Evaluation of pulmonary vein stenosis by transesophageal echocardiography.

Pulmonary vein stenosis was diagnosed by transesophageal echocardiography in five patients who underwent the study for different clinical indications. Stenosis was encountered in the right upper pulmonary vein in two patients, the right lower pulmonary vein in two patients, and at the confluence of the left pulmonary veins in one patient. In only one patient was the diagnosis suspected on transthoracic echocardiography. Contralateral normal veins from the same patient served as the control. Vessel diameter and peak flow velocity were measured and compared. The diameter of the stenosed veins ranged from 0.3 to 0.8 cm (mean 0.4 +/- 0.09 cm [SEM]), whereas for normal veins the diameter was 0.9 to 1.2 cm (mean 1.0 +/- 0.05 cm [SEM]; p < 0.001). Peak flow velocity in the stenosed veins ranged from 1.1 to 1.6 m/sec (mean 1.4 +/- 0.1 m/sec [SEM]), whereas in normal veins peak flow velocity ranged from 0.4 to 0.7 m/sec (mean 0.6 +/- 0.04 m/sec [SEM]; p < 0.001). There was a strong negative correlation between vessel diameter and peak flow velocity (R = 0.89; p < 0.001). Peak flow velocity of 0.8 m/sec appears to provide the best separation between normal and stenosed pulmonary veins. We conclude that pulmonary vein stenosis is associated with increased flow velocity and turbulence and deformity of the flow signal. Transesophageal echocardiography is a powerful tool in the study of pulmonary vein stenosis.

Primary cardiac valve tumors.

Cardiac valve tumors are rare, but may have significant clinical manifestations. We report three cases of mitral valve tumor successfully treated by surgical excision. Two out of three patients presented with neurologic symptoms, and by utilizing echocardiography the valvular lesions were discovered. Surgical removal with preservation of normal valve tissue and function was accomplished without difficulty in all cases. A literature review was performed which comprises case reports of one hundred and twenty-eight patients. Most were asymptomatic, but when symptoms did occur, they could be disabling, such as stroke, myocardial infarction and sudden death. Transthoracic and transesophageal echocardiography has greatly enhanced the ability to make this diagnosis in a timely fashion. Papillary fibroelastoma is by far the most common lesion and is amenable to simple surgical excision with minimal morbidity and mortality. Recurrence has not been reported.

Diagnosis of right atrial mass lesions by transesophageal and transthoracic echocardiography.

The echocardiographic findings by transesophageal and transthoracic techniques were compared in 16 patients with right atrial mass lesions diagnosed by transesophageal echocardiography. In only 8 of the 16 patients were the masses imaged by transthoracic echocardiography. Masses in the main body of the right atrium (three of five), as well as those associated with indwelling catheters and pacer wires (three of four) were more likely to be imaged by transthoracic echocardiography than masses in the right atrial appendage (zero of three) or in the superior or inferior vena cava (one of three). Associated masses in other cardiac chambers were detected by transthoracic echocardiography in three of six patients. Other features such as size, mobility, and site of attachment of right atrial masses in general were better defined by transesophageal echocardiography. Thus, patients with suspected right atrial masses should be investigated with transesophageal echocardiography.

Coronary artery fistula: diagnosis by biplane transesophageal echocardiography.

A 56-year-old man underwent coronary angiography during evaluation of severe mitral regurgitation. A right coronary artery fistula was incidentally discovered but its site of termination was uncertain. Transthoracic echocardiography also did not reveal the location of its drainage. The correct diagnosis of a right coronary artery to left atrial fistula was made using biplane transesophageal echocardiography. This case demonstrates the utility of biplane transesophageal echocardiography in the diagnosis of the origin and termination of congenital coronary artery anomalies.

Cor triatriatum with isolated pulmonary venous stenosis in an adult: diagnosis with transesophageal two-dimensional echocardiography.

The diagnosis of cor triatriatum in an adult was made from routine two-dimensional transthoracic echocardiography. The findings of aliasing and turbulence in the roof of the left atrium suggested pulmonary venous stenosis. A transesophageal echocardiogram defined both the hemodynamic features of nonobstructing cor triatriatum and the presence of isolated pulmonary venous stenosis. The clinical use of transesophageal echocardiography with color flow Doppler in the elucidation of complex anatomic substrate is demonstrated.

Primary osteosarcoma of left atrium: complete surgical excision.

A patient with primary osteogenic sarcoma of the left atrium with clinical features of severe congestive heart failure is described. The operative procedure required excision of the posterior atrial wall in continuity with the left pulmonary veins. The resultant defect in the atrium was reconstructed with the left atrial appendage. The left pulmonary artery was ligated, and the lung was removed at a subsequent procedure. The patient survived operation but subsequently was found to have distant metastasis. He died seven months after the operation.

Approach in the management of atrial myxoma with long-term follow-up.

Between 1972 and 1982, 9 patients underwent successful excision of atrial myxomas at the Upstate Medical Center. Eight patients had a left atrial myxoma and 1 a biatrial myxoma. There were 5 female and 4 male patients ranging from 16 to 63 years of age. Preoperative findings consisted of cerebral or peripheral emboli, congestive heart failure, and nonspecific symptoms. Diagnosis was confirmed by echocardiography and angiography in all but 1 patient. A biatrial operative approach was utilized in all patients except 1. Complete excision of the tumor with a cuff of normal tissue was performed. All heart chambers were carefully explored for presence of multicentric myxomas or tumor debris. There were no operative deaths or intraoperative embolizations. Follow-up has been 1 1/2 to 11 years. There has been 1 late noncardiac death. All patients underwent echocardiography postoperatively with no recurrence. The risk of intraoperative embolization and late recurrence is minimal with the biatriotomy technique. Two-dimensional echocardiography is extremely accurate in early diagnosis of myxomas and in the late follow-up of patients.

Death from cerebral hypoperfusion during nitroprusside treatment of acute angiotensin-dependent hypertension.

A 37-year-old woman, while being treated with nitroprusside for acute hypertension due to an intramural renal artery hemorrhage, became blind on the fourth hospital day, comatose on the fifth, and brain dead on the seventh. Postmortem examination of her brain revealed border-zone infarcts in the parietal-occipital regions and cerebrellum of the sort associated with cerebral hypoperfusion due to hypotension. Yet her blood pressure had been lowered judiciously to a mean pressure in the vicinity of 110 to 120 mm Hg, and episodes of hypotension had been avoided. As possible explanations for this unusual complication, the roles of acute hyperangiotensinemia and nitroprusside administration are discussed.

Successful removal of papillary endocardial fibroma.

We report a case of systemic embolization secondary to a small papillary endocardial fibroma, a rare cardiac tumor. It was attached to a chords of the mitral valve by a short stalk. The tumor was successfully excised and the mitral valve was preserved. Two-dimensional echocardiography played the major role in the diagnosis of this small endocardial tumor.

Echocardiography in pulmonary embolism.

Echocardiography was performed on 10 patients with suspected acute pulmonary embolism. In 3 patients with normal echocardiograms, the diagnosis was excluded by pulmonary angiography. Two with small emboli on angiography had a pulmonary arterial pressure less than or equal to 35 mmHg and normal echocardiograms. Five had an increased right ventricular end-diastolic dimension (RV-EDD) and 4 had a left ventricular end-diastolic dimension (LV-EDD) below normal or in low normal levels. The RVEDD/LVEDD ratio was increased in 4 patients, 3 of whom had paradoxical interventricular septal motion. The mitral valve E-F slope and left atrial dimension changed variably. The posterior aortic wall O-V excursion (PAW-OV-Ex) decreased in 5 and was correlated with LVEDD (r = +0.92, p less than 0.01) and the RVEDD/LVEDD ratio (r = -0.87, p less than 0.025). Follow-up echocardiography in 3 cases after recovery showed a decreased RVEDD/LVEDD ratio, normal septal motion and improved LVEDD and PAW-OV-Ex. The PAW-OV-Ex seems to mirror the abnormalities in volume changes of the left side of the heart resulting from pulmonary embolism. An entirely normal echocardiogram would be unlikely in the presence of a hemodynamically significant pulmonary embolism.

Echo- and phonocardiographic studies in patients with Lillehei-Kaster aortic valve prostheses.

Simultaneous echo- and phonocardiographic studies were performed in 17 patients with normally functioning Lillehei-Kaster (LK) tilting disc prosthesis in the aortic position. The LK aortic valve prosthesis was well recorded by echocardiography with a disc excursion of 14 to 25 mm and very fast opening and closing velocities, too rapid for quantitative assessment. On phonocardiography the opening click of the prosthesis was only rarely observed (2 out of 17 cases), while the closing sound was consistently present in all patients, occurring within 5 msec of the point of complete closure of aortic disc prosthesis by echocardiography. Systolic time intervals (STI) measured by combined echo-and phonocardiography were similar to the predicted values in 15 patients who had no evidence of residual cardiac dysfunction. In the remaining 2 patients, one or more components of the STI differed by more than 2 standard deviations from the predicted values, and in these there were associated findings to explain the discrepancies. This study illustrates the echo- and phonocardiographic features of the normally functioning LK aortic valve prosthesis. In addition, precise measurements of the isometric contraction and relaxation periods as well as standard systolic time intervals are possible with these techniques.

Improvement in arterial oxygenation by saralasin infusion in man.

Simultaneous hemodynamic and blood gas measurements were performed in 26 hypertensive adults, who were cigarette smokers, before and after a 30-minute infusion of saralasin (5 microgram/kg/min) which is a highly specific competitive antagonist of angiotensin II (AII). The arterial pressure fell in nine, rose in seven and was unchanged in ten patients. The mean cardiac index for the entire group remained unchanged. Pulmonary arterial or wedge pressure, pulmonary vascular resistance, arterial PCO2 and pH did not change. Unrelated to the hemodynamic changes, the mean arterial oxygen pressure (PaO2) increased from 68.6 +/- 2.2 mm Hg to 73.9 +/- 2.1 mm Hg (P less than 0.001). In the absence of a significant increase in alveolar ventilation as indicated by an unchanged mean PCO2 and lacking a hemodynamic explanation, the mechanism for the rise in PaO2 is speculative at this stage. The possibility of an improvement in the distribution of ventilataion by saralasin infusion is under investigation.

Sodium nitroprusside therapy in congestive cardiomyopathy-variability in hemodynamic response.

Twelve of 17 patients (group A) with congestive cardiomyopathy improved hemodynamically during sodium nitroprusside (NP) infusion. Five patients (group B) failed to increase their cardiac output. The two groups were identical in clinical presentation and had comparable cardiomegaly and left ventricular filling pressure (LVFP). However, group A had a baseline cardiac index (CI) lower than 2.5 L/min/m2 and high peripheral systemic (PSR) and total pulmonary vascular resistance (PR). In contrast, group B had a control of CI of higher than 2.5 L/min/m2 and near normal PSR and PR. Furthermore, a highly significant correlation was observed between the calculated levels of control PSR and their subsequent reduction during NP infusion. The higher the initial resistance, the more marked was its fall on NP as documented in group A. In group B, the PSR was probably not high enough for NP to be effective in increasing the cardiac output further by vasodilatation. We conclude that NP infusion may not increase cardiac output in congestive cardiomyopathy, in spite of a high LVFP, if the PSR is near normal.

Effects of sublingual nitroglycerin on resting pulmonary gas exchange and hemodynamics in man.

Simultaneous hemodynamic, ventilation and blood gas measurements were performed in 19 males during cardiac catheterization for evaluation of chest pain syndrome before and 3 to 5 min after 0.4 mg sublingual nitroglycerin. Pulmonary arterial pressures and total pulmonary vascular resistance fell (P less than 0.001 for both), and mean systemic arterial pressure decreased (P less than 0.05). However, peripheral vascular resistance, cardiac output, and mixed venous PO2 did not change. Total and tidal ventilation, PCO2, pH, and base excess remained unchanged. However, the arterial PO2 decreased from a mean of 80 +/- 3 (SEM) to 72 +/- 2 mm Hg (P less than 0.001) and mean venous admixture increased from 8.8 +/- 1% to 12.6 +/- 1.5% (P less than 0.001). The alveolar arterial PO2 difference increased (P less than 0.001) and the dead space tidal volume ratio rose (P less than 0.05). We conclude that the decrease in arterial PO2 following sublingual nitroglycerin is caused by redistribution of pulmonary blood flow with imbalance in ventilation-perfusion relationships or shunting.

Elevated ejection fractions in patients with the anginal syndrome and normal coronary arteriograms.

The etiology of chest pain in patients with the anginal syndrome and normal coronary arteriograms has not been established. There has been no explanation for the association of electrocardiographic, hemodynamic, and myocardial metabolic abnormalities consistent with myocardial ischemia observed in some patients with this disorder. Historical, clinical, laboratory, and hemodynamic data of 45 patients (24 females, 21 males), mean age 47.5 years, with chest pain and normal coronary arteriograms are reviewed. Left ventriculograms were analyzed utilizing the single-plane cineangiographic measurement of left ventricular volume. Systolic ejection fractions for the 45 patients ranged from 0.66 to 0.91 (mean 0.80 +/- 0.01 SEM). Ventricular volumes determined angiographically revealed mean end-diastolic and end-systolic volumes of 83 +/- 5 ml and 18 +/- 2 ml, respectively. The mean changes in longitudinal and transverse segmental axis shortening that occurred during ventricular systole were 28.8% and 50.7%, respectively. These elevated values for ejection fraction, and reduced measurements of ventricular volumes, indicate that some patients with chest pain and normal coronary arteriograms may have small hearts with hyperdynamic ventricular contraction. These findings suggest that hyperdynamic ventricular contraction may play a causative role in the development of transient, angina-like chest pain in these patients. The etiology of the proposed hyperdynamic ventricle is unknown, but it may be attributable to increased beta-sympathetic stimulation of the myocardium.

Hemodynamic, ventilatory and blood gas changes during infusion of sodium nitroferricyanide (nitroprusside). Studies in patients with congestive heart failure.

Simultaneous hemodynamic, ventilatory, and blood gas studies were performed in 16 men with congestive heart failure before and during infusion of sodium nitroferricyanide (nitroprusside). The cardiac index increased from 2.00+/-0.16 L/min/sq m (SE) to 2.38+/-0.14 L/min/sq m, and the total pulmonary and systemic peripheral resistances fell from 928+/-123 to 494+/-57 dynes sec cm-5 and from 2,208+/-210 to 1,558+/-121 dynes sec cm-5, respectively. Both systemic and pulmonary arterial decreased during infusion of sodium nitroferricyanide, and the mixed venous oxygen pressure increased. There was no change in total or alveolar ventilation, arterial carbon dioxide tension, pH, or base excess; however, the mean arterial oxygen pressure (PaO2) decreased from 74+/-3 mm Hg to 68+/-3 mm Hg and the venous admixture effect increased from 8+/-1% to 13+/-2%. We conclude that the decrease in PaO2 during infusion of sodium nitroferricyanide resulted from a worsening of the ventilation-perfusion relationships due to increased perfusion of underventilated pulmonary units.