in the treatment of life threatening colonic haemorrhage.

PATIENTS AND METHODS

Thirty eight patients with fresh haemorrhage per rectum were referred for surgery because of failed conservative treatment. All underwent angiography; in 14 a bleeding site or vascular abnormality was detected. A coaxial catheter was directed to the most distal bleeding artery and this was embolised with platinum coils.

RESULTS

Detection of a bleeding site correlated with haemodynamic stability at the time of angiography (r = 1 for a systolic blood pressure less than 100 mm Hg). Bleeding sites or vascular abnormalities were detected and embolised in 14 patients (37%). In 12/14 there was immediate and sustained haemodynamic improvement; two continued to bleed and required emergency hemicolectomy (14%). Three developed ischaemic complications (21.4%); these were managed conservatively and required no intervention. The 30 day mortality was 7.1% in the embolotherapy group and 10.5% in the overall group of 38 patients.

CONCLUSION

Colonic embolotherapy for life threatening haemorrhage is an effective, relatively safe procedure with a low incidence of major complications. Its use depends on the identification of a focal bleeding point or vascular abnormality, which in turn depends on the haemodynamic stability of the patient at the time of angiography.

Treatment of malignant superior vena cava obstruction: metal stents or radiation therapy

PURPOSE

The results of treating malignant superior vena cava obstruction by means of percutaneous self-expanding stent insertion or by means of radiation therapy were compared.

PATIENTS AND METHODS

Seventy-six patients with malignant superior vena cava obstruction who were treated by stent insertion were studied prospectively and 25 patients who were treated by radiation therapy were studied retrospectively. A superior vena cava obstruction score was devised to measure treatment effectiveness. Speed of symptom relief and complications were recorded. End points in the study were recurrent obstruction or death. Asymptomatic survival times were compared by log rank and Mann Whitney tests of significance, as well as Kaplan-Meier analysis. A subgroup of 26 patients who were treated by stent placement only were compared with the radiation therapy group and analyzed separately.

RESULTS

There were seven complications in the overall stent group, one in the stent-only group, and 25 in the radiation therapy group. Stent insertion provided faster relief of symptoms and significantly greater improvement in the superior vena cava obstruction score than radiation therapy (P < .001, Mann-Whitney U test). A Kaplan-Meier analysis of asymptomatic survival demonstrated that significantly fewer patients in the overall and stent-only groups developed recurrent symptoms (P = .0005 and .001, respectively, log rank test).

CONCLUSION

This study suggests that percutaneous stent insertion in malignant superior vena cava obstruction fulfills the requirements of a palliative procedure significantly better than radiation therapy and that it should be the procedure of first choice.

Tophaceous gout of the spine causing spinal cord compression

Tophaceous gout of the spine rarely causes spinal cord compression. Only eight cases have been reported previously. We report a further case presenting with progressive quadriparesis caused by gouty tophi at C1, treated successfully by decompressive laminectomy and internal fixation. This case and the previously reported cases are reviewed.

Angiographic prediction of dissection followed by ischaemic complications during coronary angioplasty

Ischaemic problems occur in about 8% of coronary angioplasties and are the major cause of morbidity and mortality associated with the procedure. Although the ischaemic event is usually due to acute vessel closure due to vessel dissection, it is noteworthy that 80-90% of radiographically visible dissections cause no problem. We have reviewed 200 consecutive coronary angioplasties in order to find predictive factors for those patients likely to suffer dissection followed by ischaemic complications. Thirty-four (17%) of the patients undergoing coronary angioplasty had radiographically visible dissections, of whom 12 (35%) suffered ischaemic complications. There were 16 (8%) major ischaemic complications following angioplasty. In four of these cases no obvious dissection was visible within the vessel. Eight out of a subgroup of 16 patients who had sequential stenoses along one vessel dilated at angioplasty had a dissection. Six of these eight patients suffered a major ischaemic complication following the dissection. Thus in this group of patients, sequential stenosis not only conferred a high probability of dissection during angioplasty but additionally carried an increased risk of ischaemic complications following the dissection. Awareness of this may affect case selection and may indicate the need for early re-examination of the vessel should problems occur following angioplasty.

The use of transoesophageal echocardiography for detecting early recurrence of atrial myxoma

A comparison between praecordial and transoesophageal cross-sectional echocardiography was undertaken in the follow-up of 14 patients who had previously undergone surgical excision of atrial myxoma. The mean interval between surgery and follow-up was 39 months. Evidence of recurrent tumour was seen in two patients by transoesophageal echocardiography but went undetected in one of these using the praecordial approach. Clear visualisation of the atria and interatrial septum was possible in all remaining cases using transoesophageal echocardiography and this allowed confident exclusion of tumour recurrence. Using praecordial echocardiography, technically inadequate studies meant that this was not possible in 4 patients. The significant late recurrence rate of excised atrial myxomas, emphasises the need for serial, postoperative echocardiographic studies. Praecordial echocardiography may be unreliable in the detection of recurrent atrial myxoma in its early stages and for this reason transoesophageal echocardiographic follow-up is justified in high risk patients.

The value of transesophageal echocardiography in the investigation of acute prosthetic valve dysfunction

When patients present with suspected prosthetic valve dysfunction, investigation is usually instituted to delineate the site and cause thereof. Precordial cross-sectional echocardiography is often helpful in this respect, but in the patient with acute pulmonary edema, imaging may be impaired because of discomfort and respiratory distress. The information obtained may also be suboptimal as a result of concomitant obesity, chest wall deformity, and pulmonary disease. In addition, further difficulties may relate to the acoustic shadowing produced by the metallic portion of the valve and its sewing ring, especially with valves in the mitral position. In such patients, cardiac catheterization may cause further decompensation and is associated with a recognized increase in morbidity and mortality. Angiography does not accurately site regurgitant jets in relation to the prosthetic valve concerned and will not detect the presence of vegetations. Transesophageal echocardiography circumvents many of these imaging difficulties and we evaluated its use in five patients with prosthetic heart valves who presented acutely ill, in severe pulmonary edema and suspected prosthetic heart valve failure. In each case, the diagnosis of valve dysfunction was established, and precise information regarding the site and cause of the failure was obtained. No complications or deterioration in patient condition resulted from the procedure and the findings were confirmed at surgery performed within 24 hours in all five patients. Transesophageal echocardiography should be included in the assessment of acute prosthetic heart valve failure.

Recurrent cardiac myxoma: the surgical implications of two distinct groups of patients

15 consecutive cases where patients (11 female, 4 male) had undergone surgical excision of cardiac myxoma were reviewed. The 11 survivors were re-assessed by trans-oesophageal echocardiography and recurrent myxoma was detected in 2 patients. These two were the only patients who had originally presented with multiple myxomas. Analysis of these cases in conjunction with 26 previously reported cases of recurrence identifies two distinct groups of patients. In one group (12 cases, mean age 48.7 years) recurrence occurred at the site of previous excision, typically following the removal of a single septal myxoma by partial thickness excision. In the second group, which includes our two cases, (16 cases, mean age 30.6 years) recurrent myxoma was found distant to the site of previous excision, typically in younger patients who had multiple myxomas at original operation. These results suggest that 1) single myxomas should be removed by full thickness excision 2) in younger patients with multiple myxomas surgery should be as radical as possible.

Fatal acute left ventricular outflow obstruction due to interventricular septal haematoma--diagnosis by transoesophageal echocardiography

We describe a case of fatal left ventricular outflow obstruction detected by intraoperative transoesophageal echocardiography. This resulted from acute haematoma formation within the interventricular septum following internal mammary artery grafting to the left anterior descending coronary artery. This unusual case highlights the emerging role of transoesophageal echocardiography in the diagnosis and management of the complications of cardiac surgery.

Can left ventricular end-diastolic pressure be estimated non-invasively?

The relationship between the velocity waveforms due to the early and late phases of ventricular filling recorded by pulsed Doppler changes with abnormalities of left ventricular diastolic function and it has previously been suggested that quantitative assessment of these changes may provide a clinically useful estimate of left ventricular end-diastolic pressure. Pulsed Doppler ultrasound was used to record transmitral blood flow velocities simultaneously and on the same recorder as left ventricular pressure measurements in 30 patients undergoing cardiac catheterisation for the investigation of ischaemic heart disease. Contrary to previous reports we found no relationship between transmitral flow and left ventricular end-diastolic pressure. Caution is required in the conclusions drawn from transmitral flow velocity patterns whose relationship to left ventricular end-diastolic pressure remains uncertain.

Reproducibility and persistence of abnormal transmitral flow velocity patterns detected by pulsed Doppler ultrasound

This prospective study examines the reproducibility and persistence of abnormal transmitral flow detected using pulsed Doppler ultrasound on 2 separate occasions between 2 days and 6 weeks apart. The 22 patients included were accepted consecutively from those having an abnormal diastolic flow pattern at initial examination. Abnormal flow velocity patterns were defined as those exhibiting reversal of the ratio of the passive filling velocity (E) and active atrial transport velocity (A). There was no significant difference between the separately recorded values for the ratio of the peak E and A velocities or of the ratio of the planimetered areas beneath each of the velocity waves, with positive correlations for both sets of values (r = 0.68, r = 0.67). Significant positive correlation also existed between the mean rates of acceleration to each of the E and A velocity peaks of the transmitral waveform recorded on separate occasions (r = 0.68, r = 0.95). Interobserver variation for the analysis of hard-copy pulsed Doppler recordings between two trained observers was less than 5% and intraobserver error for recording analysis was less than 2% for both observers. Abnormal transmitral flow velocity patterns persist unchanged in the absence of therapeutic intervention and the acceptably small observer error in the recording and analysis of such flow patterns allows consistent and clinically reliable data to be obtained.