Graded contrast echocardiography in pulmonary arteriovenous malformations.

To compare the results of transthoracic contrast echocardiography (TTCE) adding a grading scale with the results of thoracic computed tomography (CT) in order to optimise the use of both techniques. 95 patients with hereditary haemorrhagic telangiectasia (HHT) were examined with TTCE and thoracic CT to detect pulmonary arteriovenous malformations (PAVMs). According to previous studies, TTCE was divided into a four grade scale depending on the degree of opacification of the left ventricle after the administration of a contrast agent. Of the 95 patients (50.5% female; mean age 46 yrs), none with normal or grade 1 TTCE had detectable PAVMs on thoracic CT. Shunts of grades 2, 3 and 4 were associated with PAVMs according to thoracic CT in 25, 80, and 100% of the cases. There was a statistically significant association between the TTCE grade and the detection of a PAVM by thoracic CT. There were also statistically significant associations between TTCE grade and the cardiac cycle when the contrast was first visible in the left atrium, and size of the feeding artery. Graded TTCE and timing of left atrium opacification may be useful techniques in selecting HHT patients for PAVM screening with thoracic CT scans.

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An integrated approach to the quantification of aortic regurgitation by Doppler echocardiography.

BACKGROUND: Although different Doppler methods have been proposed for the quantification of aortic regurgitation, no study has prospectively compared these methods with each other and their correlation with angiography. The aim of this study was to prospectively analyze the usefulness of different Doppler echocardiography parameters by testing all such parameters in each patient. METHODS: Fifty-one patients with aortic regurgitation underwent 2-dimensional and Doppler echocardiographic studies and catheterization. The following Doppler indexes were analyzed and compared with aortography. Color Doppler: (1) jet color height/left ventricular outflow tract height in parasternal long-axis view, and (2) jet color area/left ventricular outflow tract area in short-axis view. Continuous Doppler: (3) regurgitant flow pressure half-time, (4) regurgitant flow time velocity integral (in centimeters), and (5) regurgitant flow time velocity integral (in centimeters)/diastolic period (in milliseconds). Pulsed Doppler in thoracic and abdominal aorta: (6) time velocity integral of diastolic reverse flow (in centimeters), (7) time velocity integral of systolic anterograde flow/integral of diastolic reverse flow, (8) (time velocity integral of diastolic reverse flow/diastolic period) x 100, and (9) diastolic reverse flow duration/diastolic period (as a percentage). We compared these parameters with severity of regurgitation measured by angiography and classified as mild, moderate, or severe. RESULTS: The most useful parameters were (1) jet color height/left ventricular outflow tract height (correctly classified 42 of 49 patients), (2) (time velocity integral of diastolic reverse flow/diastolic period) x 100 in the thoracic aorta (correctly classified 41 of 46 patients), and (3) (time velocity integral of diastolic reverse flow/diastolic period) x 100 in the abdominal aorta (correctly classified 42 of 49 patients). Sequential integration of these 3 parameters correctly classified 96% of patients (44 of 46 patients) and was achieved in 90% of cases. CONCLUSION: An integrated combination of several Doppler parameters can quickly and accurately classify the degree of aortic regurgitation as determined by angiography.

Balloon mitral commissurotomy in patients with previous annuloplasty. Our experience.

Balloon mitral commissurotomy is an alternative to surgical commissurotomy in the treatment of mitral stenosis and different studies have shown its usefulness for restenosis following surgical commissurotomy. We describe our experience in balloon mitral commissurotomy in five patients with previous commissurotomy and annuloplasty. Among 360 balloon commissurotomies performed in our hospital up to December 1993, 29 procedures were performed on patients with restenosis after surgical commissurotomy, five of whom also had an annuloplasty (flexible ring in four and rigid in one). The balloon commissurotomy was performed without complications using the Inoue single balloon technique. Mitral valve area increased from 0.9 +/- 0.1 cm2 to 1.0 +/- 0.1 cm2 by pressure half-time, and from 1.0 +/- 0.2 cm2 to 1.3 +/- 0.1 cm2 by Gorlin formula. Two patients in functional class III underwent mitral valve replacement, 32 and 11 months later; the other three patients were in class II 38, 10 and 7 months later. The presence of a mitral ring should not constitute a contraindication to balloon commissurotomy. However, the haemodynamic results are not favourable in our patients, probably due to the practical absence of commissural fusion and the ring's restrictive effect on valvular stretching.

[The estimation of the severity of tricuspid insufficiency by Doppler color: the effects of gain, pulse repetition frequency and the echographic view]. / Estimación de la severidad de la insuficiencia tricúspide por Doppler color: efectos de la ganancia, frecuencia de repetición de pulsos y plano ecocardiográfico.

INTRODUCTION AND OBJECTIVES: Regurgitant jet area is to date the most widely accepted color Doppler parameter for quantitation of atrium-ventricular regurgitations. In experimental studies, it has been demonstrated that color regurgitant jet area is greatly influenced by technical settings. The present study was aimed to analyze the effect of gain setting, pulse repetition frequency and echocardiographic plane on color jet area in patients with tricuspid regurgitation. METHODS: We studied 64 patients with nontrivial (more than 1 cm2), rheumatic tricuspid regurgitation. Examinations were performed in apical four-chamber and right ventricle inflow-tract views, at two gain settings (subsaturation gain and 1/3 reduced gain) and at two pulse repetition frequencies (3.1 and 3.8 kHz). Therefore, every regurgitant jet was study under 8 different technical conditions. The remaining technical settings were held unchanged included throughout the studies. The traced area induced central varianced and aliased signals, as well as the immediately contiguous nonturbulent velocities that were moving in the same direction as the jet. Measurements were taken from 5 and 3 representative cycles in patients with atrial fibrillation and sinus rythm, respectively. RESULTS: Globally, reduction in gain setting produced a color area decrease by 50%. This reduction was of greater extent for small jets (less than 5 cm2, 45 +/- 17%) with respect to larger jets (more than 5 cm2, 61 +/- 30%, p = 0.0009). Results were similar for both apical four-chamber and right ventricle inflow views and for the two pulse repetition frequencies. At a given color gain level and echocardiographic view, pulse repetition frequency at 3.1 kHz produced greater color areas (by 3-11%) than frequency at 3.8 kHz, but the difference was not significant. Overall, color jet area was significantly greater in right ventricle inflow view than in apical four-chamber view, but substantial individual variability was observed. Difference between both views was greater than 40% in 28% of patients, with the largest color area in right ventricle inflow view in most, especially in those patients with eccentric jets. CONCLUSIONS: Gain setting and echocardiographic view greatly affect regurgitant jet area by color Doppler in patients with tricuspid regurgitation. Therefore, standardization of technical settings is mandatory in order to avoid diagnostic pitfalls.

Assessment of tricuspid regurgitation by Doppler color flow imaging: angiographic correlation.

The correlation between data obtained by Doppler color flow imaging and angiographic severity has been investigated in mitral and aortic regurgitation. However, similar studies have not been performed for tricuspid regurgitation (TR). This study was performed to establish the correlation between measurements of regurgitant jet area by Doppler color flow imaging and the angiographic severity of TR. Fifty-four patients with rheumatic heart disease who underwent right ventriculography and transthoracic Doppler color flow imaging were studied. The regurgitant jet area was measured as the largest clearly definable flow disturbance in apical four-chamber and right ventricle inflow views, and expressed in both views as the absolute jet area or as the ratio of maximal jet area to right atrial area. Correlation of all Doppler color flow measurements with angiographic grades of TR were comparable, absolute jet area in apical four-chamber view being closest at r = 0.80. A regurgitant jet area in apical four-chamber view < 5 cm2 predicted minimal or mild TR by angiography with a sensitivity of 78% and a specificity of 100%, whereas a regurgitant jet area > 10 cm2 predicted severe TR with a sensitivity of 92% and a specificity of 91%. Values between 5 and 10 cm2 predicted moderate TR with a sensitivity of 89% and a specificity of 89%. Sensitivity and specificity were not improved with use of the ratio of jet area to right atrial area or with use of right ventricle inflow view. Thus, Doppler color flow jet measurements correlate closely with angiographic results in the evaluation of TR.(ABSTRACT TRUNCATED AT 250 WORDS)