RESUMO
BACKGROUND: This retrospective review focuses on peripartum anesthetic management and outcome of a series of five pregnant women with left ventricular noncompaction (LVNC). METHODS: The Mayo Clinic Advanced Cohort Explorer medical database was utilized to identify women diagnosed with LVNC who had been admitted for delivery at the Mayo Clinic in Rochester, Minnesota, between January 2001 and September 2021. Echocardiograms were independently reviewed by two board-certified echocardiographers, and those determined by both to meet the Jenni criteria and/or having compatible findings on magnetic resonance imaging (MRI) were included. Electronic medical records were reviewed for information pertaining to cardiac function, labor, delivery, and postpartum management. RESULTS: We identified 44 patients whose medical record included the term "noncompaction" or "hypertrabeculation" and who had delivered at our institution during the study period. Upon detailed review of the medical records, 36 did not meet criteria for LVNC, and three additional patients did not receive the diagnosis until after delivery, leaving five patients with confirmed LVNC who had undergone six deliveries during the study interval. All five patients had a history of arrhythmias or had developed arrhythmias during pregnancy. One patient underwent emergency cesarean delivery due to sustained ventricular tachycardia requiring three intra-operative cardioversions. CONCLUSIONS: This case series adds new evidence to that already available about pregnancies among women with LVNC. Favorable obstetrical outcomes were achievable when multidisciplinary teams were prepared to manage the maternal and fetal consequences of intrapartum cardiac arrhythmias and hemodynamic instability.
Assuntos
Anestésicos , Cardiopatias Congênitas , Miocárdio Ventricular não Compactado Isolado , Humanos , Feminino , Gravidez , Miocárdio Ventricular não Compactado Isolado/diagnóstico , Período Periparto , Ventrículos do Coração , EcocardiografiaRESUMO
BACKGROUND: P-selectin - a biomarker of platelet and endothelial cell activation is elevated in patients with non-valvular atrial fibrillation (NVAF). However, the association between sP-selectin level and thromboembolic complications in NVAF patients remains controversial. We tested the hypothesis that plasma soluble P-selectin (sPSL) level correlates with the measures of left atrial blood stasis in NVAF. METHODS: Plasma sPSL concentration was measured using solid-phase ELISA in 103 NVAF patients (age 63⯱â¯14â¯years; 26% women) and 48 normal sinus rhythm controls (NSR; age 64⯱â¯14â¯years; 41% women) who were not on aspirin. Within the group of NVAF cases, 27 had no spontaneous echocardiographic contrast (SEC) detected by transesophageal echocardiography, 31had mild SEC, 15 moderate, 20 severe, and 10 patients had left atrial appendage thrombus (LAAT). RESULTS: The median soluble sPSL level was higher in NVAF cases compared to NSR controls [(interquartile range) 26 (20-32) ng/mL vs 22 (15-29) ng/mL, pâ¯=â¯0.0045]. Only NVAF patients with CHA2DS2-VASc scoreâ¯≥â¯1 had higher sPSL level compared to NSR controls. Patients with severe SEC had significantly higher sPSL levels [32 (24-38) ng/mL] compared to all other NVAF patients (pâ¯=â¯0.0042) and to NSR controls (pâ¯<â¯0.0001). Also NVAF patients with LAAT had higher sPSL level compared to NSR controls. CONCLUSIONS: There is a direct correlation between p-selectin level and severe blood stasis in the left atrium. Only NVAF patients with CHA2DS2-VASc scoreâ¯≥â¯1 or with LAAT had higher sPSL level compared to NSR controls.
Assuntos
Fibrilação Atrial/sangue , Fibrilação Atrial/complicações , Selectina-P/sangue , Trombose/sangue , Trombose/etiologia , Idoso , Apêndice Atrial/patologia , Fibrilação Atrial/patologia , Ecocardiografia , Feminino , Átrios do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Trombose/patologiaRESUMO
A 31-year-old male with pulmonary atresia, ventricular septal defect presented with exercise intolerance and severe cyanosis. A restrictive coronary-pulmonary artery fistula was identified as the main source of pulmonary blood flow. We report transcatheter stent implantation in the fistula to augment pulmonary flow as a palliative management option in the adult patient with complex congenital heart disease.
Assuntos
Artérias/cirurgia , Fístula Artério-Arterial/complicações , Fístula Artério-Arterial/cirurgia , Vasos Coronários/cirurgia , Cianose/complicações , Cianose/cirurgia , Comunicação Interventricular/complicações , Comunicação Interventricular/cirurgia , Implantação de Prótese/métodos , Artéria Pulmonar/cirurgia , Atresia Pulmonar/complicações , Atresia Pulmonar/cirurgia , Stents , Procedimentos Cirúrgicos Vasculares/instrumentação , Adulto , Humanos , Pulmão/irrigação sanguínea , Masculino , Índice de Gravidade de DoençaRESUMO
Because congenital ventricular septal defects are of different sizes and locations, their clinical presentation, natural history, and treatment vary greatly. This review discusses the different types of ventricular septal defects commonly seen in adults in the authors' experience and in published literature. Ventricular septal defects are either isolated small defects or larger defects associated with pulmonary stenosis, pulmonary hypertension, or aortic regurgitation. These associations play an important role in the pathophysiologic consequences of the defect, its long-term complications, and treatment options. Knowledge of the different clinical presentations in adulthood and the specific features pertinent to these defects will help in the assessment and the care of adult patients with one of the most common congenital cardiac malformations.
Assuntos
Comunicação Interventricular , Adulto , Diagnóstico por Imagem , Comunicação Interventricular/diagnóstico , Comunicação Interventricular/mortalidade , Comunicação Interventricular/fisiopatologia , Comunicação Interventricular/terapia , Humanos , Exame FísicoRESUMO
OBJECTIVES: The study sought to determine the outcome of pregnancy in women with coarctation of the thoracic aorta. BACKGROUND: Patients with coarctation of the thoracic aorta are expected to reach childbearing age, but data on the outcome of pregnancy in this population are limited. METHODS: The Mayo Clinic database was reviewed for women of childbearing age (> or =16 years old) with a diagnosis of aortic coarctation evaluated from 1980 to 2000. Spectrum of cardiovascular disease, surgical history, and obstetrical and neonatal outcomes were determined. RESULTS: Fifty women with coarctation had pregnancies: 30 had coarctation repair before pregnancy, 10 had repair after pregnancy, 4 had repair both before and after pregnancy, and 6 had no history of repair. The 50 women had 118 pregnancies resulting in 106 births. There were 11 miscarriages (9%), 4 premature deliveries (3%), and 1 early neonatal death; 38 deliveries (36%) were by cesarean section. Of the 109 offspring, 4 (4%) had congenital heart disease. A patient with Turner syndrome died of a Stanford type A dissection at 36 weeks of pregnancy. Nineteen women (38%) were known to have hemodynamically significant coarctation during pregnancy (gradient > or =20 mm Hg). Fifteen women (30%) had hypertension during their pregnancy, 11 of whom (73%) had hemodynamically significant coarctation during that time (8 with native and 3 with residual/recurrent coarctation). CONCLUSIONS: Major cardiovascular complications were infrequent but continue to be a source of concern for patients with coarctation who become pregnant. Systemic hypertension during pregnancy was common and related to the presence of a significant coarctation gradient.
Assuntos
Coartação Aórtica/complicações , Resultado da Gravidez , Adolescente , Adulto , Aorta Torácica , Coartação Aórtica/cirurgia , Feminino , Humanos , Hipertensão/complicações , Recém-Nascido , Gravidez , Complicações Cardiovasculares na Gravidez , Estatísticas não ParamétricasRESUMO
IMPLICATIONS: Atrial septal defect is usually diagnosed and surgically repaired in childhood. We present a case of previously asymptomatic atrial septal defect that presented during total hip arthroplasty during general anesthesia in a 72-yr-old woman. Intraoperative transesophageal echocardiography assisted in the diagnosis and in determining the appropriate treatment.
Assuntos
Artroplastia de Quadril , Comunicação Interatrial/diagnóstico , Idoso , Ecocardiografia Transesofagiana , Feminino , Comunicação Interatrial/diagnóstico por imagem , Humanos , Hipóxia/etiologia , Complicações IntraoperatóriasRESUMO
Primary cardiac osteosarcomas are rare and usually originate in the left atrium. In contrast, osteosarcomas metastatic to the heart most commonly involve the right cardiac chambers. This case report describes an unusual primary cardiac osteosarcoma, initially observed as a slowly growing, densely calcified mass of the left ventricle with subsequent secondary pulmonary metastasis. Although cardiac tumors may be asymptomatic, this patient had recurrent bouts of ventricular tachyarrhythmia. We describe the clinical, echocardiographic, and radiological observations spanning 6 years and the gross and microscopic features at autopsy.
Assuntos
Calcinose/diagnóstico , Cardiomiopatias/diagnóstico , Ecocardiografia , Neoplasias Cardíacas/diagnóstico , Osteossarcoma/diagnóstico , Tomografia Computadorizada por Raios X , Calcinose/patologia , Cardiomiopatias/patologia , Diagnóstico Diferencial , Evolução Fatal , Seguimentos , Neoplasias Cardíacas/patologia , Ventrículos do Coração/patologia , Humanos , Neoplasias Pulmonares/secundário , Masculino , Pessoa de Meia-Idade , Osteossarcoma/patologia , Osteossarcoma/secundário , Taquicardia Ventricular/etiologiaRESUMO
BACKGROUND: Idiopathic restrictive cardiomyopathy is a poorly recognized entity of unknown cause characterized by nondilated, nonhypertrophied ventricles with diastolic dysfunction resulting in dilated atria and variable systolic function. METHODS AND RESULTS: Between 1979 and 1996, 94 patients (61% women) 10 to 90 years old (mean, 64 years) met strict morphological echocardiographic criteria for idiopathic restrictive cardiomyopathy, mainly dilated atria with nonhypertrophied, nondilated ventricles. None had known infiltrative disease, hypertension of >5 years' duration, or cardiac or systemic conditions associated with restrictive filling. Nineteen percent were in NYHA class I, 53% in class II, and 28% in class III or IV. Atrial fibrillation was noted in 74% of patients and systolic dysfunction in 16%. Follow-up (mean, 68 months) was complete for 93 patients (99%). At follow-up, 47 patients (50%) had died, 32 (68%) of cardiovascular causes. Four had heart transplantation. The death rate compared with actuarial statistics was significantly higher than expected (P<0.0001). Kaplan-Meier 5-year survival was 64%, compared with expected survival of 85%. Multivariate analysis using proportional hazards showed that the risk of death approximately doubles with male sex (hazard ratio [HR] = 2.1), left atrial dimension >60 mm (HR = 2.3), age >70 years (HR = 2.0), and each increment of NYHA class (HR = 2.0). CONCLUSIONS: Idiopathic restrictive cardiomyopathy or nondilated, nonhypertrophic ventricles with marked biatrial dilatation, as defined morphologically by echocardiography, affects predominantly elderly patients but can occur in any age group. Patients present with systemic and pulmonary venous congestion and atrial fibrillation and have a poor prognosis, particularly men >70 years old with higher NYHA class and left atrial dimension >60 mm.
Assuntos
Cardiomiopatia Restritiva/fisiopatologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Biópsia , Cateterismo Cardíaco , Cardiomiopatia Restritiva/complicações , Cardiomiopatia Restritiva/patologia , Criança , Doença Crônica , Dilatação Patológica , Ecocardiografia , Eletrocardiografia , Feminino , Seguimentos , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Radiografia Torácica , Fatores Sexuais , Taxa de SobrevidaRESUMO
OBJECTIVES: The purpose of this study was to evaluate the morbidity and mortality associated with noncardiac surgery (NCS) in patients (pts) with Eisenmenger syndrome. BACKGROUND: Noncardiac surgery in pts with Eisenmenger syndrome is associated with increased cardiovascular complications. METHODS: Fifty-eight pts with Eisenmenger syndrome (17M, 41F aged 18 to 69 years (mean 41 years) who had been followed for up to 41.5 years (mean 9.3 years) were retrospectively evaluated for any NCS done at > or = 17 years of age. RESULTS: Twenty-four pts had a total of 28 NCSs at an age of 17 to 55 years (mean 29 years) including 9 tubal ligations, 3 neurosurgeries, 3 cholecystectomies, 3 hysterectomies, 3 vasectomies, and 1 each spinal fusion, appendectomy, eye enucleation, hernia repair, hand surgery, tonsillectomy and therapeutic abortion. There were two deaths (7%), one following spinal fusion and the other following appendectomy at another institution. Fourteen of these NCSs were performed at our institution, including 11 under general anesthesia. The duration of anesthesia varied from 75 to 525 min (mean 165 min). All pts remained in sinus rhythm. The lowest systolic blood pressure (BP) ranged from 78 to 125 mm Hg. Of those 11 pts, 9 were extubated immediately after surgery and 2 needed dopamine. Ten patients were discharged without any complications, including 3 within 1 day of surgery. One death occurred 10 days following spinal fusion. This pt had the longest anesthesia (525 min) and an intraoperative systolic BP as low as 78 mm Hg. She also needed the largest fluid administration (6,475 cc) in addition to postoperative mechanical ventilation and dopamine. CONCLUSIONS: Adult pts with Eisenmenger syndrome are at increased risk with NCS, but with current/modern techniques, the risk of death is less than previously thought. In the vast majority of cases, NCS can be undertaken without substantial morbidity, and early extubation is achievable. However, even with relatively minor surgery, significant complications, including death, can occur. Referral to major centers with expertise in the care of pts with Eisenmenger syndrome is advisable.
Assuntos
Complexo de Eisenmenger/cirurgia , Complicações Pós-Operatórias/mortalidade , Adolescente , Adulto , Idoso , Causas de Morte , Complexo de Eisenmenger/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Risco , Taxa de SobrevidaRESUMO
The purpose of this study was to determine the most discriminating clinical and echocardiographic features that are most helpful in correctly identifying Ebstein's anomaly of the tricuspid valve from other causes of tricuspid regurgitation. Ebstein's anomaly is an uncommon malformation of the tricuspid valve with diagnostic echocardiographic features. Other cardiac disorders associated with tricuspid valve regurgitation and predominate right-sided heart chamber enlargement can be misdiagnosed as Ebstein's anomaly. All patients who were referred to our institution between 1982 and 1995 with the diagnosis of Ebstein's anomaly but were found to have other abnormalities of the tricuspid value or right ventricle were identified. Their clinical, echocardiographic, and surgical records were reviewed retrospectively. Twenty-two patients (12 males and 10 females), aged 7 to 68 years (mean 33 years), were referred to our institution with the diagnosis of Ebstein's anomaly but were found to have another abnormality that mimicked clinical and diagnostic features of Ebstein's anomaly. The most common initial symptom was exercise intolerance (13 [59%] patients) followed by atrial arrhythmia (seven [32%] patients). Two patients had cyanosis. Three patients had paroxysmal and six had chronic atrial fibrillation/flutter. Cardiomegaly on chest x-ray film was noted in 18 (82%) patients. Referral diagnosis of Ebstein's anomaly had been made by echocardiography (12 patients), cardiac catheterization (four patients), both techniques (five patients), and echocardiography and magnetic resonance imaging (one patient). All 22 patients had predominate right atrial and right ventricular enlargement, and 18 (82%) of 22 patients also had right ventricular dysfunction. However, Ebstein's anomaly was confidently ruled out with repeat comprehensive echocardiography at our institution by establishing (1) absence of significant apical displacement of the septal tricuspid valve leaflet (> or = 8 mm/m2) and (2) lack of a redundant, elongated, anterior tricuspid valve leaflet in all 22 patients (100%). All had significant tricuspid regurgitation caused by tricuspid valve dysplasia (nine patients), tricuspid valve prolapse (four patients), trauma (four patients), right ventricular dysplasia (three patients), endocarditis (one patient), and annular dilation caused by free pulmonary regurgitation (one patient). In all 15 patients who subsequently underwent surgery (tricuspid valve repair [seven patients] or replacement [eight patients]), the absence of Ebstein's anomaly was confirmed. Echocardiographic absence of the characteristic degree of displacement of the septal leaflet of the tricuspid valve (> or = 8 mm/m2) and the presence of a nonelongated, nonredundant anterior tricuspid valve leaflet consistently excluded the diagnosis of Ebstein's anomaly. Under such circumstances, other anomalies of the tricuspid valve or right ventricle were consistently identified. Recognition of the mimics of Ebstein's anomaly had important surgical implications.
Assuntos
Anomalia de Ebstein/diagnóstico , Adolescente , Adulto , Idoso , Criança , Diagnóstico Diferencial , Anomalia de Ebstein/complicações , Anomalia de Ebstein/diagnóstico por imagem , Anomalia de Ebstein/cirurgia , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Insuficiência da Valva Tricúspide/etiologiaRESUMO
Partial anomalous pulmonary venous connection, a rare congenital anomaly, most commonly involves the right lung, with one or more pulmonary veins anomalously connecting most frequently to the superior vena cava and less commonly to the right atrium or inferior vena cava. This article describes an unusual case of anomalous pulmonary venous connection of the right lung to the azygos vein in an adult. This anomaly was clearly delineated with angiography, computed tomography of the chest, and transesophageal echocardiography. The transesophageal echocardiographic features of the anomaly are described as a means to prevent further diagnostic misinterpretation.
Assuntos
Veia Ázigos/anormalidades , Ecocardiografia Transesofagiana , Veias Pulmonares/anormalidades , Angiografia , Veia Ázigos/diagnóstico por imagem , Diagnóstico Diferencial , Dilatação Patológica/diagnóstico por imagem , Feminino , Humanos , Pulmão/irrigação sanguínea , Pulmão/diagnóstico por imagem , Pessoa de Meia-Idade , Veias Pulmonares/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resistência Vascular , Veia Cava Superior/diagnóstico por imagemRESUMO
OBJECTIVE: This study sought to demonstrate that with proper technique, identification of the normal and abnormal pulmonary venous connection can be made with confidence using transesophageal echocardiography (TEE). BACKGROUND: Partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly whose diagnosis has classically been made using angiography. METHODS: We performed a retrospective review of all patients of all ages with PAPVC diagnosed at the Mayo Clinic who had undergone TEE because of either right ventricular volume overload or suspected intracardiac shunting by transthoracic echocardiography or intraoperatively. RESULTS: A total of 66 PAPVCs were detected in 43 patients (1.5/patient); in 2 additional patients, TEE suggested, but did not diagnose, PAPVCs. Shortness of breath was the most common presenting symptom (42.2%), followed by heart murmur and supraventricular tachycardia. Right-sided anomalous veins were identified in 35 patients (81.4%), left-sided in 7 (16.3%) and bilateral in 1 (2.3%). There was a single anomalous connecting vein in 23 patients (53.5%), two in 18 (41.9%), three in 1 (2.3%) and four in 1 (2.3%). The connecting site was the superior vena cava (SVC) in 39 veins (59.1%), right atrial-SVC junction in 6 (9.1%), right atrium in 8 (12.1%), inferior vena cava in 1 (1.5%) and the coronary sinus in 2 (3.0%). Ten anomalous left pulmonary veins were connected by a vertical vein to the innominate vein (15.1%). Sinus venosus atrial septal defect (ASD) was the most common associated anomaly in 22 patients (49%), followed by ostium secundum ASD in 6 and patent foramen ovale in 4. Fifteen patients had an intact atrial septum. Thirty-one patients (68.8%) underwent surgical repair. PAPVC was confirmed in all patients, including the two whose TEE results were suggestive of PAPVC. All 49 PAPVCs detected by TEE preoperatively were confirmed at the time of operation. CONCLUSIONS: TEE is highly diagnostic for PAPVC and can obviate angiography. Accurate anatomic diagnosis may influence the need for medical and surgical management. TEE should be performed in patients with right ventricular volume overload when the precordial examination is inconclusive.
Assuntos
Ecocardiografia Transesofagiana , Cardiopatias Congênitas/diagnóstico por imagem , Veias Pulmonares/anormalidades , Adulto , Angiografia , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Hipertensão Pulmonar/etiologia , Hipertrofia Ventricular Direita/etiologia , Masculino , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: We sought to determine the frequency of spontaneous cerebrovascular events in adult patients with cyanotic congenital heart disease and to evaluate any contributing factors. BACKGROUND: Cerebrovascular events are a serious complication of cyanotic congenital heart disease in infants and children but are said to be uncommon in adults. METHODS: Between 1988 and 1995, 162 patients with cyanotic congenital heart disease (mean age 37 years, range 19 to 70) were retrospectively evaluated for any well documented cerebrovascular events that occurred at > or = 18 years of age. Events related to procedures, endocarditis or brain abscess were excluded. RESULTS: Twenty-two patients (13.6%) had 29 cerebrovascular events (1/100 patient-years). There was no significant difference between those with and without a cerebrovascular event in terms of age, smoking history, degree of erythrocytosis, ejection fraction or use of aspirin or warfarin (Coumadin). Patients who had a cerebrovascular event had a significantly increased tendency to develop hypertension, atrial fibrillation, microcytosis (mean corpuscular volume < 82) and history of phlebotomy (p < 0.05). Even when patients with hypertension or atrial fibrillation were excluded, there was an increased risk of cerebrovascular events associated with microcytosis (p < 0.01). CONCLUSIONS: Adults with cyanotic congenital heart disease are at risk of having cerebrovascular events. This risk is increased in the presence of hypertension, atrial fibrillation, history of phlebotomy and microcytosis, the latter condition having the strongest significance (p < 0.005). This finding leads us to endorse a more conservative approach toward phlebotomy and a more aggressive approach toward treating microcytosis in adults with cyanotic congenital heart disease.
Assuntos
Transtornos Cerebrovasculares/etiologia , Cardiopatias Congênitas/complicações , Adulto , Idoso , Anemia Ferropriva/complicações , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Fibrilação Atrial/complicações , Feminino , Humanos , Hipertensão/complicações , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Fumar , Varfarina/uso terapêuticoRESUMO
Adult patients with double-inlet left ventricle and perfectly balanced circulation may survive into the sixth decade with good functional capacity and preserved ventricular function. This should be considered before such patients are referred for a Fontan repair.
Assuntos
Cardiopatias Congênitas , Ventrículos do Coração/anormalidades , Sobreviventes , Adulto , Idoso , Feminino , Cardiopatias Congênitas/patologia , Cardiopatias Congênitas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Função Ventricular EsquerdaRESUMO
OBJECTIVES: The objective of this study was to determine the frequency of left atrial thrombus in patients with acute atrial fibrillation. BACKGROUND: It is commonly assumed but unproved that left atrial thrombus in patients with atrial fibrillation begins to form after the onset of atrial fibrillation and that it requires > or = 3 days to form. Thus, patients with acute atrial fibrillation (i.e., < 3 days) frequently undergo cardioversion without anticoagulation prophylaxis. METHODS: Three hundred seventeen patients (250 men, 67 women; mean [+/- SD] age 64 +/- 12 years) with acute (n = 143) or chronic (n = 174) atrial fibrillation were studied by two-dimensional transesophageal echocardiography. RESULTS: Left atrial appendage thrombus was present in 20 patients (14%) with acute and 47 patients (27%, p < 0.01) with chronic atrial fibrillation. In patients with a recent embolic event, the frequency of left atrial appendage thrombus did not differ between those with acute (5 [21%] of 24) and those with chronic (12 [23%] of 52, p = NS) atrial fibrillation. Patients with acute versus chronic atrial fibrillation, respectively, did not differ (p = NS) in mean age (64 +/- 13 vs. 65 +/- 11 years), frequency of concentric left ventricular hypertrophy (32% vs. 26%), hypertension (32% vs. 41%), coronary artery disease (35% vs. 39%), congestive heart failure (43% vs. 48%), mitral stenosis (4% vs. 7%) or mitral valve replacement (1.4% vs. 6%). The minimally detectable difference in proportions between patients with acute and chronic atrial fibrillation based on a power of 0.80 and base proportion of 0.20 was 14%. CONCLUSIONS: Left atrial thrombus does occur in patients with acute atrial fibrillation < 3 days in duration. The frequency of left atrial thrombus in patients with recent emboli is comparable between those with acute and chronic atrial fibrillation. These data suggest that patients with acute atrial fibrillation for < 3 days require anticoagulation prophylaxis or evaluation by transesophageal echocardiography before cardioversion and should not be assumed to be free of left atrial thrombus.
Assuntos
Fibrilação Atrial/complicações , Transtornos Cerebrovasculares/epidemiologia , Ecocardiografia Transesofagiana , Cardiopatias/epidemiologia , Trombose/epidemiologia , Doença Aguda , Anticoagulantes/uso terapêutico , Fibrilação Atrial/terapia , Transtornos Cerebrovasculares/etiologia , Doença Crônica , Cardioversão Elétrica , Feminino , Átrios do Coração , Cardiopatias/diagnóstico por imagem , Cardiopatias/etiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Trombose/diagnóstico por imagem , Trombose/etiologia , Fatores de TempoRESUMO
Atrial pacing and dipyridamole transesophageal echocardiography have been shown to be sensitive and specific tests for the detection of coronary artery disease. However, the sensitivity and specificity of dobutamine transesophageal echocardiography have not been reported. The purpose of this study was to determine the feasibility, sensitivity, and specificity of dobutamine transesophageal echocardiography for the detection of coronary artery disease. Transesophageal echocardiographic assessment of left ventricular function was performed in 81 adult patients aged 62 +/- 12 years during stepwise infusion of dobutamine from 5.0 to 40 micrograms/kg/min. Ischemia was diagnosed by the development of severe hypokinesis, akinesis, or dyskinesis of a previously contractile left ventricular segment. Coronary artery disease was defined by angiography as a reduction in luminal diameter of > or = 70% of an epicardial or > or = 50% of the left main coronary artery. In patients who had undergone coronary artery bypass graft surgery, a stenotic bypass graft was defined as a reduction in luminal diameter of > or = 70%. In patients without previous CABG, significant coronary artery disease was present in 21 patients: 5 with single-vessel disease, 7 double-vessel disease, 8 triple-vessel disease, and 1 left main coronary disease. Dobutamine transesophageal echocardiography had a sensitivity of 90% (19 of 21) and specificity of 94% (49 of 52) for the detection of coronary artery disease. In patients with previous CABG (n = 8), the sensitivity and specificity for the detection of bypass graft stenosis were 100% (4 of 4) and 75% (3 of 4), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Doença das Coronárias/diagnóstico por imagem , Dobutamina , Ecocardiografia Transesofagiana , Ecocardiografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Angiografia Coronária , Doença das Coronárias/diagnóstico , Doença das Coronárias/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Vasos Coronários/fisiopatologia , Eletrocardiografia , Teste de Esforço , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/fisiopatologia , Segurança , Sensibilidade e Especificidade , Função Ventricular Esquerda/efeitos dos fármacos , Função Ventricular Esquerda/fisiologiaRESUMO
Two-dimensional transthoracic echocardiography has been shown to be a reliable and accurate method of measuring stenotic mitral valve orifice area. Little data exist on the role of two-dimensional transesophageal echocardiography for this purpose. Thus in 45 adult patients with mitral stenosis mitral valve area was determined by direct planimetry with the use of two-dimensional transesophageal and transthoracic echocardiography. Transesophageal was less feasible than transthoracic echocardiography in the 45 patients (69% vs. 89%, p < 0.025). In 14 patients, two-dimensional transesophageal echocardiography was not feasible, primarily because of leaflet dropout. In 30 patients, transesophageal and transthoracic echocardiography were feasible, and measurements of mitral valve area by the two techniques correlated well (r = 0.91, SEE = 0.33 cm2, p < 0.0001). Mean mitral valve orifice area determined by transesophageal echocardiography (1.54 +/- 0.75 cm2; range 0.56 to 3.49 cm2) and by transthoracic echocardiography (1.55 +/- 0.78 cm2; range 0.62 to 3.68 cm2) did not differ (p = NS). The absolute (0.24 +/- 0.22 cm2) and percent (19% +/- 21%) differences between mitral valve area determined by transesophageal versus transthoracic echocardiography were small. These data show that mitral valve area in patients with mitral stenosis can be accurately measured by direct planimetry with two-dimensional transesophageal echocardiography. Technical refinements such as lateral-gain-compensation features may improve the feasibility of two-dimensional transesophageal echocardiography for measurements of mitral stenosis area, and this technique may become an adjunct to transthoracic echocardiography in the assessment of severity of mitral stenosis.
Assuntos
Ecocardiografia Transesofagiana , Estenose da Valva Mitral/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Adulto , Idoso , Ecocardiografia/estatística & dados numéricos , Ecocardiografia Transesofagiana/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/epidemiologia , Estudos Prospectivos , TóraxRESUMO
Measurement of cardiac output is a clinically valuable and widely used index of cardiac function. Although transesophageal echocardiography has been used to assess left ventricular function, little data exist on the accuracy of this technique in the measurement of cardiac output. Therefore cardiac output derived by pulsed Doppler transesophageal echocardiography and thermodilution methods were compared in adult patients being mechanically ventilated. The left ventricular outflow tract diameter was determined from a transgastric long-axis view of the left ventricle by using the transverse plane and longitudinal plane of the transesophageal scope. The cross-sectional area of the left ventricular outflow tract was calculated from the diameter assuming a circular shape. Pulsed Doppler recordings were obtained at the left ventricular outflow tract. Doppler time-velocity integrals were measured from the leading edge of the velocity curve. Cardiac output derived by transesophageal echocardiography was calculated as time-velocity integral multiplied by left ventricular outflow tract area and heart rate. Cardiac output derived by transesophageal echocardiography from the transverse plane (n = 26) and longitudinal plane (n = 22) were correlated with simultaneous thermodilution measurements. Thermodilution-derived cardiac output demonstrated excellent correlation with cardiac output measured by using transesophageal echocardiography from the transverse plane (r = 0.97, SEE = 0.84 L/min; p < 0.0001) and longitudinal plane (r = 0.95, SEE = 0.97 L/min; p < 0.0001). Transesophageal echocardiography is a promising technique in the measurement of cardiac output and expands the clinical use of this modality in the assessment of cardiac function.
Assuntos
Débito Cardíaco , Ecocardiografia Transesofagiana/métodos , Termodiluição/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal , Ecocardiografia Transesofagiana/instrumentação , Ecocardiografia Transesofagiana/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Termodiluição/instrumentação , Termodiluição/estatística & dados numéricosRESUMO
There has been little technical advancement in catheter shape for diagnostic cardiac catheterization since the early reports of Sones and colleagues during the development of the procedure. In order to determine the utility of a new catheter that directly, without torque or rotation, engages the right coronary artery (RCA), one hundred patients were randomized between 6Fr standard RCA Judkins (6Fr R4) (Cordis Corporation, Miami, FL, USA) or 6Fr Novoste RCA catheters (Novoste Corporation, Aguadilla, Puerto Rico). Endpoints included the duration of the various aspects of the procedure and a qualitative and quantitative assessment of angiographic quality. The Novoste RCA catheters were associated with statistically decreased times of catheter insertion (42 +/- 37 vs 90 +/- 119 secs), and engagement (31 +/- 35 vs 77 +/- 117 secs), of the right coronary artery as compared to Judkins catheters. Judkins RCA catheters had a significantly higher primary success rate (96%) than the Novoste group (84%, P = 0.045). There was no difference in angiographic quality in either group and no complications occurred during the study. While taller patients (mean 68 in) had increased success with the Novoste catheter, no other clinical, demographic, or anatomical characteristics of the RCA orifice predicted successful engagement and angiography. The direct engagement Novoste RCA catheter is associated with a more expeditious procedure than Judkins catheters when they can engage the RCA orifice. However, Novoste catheters were less successful and required more frequent exchanges to complete the procedure.