Mitral valve replacement and endocavitary patch repair for a giant left ventricular pseudoaneurysm.

We present a case of a giant inferior left ventricular (LV) wall pseudoaneurysm. The patient had New York Heart Association class IV heart failure due to severe mitral valve regurgitation and poor LV function. Our operative approach included right thoracotomy, excision of the mitral valve, and patch repair of the pseudoaneurysm neck from inside of the dilated LV cavity followed by mitral valve replacement. Surgery was performed without aortic cross-clamping on a normothermic perfused beating heart. The patient had an uncomplicated cardiac recovery and is doing well 15 months after surgery.

Iatrogenic paradoxical air embolism in pulmonary hypertension.

Paradoxical systemic air embolism (PAE) occurring as a complication of right-to-left intracardiac shunting during evaluation and treatment of pulmonary hypertension (PH) has not been previously reported. We report four cases of PH-associated PAE recently encountered at our center. Two patients with PH experienced transient neurologic deficits during agitated-saline contrast echocardiography (ASCE), and a patent foramen ovale was subsequently diagnosed in both patients. Two patients with Eisenmenger's syndrome (ES), while receiving epoprostenol via multilumen catheters, experienced transient neurologic deficits while flushing the unused port of the catheter. No patient experienced permanent neurologic deficits. We conclude that ASCE poses a risk for PAE in patients with PH and clinically silent, previously undetected, right-to-left intracardiac shunts, and that multilumen catheters used for long-term epoprostenol therapy in ES carry a risk of PAE.

Long-lasting improvement after septal myectomy for hypertrophic obstructive cardiomyopathy.

BACKGROUND: The most effective treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy is still disputed. Treatment options include medical therapy, pacemaker insertion, percutaneous transluminal septal myocardial ablation, mitral valve replacement, and surgical resection of obstructing muscle. The long-term results of the various treatment options are not well defined. We aimed to demonstrate that septal myectomy is efficacious in reducing or abolishing left ventricular outflow tract gradient and leads to long-lasting symptomatic improvement in most patients. METHODS: Twenty-two consecutive patients had septal myectomy between 1981 and the present. Their records were reviewed to document the details of their preoperative status, hospital course, their subsequent clinical outcome, and current status. RESULTS: Mean age at operation was 31.3 years. Preoperatively all patients were disabled by typical symptoms despite aggressive medical treatment. Mean resting gradient was 78 mm Hg. Nine patients required simultaneous associated cardiac procedures. There were no perioperative deaths and minimal morbidity. Two patients died at 6 and 9 years postoperatively of congestive heart failure and arrhythmias. Long-term survivors have been followed up for a mean of 6.6 years. Currently all have minimal or no symptoms. The mean resting gradient was 12 mm Hg. No patient has required reoperation for residual obstruction. CONCLUSIONS: Septal myectomy reduces or abolishes left ventricular outflow tract gradient in hypertrophic obstructive cardiomyopathy. Myectomy provides long-lasting symptomatic improvement in most patients. The clinical status of patients late postoperatively can be affected by arrhythmias and myocardial dysfunction.

Echocardiography in infective endocarditis.

BACKGROUND: Echocardiographic demonstration of valvular infection now ranks with positive blood cultures as one of the two major clinical criteria for diagnosis of infective endocarditis (IE), according to new, more accurate guidelines for diagnosis. Because early detection of IE and its complications is essential for determining whether to pursue medical therapy or to intervene surgically, transthoracic echocardiography (TTE) is an essential part of the initial examination of patients with suspected IE. METHODS: Using MEDLINE, we searched and reviewed all articles with the key words infective endocarditis and transesophageal echocardiography. RESULTS: With its superior imaging, transesophageal echocardiography (TEE) has proven to be more sensitive than TTE for the diagnosis of IE as well as in the detection of IE-associated complications. CONCLUSIONS: While superior in predicting which patients with IE have perivalvular abscess or prosthetic valve dysfunction and which are most susceptible to systemic embolism, TEE is more invasive and must be used selectively.

Echocardiographic and biochemical evaluation of the development and progression of carcinoid heart disease.

OBJECTIVES: To study the applicability of a newly developed echocardiographic scoring system in the assessment of carcinoid valvular heart disease. BACKGROUND: We investigated prospectively the development, progression and regression of carcinoid valvular heart disease in patients with carcinoid syndrome by serial echocardiography, correlating these features with urinary 5-HIAA levels and clinical data collected during therapy with somatostatin analog. METHODS: Twenty-three patients with carcinoid syndrome underwent serial echocardiographic examinations. An echocardiographic carcinoid valvular heart disease (CVHD) % score was determined from points assigned for tricuspid and pulmonary valve structure and function. RESULTS: Fifteen patients had no CVHD at study entry (group 1), while 8 patients had findings of CVHD (group 2). Five patients in group q developed new CVHD (1B), while one demonstrated progression of CVHD (2B). The remaining patients did not develop (1A) or had no progression of CVHD (2B). Despite major declines in 5-HIAA levels during therapy in most patients, CVHD did not regress. There were significantly lower levels of median baseline 5-HIAA (98.8 vs. 256 mg/24 h), posttreatment 5-HIAA (50.3 vs. 324 mg/24 h) and posttreatment 5-HIAA time integral (37.3 vs. 192 g/24 h* days) in group A vs. B (p < 0.05). However, only posttreatment 5-HIAA levels independently predicted the development or progression of CVHD by multiple step-wise regression analysis (p < 0.005), with a threshold observed in the 100 mg/24 h range. CONCLUSIONS: We designed a new echocardiographic scoring system to evaluate CVHD. Correlating echocardiographic scores with biochemical and clinical markers showed that only posttreatment 5-HIAA levels independently predicted the development or progression of CVHD. This study strengthens the association between serotonin secretion and CVHD, as well as introducing a new technique for serial follow-up of these patients.

Phase III multicenter trial comparing the efficacy of 2% dodecafluoropentane emulsion (EchoGen) and sonicated 5% human albumin (Albunex) as ultrasound contrast agents in patients with suboptimal echocardiograms.

OBJECTIVES: This study was performed to compare the safety and efficacy of intravenous 2% dodecafluoropentane (DDFP) emulsion (EchoGen) with that of active control (sonicated human albumin [Albunex]) for left ventricular (LV) cavity opacification in adult patients with a suboptimal echocardiogram. BACKGROUND: The development of new fluorocarbon-based echocardiographic contrast agents such as DDFP has allowed opacification of the left ventricle after peripheral venous injection. We hypothesized that DDFP was clinically superior to the Food and Drug Administration-approved active control. METHODS: This was a Phase III, multicenter, single-blind, active controlled trial. Sequential intravenous injections of active control and DDFP were given 30 min apart to 254 patients with a suboptimal echocardiogram, defined as one in which the endocardial borders were not visible in at least two segments in either the apical two- or four-chamber views. Studies were interpreted in blinded manner by two readers and the investigators. RESULTS: Full or intermediate LV cavity opacification was more frequently observed after DDFP than after active control (78% vs. 31% for reader A; 69% vs. 34% for reader B; 83% vs. 55% for the investigators, p < 0.0001). LV cavity opacification scores were higher with DDFP (2.0 to 2.5 vs. 1.1 to 1.5, p < 0.0001). Endocardial border delineation was improved by DDFP in 88% of patients versus 45% with active control (p < 0.001). Similar improvement was seen for duration of contrast effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to affect patient management. There was no difference between agents in the number of patients with adverse events attributed to the test agent (9% for DDFP vs. 6% for active control, p = 0.92). CONCLUSIONS: This Phase III multicenter trial demonstrates that DDFP is superior to sonicated human albumin for LV cavity opacification, endocardial border definition, duration of effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to influence patient management. The two agents had similar safety profiles.

Resolution of vegetations with anticoagulation after myocardial infarction in primary antiphospholipid syndrome.

We report here a case of primary antiphospholipid syndrome with all three clinical features with acute myocardial infarction. Echocardiography showed large vegetations at both mitral valve leaflets. Laboratory evaluation showed presence of antiphospholipid antibodies. High-intensity anticoagulation was begun, and repeat echocardiographic study in 4 months showed disappearance of the mitral valve vegetations.

Functional mitral stenosis resulting from a large mitral valve prosthesis vegetation.

Obstruction of a prosthetic valve by an infective vegetation is a rare and life-threatening complication of endocarditis that demands emergent surgical intervention. In our patient's case, transthoracic echocardiography showed the large vegetation, transthoracic Doppler imaging showed severe obstruction of diastolic flow through the bioprosthetic valve, and transesophageal echocardiography showed that no perivalvular abscess was present. Rapid diagnosis of prosthetic valve infection and obstruction demanded application of all three major echocardiographic modalities and proved critical to the patient's recovery.

Optimal Albunex dosing for enhancement of Doppler tricuspid regurgitation spectra.

Intravenous albunex was more effective than agitated saline in enhancing incomplete Doppler echocardiography spectra for tricuspid regurgitation without a significant alteration in the maximal detected velocity. The optimal dose was 1 to 4 ml in most patients, using an initial dose of 1 ml and titrating further dosing on the basis of the initial contrast effect.

Acute inferior myocardial infarction complicated by rupture into the coronary sinus: diagnosis by two-dimensional echocardiography.

Ventricular rupture is a catastrophic, often fatal complication of myocardial infarction. We present a unique case of left ventricular rupture into the coronary sinus that was diagnosed by two-dimensional Doppler echocardiography in a patient with a recent inferior myocardial infarction. The echocardiographic findings essential to diagnosis were subsequently confirmed at autopsy and are reviewed in detail.

Pulmonary vein Doppler flow patterns specific for elevated left ventricular filling pressures in older cardiac patients are common in healthy adults < 40 years old.

In older cardiac patients, elevated left-sided heart filling pressures are predicted by both a systolic PV flow fraction < 40% and a greater duration during atrial systole of reversal flow into the PVs than forward flow through the mitral valve. However, this study shows that these Doppler findings are not uncommon in younger subjects without cardiac disease. Use of these PV Doppler flow parameters to assess LV filling pressures should be limited to older patients.

Doppler echocardiography in cardiac tamponade and constrictive pericarditis.

Doppler echocardiography has greatly facilitated the assessment of patients with compressive cardiac disease. Patients in whom cardiac tamponade or pericardial constriction are suspected should undergo a complete echocardiographic examination including careful Doppler analysis of transmitral flow and inflow through the hepatic vein or superior vena cava (SVC). Monitoring of both the electrocardiogram and the phase of respiration are an integral part of this examination. Patients with cardiac tamponade exhibit a > 25% reduction in E wave velocity during the first inspiratory cardiac cycle; they exhibit predominant systolic inflow through the hepatic vein or SVC (with a predominant X descent with little or no Y descent). In constrictive pericarditis the pattern of transmitral flow variation is comparable to that observed in cardiac tamponade, however, a prominent Y descent is often observed on hepatic vein or SVC Doppler study. Similar changes with respiration may be observed in mitral inflow in obese patients or in those with chronic obstructive pulmonary disease, however, in these conditions the nadir of E wave velocity is observed 2-3 cardiac cycles after the first inspiratory beat. Restrictive cardiomyopathy may produce a similar systemic venous flow pattern, but increased inspiratory flow reversals and lack of respiratory variation in transmitral flow velocity distinguish it from constrictive pericarditis.

Contrast echocardiography enhances tricuspid but not mitral regurgitation.

Tricuspid regurgitation refers to a systolic leak of blood between the right ventricle and right atrium, across the tricuspid valve. Doppler echocardiographic examination of large numbers of normal individuals has shown that trivial tricuspid regurgitation is extremely common. Measurement of the peak velocity of the regurgitant frequency spectrum on Doppler echocardiography is of considerable clinical importance since it may be used to calculate peak right ventricular and, consequently, peak pulmonary systolic pressure. Doppler recording of the frequency spectrum of a tricuspid regurgitation jet optimally shows a smooth, parabolic, sharply demarcated envelope. In many individuals with trivial tricuspid regurgitation, however, this frequency spectrum is incomplete and its envelope is poorly demarcated. Such inadequate signals do not allow measurement of the spectrum's peak velocity. Like other contrast agents, air-filled microspheres composed of sonicated human serum albumin enhance reflection of Doppler ultrasound and thus have the potential to enhance incomplete tricuspid regurgitation spectra. Furthermore, since sonicated albumin microspheres can cross the pulmonary circulation intact, they have the potential to enhance mitral regurgitation spectra. The purpose of our study was to investigate whether injection of sonicated albumin microspheres enhances incomplete tricuspid and mitral regurgitation frequency spectra to a diagnostic quality. Sonicated albumin microsphere injection enhanced tricuspid regurgitation spectra to optimal quality in 11 of 15 patients (73%). Microsphere injection caused a minor degree of enhancement of the mitral regurgitant spectrum in 1 patient, but did not optimize the spectra in any of 10 patients tested. Saline contrast injection optimally enhanced tricuspid regurgitation spectra in all 8 patients in whom it was used.(ABSTRACT TRUNCATED AT 250 WORDS)

Proximal aortic dissection with cardiac tamponade. Long-term survival without surgery.

Proximal aortic dissection in a 79-year-old woman was complicated by cardiac tamponade, aortic regurgitation, and pleural leak. Following pericardiocentesis and control of her hypertension, she survived without an operation for more than four years.

Doppler estimation of changes in pulmonary artery pressure during hypoxic breathing.

To assess the use of Doppler echocardiographic screening for abnormal pulmonary vasoreactivity, we measured pulmonary artery pressure in 10 adult patients and 11 normal subjects while recording Doppler right ventricular outflow acceleration time, pre-ejection period, and ejection time. In the normal subjects we also measured the changes in each parameter after 10 minutes of hypoxic breathing (FIO2 = 0.12). Mean pulmonary artery pressure increased by 39% during hypoxia (13 +/- 4.3 to 18 +/- 5.4 mm Hg). In the patients and normal subjects at rest, mean pulmonary artery-pressure correlated well with acceleration time (r = -0.84; standard error of the estimate, 6.6 mm Hg; p = 0.0001). Over the narrow range of mean pulmonary artery pressure in normal subjects at rest, mean pulmonary artery pressure did not correlate well with acceleration time, acceleration time/pre-ejection period, or acceleration time/right ventricular ejection time. However, changes in mean pulmonary artery pressure induced by hypoxic breathing did correlate with changes in acceleration time/right ventricular ejection time (r = 0.73; standard error of the estimate, 2.3 mm Hg; p = 0.01). Doppler ultrasound may offer a noninvasive means for detecting abnormal pulmonary vasoreactivity in asymptomatic individuals at risk for developing pulmonary hypertension.

Origin and significance of diastolic Doppler flow signals in the left ventricular outflow tract.

Diastolic Doppler flow signals (greater than or equal to 0.2 m/s) in the left ventricular outflow tract have not been well characterized, and their origin and significance remain controversial. Fifty-nine patients (55 +/- 16 years of age) with technically good Doppler echocardiographic studies were studied prospectively. There were 14 normal subjects, 21 patients with left ventricular hypertrophy, 10 with dilated cardiomyopathy and 14 with other cardiac disease. The rhythm was sinus in 55 and atrial fibrillation in 4. Two distinct Doppler flow signals were detected in the left ventricular outflow tract during diastole. These were termed E' (early) and A' (active) because they occurred 40 to 100 ms after higher velocity mitral inflow E (passive filling) and A (atrial contraction) signals. Among 59 patients, E' signals were present in 48 (81%) and had a mean velocity of 0.41 +/- 0.23 m/s. In 55 patients with normal sinus rhythm, A' signals were present in 52 (95%) and had a mean velocity of 0.52 +/- 0.24 m/s. No A' signals were present in the four patients with atrial fibrillation. The E' and A' velocities by pulsed wave Doppler ultrasound were low at the left ventricular apex and increased along the basal septum in the left ventricular outflow tract. Prominent A' velocities (greater than or equal to 0.45 m/s) were seen in 62% of patients with left ventricular hypertrophy, 50% of normal subjects and 10% of patients with dilated cardiomyopathy. The A' velocity was higher in patients with left ventricular hypertrophy (0.63 +/- 0.26 m/s) than in those with a normal heart (0.45 +/- 0.16 m/s; p less than 0.05) or dilated cardiomyopathy (0.25 +/- 0.13 m/s; p less than 0.01). The major determinants of diastolic outflow tract velocity were the mitral inflow E and A velocities and left end-diastolic dimension, particularly when combined (r = 0.64, p less than 0.0001 for E'; r = 0.72, p less than 0.0001 for A'). Distinctive E' and A' Doppler outflow tract signals result from mitral inflow and may be detected in most patients with normal heart size. These E' and A' velocities increase from apex to base and are more prominent in patients with a small, normally contracting heart or left ventricular hypertrophy.