[Hemodynamic effects of a single intravenous administration of prostaglandin E1 in a patient sample with chronic NYHA-stage II/III heart failure]

We investigated the hemodynamic effects of a single infusion of PGE1 (60 micrograms infused over a period of 2 h--this is the single dose used in courses of treatment for peripheral occlusive arterial disease) in patients with chronic heart failure NYHA class II-III. The ejection fraction of these patients was < 55%, their average age was 58.4 years (standard deviation 10 years), and their condition was stable. Nineteen of the patients had coronary heart disease and one patient had myocarditis. The hemodynamic data were obtained invasively by catheterization of the right and left heart. Blood pressure and pulse rate were measured manually. Intravenous infusion of 60 micrograms PGE1 over a period of 2 hours did not significantly alter contractility or hemodynamics. Dp/dtmax, dp/dtmax/p, and dp/dt DP40, which are parameters of left ventricular contractility, determined with the aid of a catheter-tip manometer, did not differ significantly over time from those in the placebo control group. Similarly, the other data furnished no evidence that administration of PGE1 had any hemodynamic or myocardial effects. Hence, it is reasonable to state that it is safe to administer PGE1 to patients with peripheral occlusive arterial disease.

Effects of prostaglandin E1 and buflomedil on left ventricular function in patients with severe chronic occlusive arterial disease: a prospective, randomized, double-blind trial

In this study, the effect of a course of prostaglandin E ( 1 ) (60 microg/d intravenously [i.v.]) or buflomedil (150 mg/d i.v.) treatment on parameters of left ventricular systolic function was investigated by echocardiography in patients of comparatively advanced age with severe peripheral occlusive arterial disease (Fontaine's stage III or IV). The study population was 20 patients, 12 men and 8 women, between 51 and 85 years of age (average age, 73. 7 years), with multiple coexisting medical conditions. These patients were no longer suitable candidates for other forms of interventional or surgical treatment. The patients were treated with prostaglandin E ( 1 ) or buflomedil in the dosages recommended for peripheral occlusive arterial disease for 3 weeks. The following were determined on the 1st, 11th, and 21st day, before and after drug administration: end-diastolic and end-systolic volume, ejection fraction, and pre-ejection period/left ventricular ejection time ratio. The data from all 20 patients were included in the evaluation. There was no evidence of any significant change in the ejection fraction or systolic time intervals, suggesting the safety of the drugs in this special patient population with multiple coexisting conditions.

Hemodynamic effects of a single intravenous infusion of prostaglandin E1 in patients with clinically moderate to severe chronic heart failure

In a placebo-controlled, double-blind study, we investigated the hemodynamic effects of a single infusion of prostaglandin E ( 1 ) (PGE ( 1 ); 60 microg infused over a period of 2 hours, the unit dosage used in courses of treatment for peripheral occlusive arterial disease) in 20 patients with moderate to severe chronic heart failure (New York Heart Association functional class II or III). Ejection fraction before therapy was less than 55%, and average age was 58.4 +/- 10 years in these clinically stable patients. Nineteen patients had coronary heart disease and one patient had had myocarditis underlying heart failure. Hemodynamic data were obtained by right- and left-heart catheterization and by Doppler echocardiography. Blood pressure and pulse rate were measured manually. Intravenous infusion of 60 microg PGE ( 1 ) over a period of 2 hours did not significantly alter contractility or hemodynamics. Dp/dt max, dp/dt max/p and dp/dt DP40, measures of left ventricular contractility determined with a catheter-tip manometer, did not differ significantly over time in PGE ( 1 ) -treated patients and those who received placebo. Other measures also failed to reveal PGE ( 1 ) -induced myocardial effects. We conclude that it is safe to administer PGE ( 1 ) to patients with peripheral occlusive arterial disease irrespective of heart failure.

[Prospective study of subjective stress caused by dobutamine stress echocardiography--effect on diagnostic accuracy]

We used a standardized questionnaire to assess physical and mental distress caused by dobutamine stress echocardiography (DSE). The examination was performed according to a standardized protocol (5-40 micrograms/kg/min including atropine). 91 patients (pts), 68 men (62 +/- 9 years), 23 women (65 +/- 7 years) were asked to quantify the severity of the following symptoms: palpitations, anxiety, headache, nausea, discomfort of left lateral position, angina pectoris and dyspnea. Numbers on a rating scale from 1-10 defined the degree of distress. Absence of a symptom equalled mark, 1, slight expression marks 2-4. Moderate expression was defined by marks 5-7 and very strong expression by marks 8-10.

RESULTS

86% of pts felt affected by one or more symptoms to a slight to moderate extent (mark 4 +/- 2.17). Palpitations were felt by 85% of the pts (mark 6 +/- 2.83), anxiety by 42% (mark 3 +/- 2.5), headache by 50% (3 +/- 2.54), nausea by 20% (2 +/- 1.72), angina pectoris by 42% (3 +/- 2.5), dyspnea by 30% (2 +/- 2.42) and discomfort of left lateral recumbent position by 43% (mark 3 +/- 2.59). 43 pts underwent coronary angiography. The negative predictive value of DSE to identify pts without a coronary artery stenosis extending a 50% diameter reduction was 85% for the 16 pts who reached their individual submaximal heart rate compared to 60% for those 27 pts who did not reach it. Unspecific symptoms led to test termination in these pts. The positive predictive values were comparable (89 and 94%).

CONCLUSION

DSE causes physical and mental distress. If symptoms lead to test termination before age corrected submaximal heart rate is reached, normal wall motion does not exclude significant coronary artery disease.

[Determination of systolic left ventricular time interval using the doppler technique. Analysis of aortic flow spectrum with transthoracic echocardiography]

In 10 healthy volunteers (age 21-28 years; mean age 24.8 years +/- 1.9 years) systolic left ventricular time intervals (STI) were determined by analysis of aortic Doppler flow pattern. This method was compared with conventional calculation of STI, using electrocardiogram, carotid pulse curve and phonocardiography, which were registered in synchronicity to the Doppler examination. Both, CW- and PW Doppler echocardiography constantly showed slightly lower values than the conventional method. This referred to basic measurements as well as to measurements after the application of isoprenaline and quinidine. The PW Doppler method underestimated the conventional method concerning the electromechanic systole (QS2) by on average 3.98%, the left ventricular ejection period (LVET) by on average 2.24% and the pre-ejection period (PEP) by on average 7.3%. Using CW-Doppler-method, QS2 was on average 5.31% and LVET was on average 6.67% smaller than the values determined by conventional method, whereas PEP was overestimated by on average 1.69%. The study documented that positive and negative inotropic pharmacological effects were measured reliably by the Doppler-echocardiographic method. Isoprenaline caused a significant shortening of frequency corrected QS2 (QS2c) from -55 +/- 17 to -85 +/- 20 ms (p < 0.05) using the PW-Doppler method; frequency corrected PEP (PEPc) was shortened from -40 +/- 14 to -67 +/- 14 ms (p < 0.05). The CW Doppler method also showed a statistically significant reduction of QS2c (from -64 +/- 18 to -89 +/- 25 ms; p < 0.05) and PEPc (from -37 +/- 16 to -64 +/- 12; p < 0.05). Likewise, the conventional method demonstrated statistically significant shortening of QS2c and PEPc after application of isoprenaline. LVETc did not change in a state of positive inotropy, no matter which method was used for determination. The negative inotropic effect of quinidine, measured by PW-Doppler, resulted in a prolongation of QS2c from -55 +/- 16 to -32 +/- 24 ms (p < 0.05) and of LVETc from -20 +/- 11 to +6 +/- 17 ms (p < 0.05). Using CW Doppler method, quinidine led to a lengthening of QS2c from -63 +/- 16 to -42 +/- 22 (p < 0.05) and of LVETc from -33 +/- 11 to -12 +/- 8 ms (p < 0.05). The conventional method also demonstrated a statistically significant increase of QS2c and LVETc. None of the 3 methods in question showed a statistically significant alteration of PEPc in the negative inotropic state.

CONCLUSIONS

Doppler-echocardiographic analysis of aortic flow pattern constitutes a new method for the measuring of systolic time intervals. Basic values as well as changes due to positive or negative inotropic effects are reliably determined, in comparison with conventional methods the measurements are slightly lower.

Three-dimensional imaging of cardiac mass lesions by transesophageal echocardiographic computed tomography

Three-dimensional echocardiography is a new imaging technique that allows more realistic visualization of cardiac morphology. This study presents data about the diagnostic potentials of this technique concerning cardiac mass lesions, as well as its feasibility in clinical application. After the conventional investigation, multiple cross-sectional images were obtained during automatic forward advancement of a monoplane transducer mounted on a transesophageal probe. Three-dimensional reconstruction and volume determination were performed off line. Twenty-four patients were studied. In 14 cases results of echocardiographic computed tomography (echo-CT) were compared with those of monoplane/biplane transesophageal echocardiography. In 23 patients a conventional transesophageal investigation with the echo-CT probe and in 20 patients tomographic scanning were possible. Data acquisition required 12 +/- 4 minutes and three-dimensional reconstruction required 35 +/- 14 minutes. In 13 patients mass lesions were found; in 11 of 13 patients echo-CT provided diagnostic information about the precise spatial orientation and morphology of cardiac structures that could not be obtained by monoplane/biplane transesophageal echocardiography. The technique revealed accurate distance measurements and volume determination of mass lesions. Echo-CT is a further step toward the application of clinically useful three-dimensional echocardiography.

[Echocardiographic on-line volumetry using acoustic quantification--comparison with manual echocardiographic analysis and cineventriculography]

Acoustic quantification (AQ) represents an ultrasound imaging system which provides detection and tracking of endocardial blood boundaries based on quantitative assessment of acoustic properties of tissue in real time. To assess on-line quantitation of left ventricular enddiastolic (EDV), endsystolic (ESV) volumes and ejection fractions (EF) AQ measurements were compared with off-line measurements obtained by manual analysis of video-taped images (MAN) and with cineventriculographic data (CV). Calculations by the AQ system were based on an algorithm using the monoplane disc method. One day before undergoing CV, 88 unselected patients were studied with echocardiography in the apical four-chamber view. Seventy (79.5%) patients could be studied by AQ. The regression equations for determination of EDV were y = 0.7x + 25.2; r = 0.87 (AQ vs. MAN) and y = 0.5x + 22.8; r = 0.80 (AQ vs. CV), for determination of ESV they were y = 0.8x + 11.4; r = 0.78 (AQ vs. MAN) and y = 0.7x + 6.9; r = 0.71 (AQ vs. CV), and for determination of EF they were y = 0.7x + 9.5; r = 0.77 (AQ vs. MAN) and y = 0.6x + 15.0; r = 0.71 (AQ vs. CV). Calculations of left ventricular volumes by AQ or MAN led to a systematic underestimation, compared to CV. EF was also underestimated by AQ, whereas no significant difference between the mean values of MAN and CV exists. In a heterogenous population, acoustic quantification based on quantitative assessment of tissue acoustic properties mostly permits on-line quantitation of left ventricular volumes and ejection fractions in real-time.

[Transesophageal echocardiography in cardiogenic shock in acute posterior wall infarct with rupture of the papillary muscles]

A 63-year-old male patient suffered an acute myocardial infarction entirely confined to the posterior wall. As symptoms persisted and cardiogenic shock developed immediate heart catheterization was performed, which demonstrated an occlusion of the left circumflex branch. Right-heart catheterization demonstrated an enlarged v-wave. Thus, acute infarct associated mitral regurgitation was suspected. In the catheterization laboratory transesophageal echocardiography including Doppler- and contrast echocardiography was then performed, which revealed the diagnosis of posterior papillary muscle rupture. The patient proceeded immediately to emergency surgery during which mitral valve replacement with a St. Jude prothesis was performed in addition to venous bypass revascularization of the occluded and a further stenosed coronary artery. The postoperative follow-up was without any complications and the patient recovered satisfactorily from the acute event. This case demonstrates the excellent diagnostic utility of emergency transesophageal echocardiography in the situation of infarct related myocardial rupture, which has to precede the life-saving operation.

[Diagnostic value of transesophageal echocardiography in diseases of the heart valve system]

Due to high resolution transesophageal echocardiography has been proven to have additional diagnostic benefits in valvular heart disease. The quantification of aortic and mitral valve insufficiency is possible by the use of semiquantitative methods. In aortic valve insufficiency the relation of the regurgitant jet width to the left ventricular outflow tract and in mitral valve insufficiency the relation of the regurgitant jet area to the left atrium are the parameters with the most accurate sensitivity. The main advantage of the method in this point is the rapid detection of morphological pathology at the valves. The development of multiplane transducers enhanced the quantification of aortic valve stenosis which is performed by planimetry of the orifice area in an ideal cross-section of the valve reached at a mean angle of 46 degrees. The high resolution image of mitral valve anatomy leads to the intraoperative use of the method during valve repair identifying inadequate surgical correction, which can be revised instantly. Visualization of the valvular and subvalvular mitral apparatus enables a more reliable indication for valvuloplasty by detecting the presence or absence of atrial thrombi and assessing the severity of calcification, the guide catheter and the balloon placement. Transesophageal echocardiography is the method of choice in the detection and measurement of vegetations and abscesses in infective endocarditis. Imaging an increasing extent of a vegetation during follow-up investigations can lead to the necessity of surgical intervention for preventing embolic events. The transesophageal approach especially in combination with color-doppler flow imaging is superior to the transthoracic method in the detection of abscesses and secondary complications like communication to adjacent structures or implication of the mitral valve. In this point the use of multiplane probes permits a more accurate assessment of the extent and the spatial configuration of additional masses. Concerning valve prostheses the detection rate of vegetations, abscesses as well as degenerations of bioprostheses is higher using the transesophageal method than the transthoracic approach. Abscesses located near the right coronary sinus or in the ventricular septum are difficult to detect due to shadowing caused by prosthetic artefacts. The visualization of bioprostheses allows the measurement of the thickness of the leaflets which is necessary for the diagnosis of valve sclerosis or degeneration. In combination with color-doppler flow imaging the method allows the differentiation of transvalvular and perivalvular regurgitation. The movements of the occluder can be imaged leading to a more reliable diagnosis of obstruction in combination with the trans-thoracic use of doppler-methods.

Value and limitations of transesophageal echocardiography in the evaluation of aortic prostheses

Results of 34 transesophageal (TEE) studies in patients with suspected aortic prosthetic dysfunction were compared with transthoracic echocardiographic (TTE) results and to anatomic findings. Mass lesions noted at surgery (autopsy) were correctly described in 93% by TEE versus 43% by TTE. Abscesses were detected in 88% by TEE versus 18% by TTE. Bioprosthetic degeneration was visualized in 88% versus 38% and prosthetic obstruction correctly identified in 75% versus 50% by TEE and TTE, respectively. Anatomic aortic regurgitant lesions were identified in 96% by TEE versus 77% by TTE, whereas the correct origin was detected in 88% of cases by TEE versus 54% of cases by TTE. TEE provides valuable additional information on morphologic conditions and flow pathology in aortic valve prostheses.

[Noninvasive quantification and classification of the severity of aortic stenosis using Doppler echocardiography]

The exact determination of the severity of valvular heart disease represents the basis for the indication for surgery. Apart from the clinical findings, the estimation of the severity has, up to now, been based on the chest x-ray, the electrocardiogram, and the carotid pulse curve. By means of cardiac catheterization, the aortic valve gradient is determined and the aortic valve area is calculated using the Gorlin equation. Doppler echocardiography allows for a noninvasive gradient assessment. The peak and mean pressure gradients as well as the aortic valve area can be calculated. Echocardiography provides additional information about the severity of the left-ventricular hypertrophy, the heart size, as well as about secondary complications. Doppler echocardiography was performed in 95 patients to determine the peak pressure gradient. This Doppler-derived gradient correlated well with the catheterization-derived invasive gradient. The correlation coefficient was r = 0.81, for the mean gradient r = 0.77, and for the aortic valve area r = 0.87. Based on the classical determination of the severity of aortic stenosis by means of cardiac catheterization, a Doppler-derived mean pressure gradient > 54 mm Hg or a peak pressure gradient > 89 mm Hg and an aortic valve area > 0.7 cm2 are specific for severe aortic stenosis. A mean pressure gradient between 40 and 54 mm Hg or a peak pressure gradient of 67 and 89 mm Hg and an aortic valve area of 0.7 and 1.3 cm2 indicate moderately aortic stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism

Transthoracic echocardiography generally provides only indirect signs of pulmonary embolism. In contrast, with transesophageal echocardiography the thromboembolus itself can be visualized in the central parts of the pulmonary artery. The aims of our study were to evaluate, first, the incidence of central pulmonary artery thromboemboli in patients with severe pulmonary embolism, and second, the accuracy of the echocardiographic diagnosis. Our study group comprised 60 patients with proved severe pulmonary embolism. All patients were examined by transthoracic and transesophageal echocardiography. The echocardiographic findings concerning the absence or presence of central pulmonary artery thromboemboli were compared with the results of different reference methods. Central pulmonary thromboemboli were found in 35 patients (58.3%) by echocardiography. Two types of thrombus were differentiated. Type A is a long, highly mobile thrombus, and type B is an immobile wall-adherent thrombus. In comparison with the reference methods, we determined a sensitivity of 96.7% and a specificity of 88% for the echocardiographic detection of central pulmonary artery thromboemboli in patients with severe pulmonary embolism. Transesophageal echocardiography seems to be a useful method for the diagnosis of severe pulmonary embolism. In our series, central pulmonary artery thromboemboli were present in more than half of the patients. In these cases, transesophageal echocardiography can clarify the diagnosis within a few minutes without further invasive diagnostic procedures.

[Pulmonary thrombendarterectomy in thromboembolic pulmonary hypertension. The indications and early results]

Pulmonary thrombendarterectomy was performed in 32 patients (14 men and 18 women; mean age 38 +/- 15 years) with thromboembolic pulmonary hypertension (New York Heart Association stage III: n = 22; stage IV: n = 10). The preoperative arterial pO2 averaged 59 +/- 11 mm Hg; pulmonary vascular resistance (PVR) and mean pressure (MPAP) were increased to 1,045 +/- 430 dyn.s.cm-5 and 53 +/- 12 mm Hg, respectively. The perioperative death rate was 22% (7 of 32). In the 25 survivors the pulmonary hypertension was reduced to a PVR of 194 +/- 75 dys.s.cm-5, MPAP of 28 +/- 6 mm Hg. Subsequent re-examination in 15 patients (NYHA stage I: n = 14, stage II: n = 1) after a mean of 17 +/- 5 months demonstrated an arterial pO2 averaging 92 +/- 6 mm Hg and, in 14 patients, echocardiographically normal right-ventricular volumes and function. The primary success was confirmed in eight patients by haemodynamic measurements. These data indicate that thrombendarterectomy can effectively treat the increased PVR in most patients at all stages of the disease.

Echocardiographic and angiographic evaluation of left ventricular function during percutaneous transluminal aortic valvuloplasty

Transesophageal echocardiography was used to study the effect of the balloon inflation on left ventricular function in 20 patients with critical aortic stenosis undergoing balloon valvuloplasty. Balloon inflation caused an increase of end-diastolic (15% to 34%) and end-systolic (57% to 72%) left ventricular volume. Left ventricular wall stress increased from 30 +/- 10 x 10(3) dyn/cm2 at diastole and 121 +/- 40 x 10(3) dyn/cm2 at systole to 44 +/- 11 x 10(3) dyn/cm2 and 191 +/- 55 x 10(3) dyn/cm2, respectively, when the balloon was inflated (P less than 0.05). Turbulent regurgitant jet across the mitral valve increased from 15 +/- 2% to 25 +/- 3% during balloon inflation (P less than 0.01). Continued monitoring of left ventricular function after balloon deflation demonstrated prolonged enlargement of left ventricular volumes. Our data show that balloon inflation causes an increase of left ventricular volume and impairment of contraction. Increase of left ventricular wall stress--associated with a reduction of coronary blood flow, due to lower aortic pressure--could result in ischemic myocardial injury.

[Left ventricular inflow behavior in dual chamber stimulation with differential atrioventricular conduction: an echocardiography study]

The influence of the AV interval on early passive (E) and late active diastolic filling (A) during transmitral flow was analyzed in patients with AV sequential pacing. In 16 patients with dual-chamber pacemakers at the age of 25 to 76 years CW- and color Doppler echocardiography was used to determine inflow time (t), flow velocity (Vmax), the E/A ratio, the time-velocity integral (TVI), and the inflow jet at constant AV sequential pacing (80 bpm) with various AV interval settings (50-100-150-200-250 ms). The inflow pattern was compared to findings in 16 normals (age 26 +/- 7 years). The prolongation of the AV interval from 50 to 250 ms resulted in the following changes: 1) Decrease of tE: 220 +/- 30 ms to 170 +/- 40 ms (p less than 0.05), of VmaxE: 78 +/- 12 to 68 +/- 14 cm/s) (ns) and of TVI-E: 8.5 +/- 2.1 to 5.6 +/- 1.7 cm (p less than 0.001); 2) Increase of tA: 140 +/- 30 to 270 +/- 60 ms (p less than 0.001), of VmaxA: 48 +/- 18 to 73 +/- 24 cm/s (p less than 0.001) and of TVI-A: 2.4 +/- 1.1 to 6.1 +/- 2.9 cm (p less than 0.001); 3) Decrease of the E/A ratio from 1.6 +/- 05 to 0.85 +/- 02. Longer AV intervals shortened the total diastolic filling period and produced more diastolic aliasing without change of the relative diastolic inflow jet. The AV interval of 150 ms was associated with an abnormal high atrial component of transmitral inflow, as found with abnormal diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of intracardiac dimensions and structures in normal young adult subjects by transesophageal echocardiography

Transesophageal echocardiography (TEE) has proven to be an excellent diagnostic means of diagnosing different cardiac diseases. To distinguish between normal and pathologic findings, standardized measurements of well-defined cross-sectional planes are necessary. Therefore, the 2-dimensional echocardiographic data of 25 healthy volunteers were obtained. In 13 men and 12 women, aged 19 to 30 years, recordings of the left ventricular short-axis view, the 2- or 4-chamber view with the left and right atria, the long axes of the left and right ventricles, the mitral and tricuspid valve ring and the atrial septum were analyzed. Furthermore, the aortic valve plane and the ascending and descending aorta were also measured. All data are given as mean values +/- 2 times the standard deviation. End-diastolic and end-systolic left ventricular anterior-to-posterior diameter of the left ventricular short axis was 2.5 +/- 0.3 cm/m2 and 1.7 +/- 0.3 cm/m2, with the fractional shortening ranging from 27 to 42%. The end-systolic lateral diameter was 2.4 +/- 0.5 cm/m2 for the left atrium and 2.4 +/- 0.4 cm/m2 for the right atrium, and the end-systolic anterior-to-posterior diameter was 1.5 +/- 0.6 cm/m2 for the left atrium and 2.1 +/- 0.6 cm/m2 for the right atrium. End-diastolic diameters of 3.4 +/- 0.6 cm/m2 and 2.8 +/- 0.4 cm/m2 were obtained for the long axis of the left ventricle and for the right ventricle. Measurements ranged from 1.5 to 2.2 cm/m2 for the end-diastolic diameter of the mitral ring and from 1.3 to 2.0 cm/m2 for the tricuspid ring.(ABSTRACT TRUNCATED AT 250 WORDS)

[Functional evaluation of the left ventricle using 2-dimensional and color-coded Doppler echocardiography]

A new parameter for the evaluation of left ventricular function based on color-coded Doppler echocardiography is described. From an apical transducer position the maximal diastolic inflow area across the mitral valve into the left ventricle is registered. A ratio of this area to the left ventricular area in the same plane and frame is calculated. These parameters are evaluated in 17 normal controls and 31 patients with dilatative cardiomyopathy. Additionally, the left ventricular volumes and the ejection fraction are calculated from two-dimensional echocardiography using a disc method. The maximal inflow area is correlated with the stroke volume (r = 0.69, y = 7.0 + 8.6x) and the ratio to the ejection fraction (r = 0.99, y = 0.65 + 0.98 x). The intraobserver-correlation for the maximal diastolic inflow area was r = 0.95, y = 5.5 + 0.79 x and the interobserver-correlation r = 0.89, y = 7.7 + 0.8 x. Finally, the gain dependency of the maximal diastolic inflow area was tested. By increasing the gain at low levels a steep linear increase was noted; at higher gain levels a plateau phase was observed where measurements could be performed.

Ambulatory follow-up of aortic dissection by transesophageal two-dimensional and color-coded Doppler echocardiography

Follow-up of 18 patients with aortic dissection (five with type I, one with type II, 11 with type III dissection according to DeBakey) by transesophageal, two-dimensional and color-coded Doppler echocardiography showed a persistence of the false lumen in five of seven patients (71%) after surgery and in nine of 11 patients (82%) after medical therapy. In two patients treated with surgery, the dissected part of the aorta had been resected, whereas in two patients treated medically, a progressive and complete obliteration of the false lumen was observed. In the false lumen, thrombus formation was absent in four, localized in four, and progressive in six patients. Flow within the false lumen could be registered in 14 patients, and two distinct flow patterns were differentiated (laminar biphasic flow or slowly circulating flow). Persisting intimal tears were visualized by two-dimensional echocardiography in four patients, whereas color-coded Doppler showed an additional one to three intimal tears in the descending aorta in 10 patients. Flow across these intimal tears was biphasic in 75% of patients; that is, systolic flow was directed from the true to the false lumen with diastolic flow reversal. Unidirectional flow was detected in 25% of the communications, directed in 20% from the true to the false lumen, serving as an entry only and in one (5%) as reentry only. Additional information concerning complications like extension of the dissection (one of 18 patients), localized dilatation of the regurgitation (three of 18 patients) were detected by this method. Concerning the morphologic findings and the detection of flow characteristics, the transesophageal approach was superior to conventional echocardiography especially in the descending thoracic aorta. Thus, transesophageal two-dimensional and color-coded Doppler echocardiography seems to be an ideal method not only for the easy detection of aortic dissection but also for follow-up.

Semiquantitative grading of mitral regurgitation by color-coded Doppler echocardiography

We evaluated patients with mitral regurgitation by color-coded Doppler echocardiography using a semiquantitative score system, which is useful in the clinical setting, by providing rapid discrimination between mild, moderate and severe regurgitation. The study was performed in 42 patients (19 female, 23 male) mean age 58 years, range 23-75 years with mitral regurgitation of different etiology. Color-coded Doppler measurements were compared to angiographic findings using a three point score system. In addition to such parameters as maximal jet length, area and the ratio jet area/left atrial area, we also considered the duration of regurgitant flow. The best correlation was obtained for the maximal area of the jet multiplied by the duration of regurgitant flow/cycle length (r = 0.88), determined in the apical plane where the jet was best visualized. For the parameter area of jet alone, the correlation coefficient was 0.81, for the length of the jet the value was r = 0.65 and comparison of the areas of jet and left atrium gave a coefficient of 0.77. A clear separation between mild and severe regurgitation was observed only for the parameter calculated by multiplying the area of the jet by the duration of mitral regurgitation. In only 7% of the patients with moderate and severe regurgitation could we observe an overlap. This parameter, therefore, represents a useful method for estimating in a semiquantitative manner the severity of mitral regurgitation by color-coded Doppler echocardiography.

[Diastolic opening of the pulmonary valve in a case of cardiomyopathy with restrictive dysfunction. Case report and review of the literature]

In a case of cardiomyopathy with restrictive ventricular dysfunction a complete diastolic opening of the pulmonary valve immediately following the atrial contraction could be visualized by echocardiography and at the same time a forward blood flow into the pulmonary artery could be shown by conventional and color Doppler. The velocity of this flow (0.37 m/s) was as high as the maximal velocity of the systolic outflow. As an expression of the unpaired compliance of the right ventricle and a compensatory hyperkinetic right atrium the heart catheterization revealed a high a-wave of 18 mm Hg, which was transmitted into the right ventricle and the pulmonary artery. This produced a short diastolic pressure drop between the right ventricle and pulmonary artery causing an opening of the pulmonary valve which could be shown by echocardiography. In connection with similar cases in the literature the pathophysiology of this phenomenon is discussed.

Diagnosis of aortic dissection: the value of transesophageal echocardiography

Using the transesophageal approach the descending part of the aorta can be imaged by two-dimensional enchocardiography in cross sections comparable to computer tomograms. The value of combined transesophageal and transthoracic echocardiography was evaluated in 53 patients who were studied consecutively from 1983 to 1986 with symptoms of aortic dissection and compared with computed tomography, angiography, surgery and/or autopsy. In all patients the transthoracic aorta could be visualized and the dissection could be classified according to DeBakey: in 9 of 29 patients (34%) type I dissection, in 4 (14%) type II dissection and in 16 (55%) type III dissection was found. Operation was carried out because of acute symptoms in 11 of the 29 patients, and 3 additional patients died before operation. In 24 patients aortic dissection could be ruled out. A sensitivity of 97% for transthoracic and transesophageal echocardiography, of 80% for computed tomography and of 78% for angiography was calculated. The specificity for echocardiography was 100%, for computed tomography 100% and for angiography 95%. The positive predictive accuracy for echocardiography and computed tomography was 100% and 95% for angiography. The negative predictive accuracy for echocardiography was 96%, for computed tomography 77% and for angiography 79%. In no patient was an aortic dissection found by computed tomography or angiography which was not detected by echocardiography. In 1 patient with a large ectasia of the aorta ascendens aortic dissection was overlooked as retrospective analysis demonstrated. Signs of aortic insufficiency and pericardial effusion were detected.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnostic value of the transesophageal Doppler echocardiography]

Transesophageal echocardiography has been proven to be of particular value in all patients with transthoracic echocardiograms of low quality related to pulmonary emphysema, obesity and chest deformation as well as in intensive care unit patients. Similarly, transesophageal Doppler echocardiography is of particular value in all cases in which the transthoracic Doppler, due to methodological problems, is of limited value. Mitral regurgitation can be detected and quantified and flow direction described. Only in 12/25 patients with mild, 11/12 patients with moderate and 5/8 patients with severe insufficiency was regurgitation detected by transthoracic echocardiography as compared to transesophageal echocardiography with which the lesion was consistently detected. In two patients with severe and clinically-inapparent mitral regurgitation related to papillary muscle rupture, the diagnosis was established only by the transesophageal approach in an emergency situation. Atrial septal defects were detected in 8/15 patients and the size of the defect analyzed. With transesophageal Doppler echocardiography, the relation of left-to-right and right-to-left shunts could be described. In 7/16 patients with aortic dissection, true and false lumen were differentiated by analysing the flow pattern within both lumina. In 9/16 patients differentiation was enabled through delineation of the false lumen which was filled with thrombotic material. Detection of aortic regurgitation and tricuspidal regurgitation is possible but analysis of flow patterns is difficult because flow direction is nearly orthogonal to the ultrasound beam. First attempts to quantify cardiac output have been performed. For the future, transesophageal color flow Doppler mapping appears to be a most promising method.

[18 years after a penetrating heart injury: follow-up]

This report presents a case of penetrating chest trauma leading to pericardial tamponade and ventricular septum defect successfully resuscitated by surgery in 1968 in an 11-year-old boy. 10 years later a first-size calcified hematoma was removed. However the 30% left to right intracardiac shunt flow as established by complete heart catheterization prior to surgery was not corrected. Non-invasive methods were used to assess cardiac function 18 years after the initial event including physical examination, chest X-ray, thoracic computer tomography, ECG, 24 h Holter monitoring and exercise testing, combined with myocardial scintigraphy and radionuclide angiography and echocardiographic techniques using the transthoracic and the transoesophageal approach. The diagnostic value of echocardiographic examinations is emphasized with special reference to contrast- and Doppler-echocardiography including the color-coded Doppler-flow-imaging technique.

[Combination of color Doppler and transesophageal echocardiography in emergency diagnosis of type I aortic dissections]

We report on the use of colour Doppler- and transesophageal echocardiography in 2 patients with acute type I aortic dissection according to DeBakey. Using transesophageal echocardiography we obtained information on the extension and the entry site of the dissection without interfering with respiration and external thorax configuration. Using colour Doppler we were able to differentiate between the true and false lumen in the thoracic and abdominal aorta due to characteristic phasic flow patterns. In one patient the site of the entry tear of the intimal flap was localized by this method. Furthermore, a noninvasive semiquantitative evaluation of accompanying aortic regurgitation was possible. Colour Doppler gives additional information in the emergency diagnosis of patients with aortic dissection.

[Color Doppler echocardiography in emergency diagnosis of ventricular septal rupture after acute myocardial infarct]

A 58-year-old man developed a rupture of the interventricular septum after acute posterior myocardial infarction. The two-dimensional echocardiographic features of the ruptured interventricular septum included akinesia of posterior wall, hyperkinesia of the interventricular septum and anterior wall, inferior basal septum aneurysm and visualization of the ventricular septum defect. Injection of echocardiographic contrast (Gelatin solution) into the right atrium showed a small right-to-left shunt, injection into the left ventricle (during heart catheterization) demonstrated massive crossing of echocontrast similar to the results of cineventriculography of the left ventricle. By coloured Doppler-echocardiography the left-to-right shunt could directly be visualized, as well as a diastolic right-to-left shunt. By calculation of pressure gradient using adjusted continuous wave Doppler, estimation of right ventricular pressure was possible. The results demonstrated that colour Doppler in addition to two-dimensional echocardiography has an important diagnostic role in patients with complications of myocardial infarction.