The echocardiographic spectrum of atrial myxoma: a ten-year experience.

We analyzed the echocardiograms of 28 patients with a left atrial myxoma and two with a right atrial myxoma. Our purpose was to evaluate the value of echocardiography for the diagnosis of these cardiac masses. Only 59% of the m-mode echocardiograms in patients with a left atrial myxoma showed the characteristic findings of multiple diastolic echoes within the mitral orifice as well as abnormal systolic echoes within the left atrium. M-mode echocardiograms were atypical for left atrial myxoma in the remaining patients, and a definitive diagnosis could not be established on the basis of this procedure in six of the patients (22%). Two-dimensional echocardiography showed the presence of a left atrial mass in all 16 patients who had the procedure, and aided in understanding the atypical m-mode recordings. There was a close relationship (r =.82) between two-dimensional echocardiographic measurements of the myxomas' size and pathologic measurements. Both right atrial myxomas could be identified on the m-mode echocardiogram. Our experience indicates that two-dimensional echocardiography is superior to the m-mode technique for the diagnosis and characterization of left atrial myxomas.

Auscultatory and echocardiographic features of mobile left atrial thrombus.

Free floating ball thrombus of the heart is a rare disorder that usually involves the left atrium, particularly in association with mitral stenosis and atrial fibrillation. The diagnosis of ball thrombus is suspected clinically when there are auscultatory changes in the intensity of the murmur of mitral stenosis. Two-dimensional echocardiography is especially useful in the diagnosis of this condition. By combining phonocardiographic recordings with both M-mode and two-dimensional echocardiography, attenuation and disappearance of the murmur were demonstrated as the mobile thrombus randomly drifted into the mitral valve orifice. Reappearance of the cardiac murmur was noted as the thrombus was expelled from the orifice. This study, combining simultaneous phonocardiography and two-dimensional echocardiography, identifies for the first time the relation between thrombus movement into the mitral aperture and changes of the murmur of mitral stenosis.

Surgical treatment of mitral systolic click syndrome: results in 37 patients.

From 1974 to 1983, 37 symptomatic patients with mitral systolic click (Barlow's syndrome) underwent mitral valve repair. In 11 patients (30%), the click syndrome was associated with minor mitral regurgitation. Thirty-two patients (86%) had chest pain, 20 had arrhythmia (54%), and 20 had dyspnea as a major complaint. In 5 patients, the arrhythmia was serious, and in 2 of them, it was potentially life threatening. Mitral annuloplasty using a collar prosthesis was performed in 33 patients with posterior leaflet plication in 2, shortening of the chordae in 1, and commissural plication in 2. In 4 patients, commissural plication was performed. One of these patients also required cusp plication and shortening of the chordae, and another required repair of ruptured chordae. There were no operative or late cardiac-related deaths at a mean follow-up of 4.7 years (range, 1 to 10 years). Sixty-two percent of patients with prolapse alone and 91% of those with associated regurgitation were improved by at least one New York Heart Association Functional Class, with 60% of patients obtaining relief of one or more symptoms. In the presence of major symptoms, mitral annuloplasty offers symptomatic relief for some patients with mitral systolic click syndrome without valve incompetence, but it gives substantially better results in patients with mitral regurgitation.

Comparison of two-dimensional echocardiography, radionuclide ventriculography and cineangiography in detecting surgically documented left ventricular thrombi.

To assess the diagnostic value of various imaging techniques for identifying left ventricular thrombi, we studied 35 patients who underwent left ventricular aneurysm repair and inspection of the ventricular cavity for the presence of a thrombus. All patients underwent preoperative two-dimensional echocardiography and left ventricular cineangiography; radionuclide ventriculography was also performed in 19 of these patients. Data from these procedures were analyzed as in a blind study, and were interpreted as either positive or negative for thrombus. A left ventricular thrombus was present in 22 of the 35 patients at surgery (63%). Two-dimensional echocardiography showed a sensitivity of 95%, specificity of 92% and overall predictive accuracy of 94% for the detection or exclusion of thrombi. In comparison, cineangiography yielded a sensitivity of 73%, specificity of 92% and predictive accuracy of 80%. The sensitivity of radionuclide ventriculography was 60%, specificity was 100%, and predictive accuracy was 79%. Our data, based on a surgical-pathological standard, shows that two-dimensional echocardiography is a highly accurate technique for the diagnosis of left ventricular thrombi, and may be the procedure of choice for this purpose.

Two-dimensional echocardiographic assessment of complications involving the Ionescu-Shiley pericardial valve in the mitral position.

The function of the Ionescu-Shiley bovine pericardial xenograft in the mitral position was investigated in 70 patients by two-dimensional echocardiography. Echocardiographic data from 21 patients with suspected bioprosthetic dysfunction and 49 patients with normal clinical findings were analyzed in a double-blind fashion. Confirmation of cardiovascular status was obtained by means of cardiac catheterization, surgery, autopsy or other techniques in 19 of the 21 symptomatic patients. Two-dimensional echocardiography correctly evaluated bioprosthetic function in 98% of the patients. Six of the seven patients with proven xenograft dysfunction demonstrated echocardiographic evidence of malfunction. There was one false negative evaluation but no false positive results. Valve dysfunction included endocarditic mass lesions, mitral regurgitation resulting from dehiscence of a leaflet or the sewing ring or mitral stenosis due to calcification or malposition of the valve. This experience indicates that two-dimensional echocardiography is useful for assessing the Ionescu-Shiley mitral bioprosthesis, particularly in those patients who develop nonspecific symptoms.

Aneurysm of the interatrial septum occurring as an isolated anomaly.

We report a case of aneurysm of the atrial septum occurring as an isolated abnormality in a patient with atypical chest pain. Apical two-dimensional echocardiography demonstrated phasic bulging of the fossa ovalis region of the atrial septum into the right atrium. Biplane cineangiography confirmed the presence of a large septal aneurysm in an otherwise normal heart. The incidence, pathogenesis, and complications of this unusual anomaly are briefly discussed.

Noninvasive assessment of the Ionescu-Shiley pericardial xenograft in the mitral position: preliminary experience.

To establish noninvasive criteria for assessment of the Ionescu-Shiley pericardial xenograft in the mitral position, 29 patients with a normally functioning bioprosthesis were studied with m-mode echocardiography and phonocardiography. Two-dimensional echocardiograms were also obtained in ten of the patients. Although two-dimensional echocardiography provided simultaneous visualization of a greater number of stents and leaflets than the m-mode technique, the superior resolution of m-mode ultrasound permitted more detailed analyses of the xenograft's motion patterns. The anterior leaflet, recorded in all patients, had an average excursion of 1.2 +/- 0.22 cm. Leaflet thickness measured 4 mm or less. Coarse diastolic vibration of the anterior leaflet was recorded in two patients in the absence of both aortic insufficiency and prosthesis dysfunction. Ultrasonic estimates of prosthesis height and orifice diameter did not correlate with micrometer measurements, possibly due to the limited resolution of pulsed ultrasound in the presence of a highly reflective substance. Opening and closing of the pericardial leaflets were associated with the production of high frequency vibrations on the phonocardiogram. The potential usefulness and limitations of echocardiography for evaluating the function of bioprosthetic valves are discussed.

Initial diastolic indentation of the mitral valve in aortic insufficiency.

An abnormal diastolic indentation of the mitral valve has been noted on short-axis two-dimensional echocardiograms in patients with aortic insufficiency. In order to assess the clinical usefulness of this finding, we reviewed the echocardiograms of 18 patients with this lesion who had undergone cineaortography. Results were compared with those of a control group of 100 patients. Initial diastolic indentation of the anterior mitral leaflet occurred in 8 of 12 patients with 3+ to 4+ aortic insufficiency. None of the patients with lesser regurgitation and no patients from the control group demonstrated this pattern. The presence of this abnormality appears to be a specific indicator of critical aortic insufficiency.

Premature closure of prosthetic mitral valves as a consequence of gravity.

To determine the influence of gravity on premature closure of prosthetic mitral valves, we studied 17 patients in whom this phenomenon had been observed during routine examination. All patients were in atrial fibrillation and none had aortic incompetence. Patients were studied in multiple positions by means of simultaneous echocardiography, phonocardiography, and cinefluoroscopy. In all patients premature closure was observed when the atrial side of the prosthesis was below the ventricular side, resulting in a downward motion of the occluder inside the valve cage. When patients were studied in positions in which the atrial side of the valve was higher that the ventricular side, premature closure never occurred, even during extremely prolonged diastolic periods. Since minor positional changes, which were found to determine whether premature closure occurred or not, are unlikely to produce significant alterations in pressure and flow across the mitral orifice during diastole, we conclude that position-dependent premature closure of prosthetic mitral valves in patients with atrial fibrillation is best explained by the effect of gravity on the prosthetic occluder. Examination of such patients in multiple positions should be helpful in distinguishing premature valve closure caused by aortic regurgitation from gravity-related presystolic closure. Inability to produce premature closure in patients in whom it had previously been demonstrated in the presence of similar R-R intervals may even prove useful in diagnosing new orifice obstruction.

Major dehiscence of a prosthetic aortic valve: detection by echocardiography.

A 21-year-old man had acute aortic insufficiency three months after insertion of an aortic valve prosthesis. Chest roentgenography demonstrated abnormal orientation of the prosthesis. M-mode echocardiography showed dense, linear echoes from the prosthetic valve between the interventricular septum and the mitral valve, along with loss of normal poppet motion within the aortic root. At surgery, the prosthesis was found to be extensively disrupted, resulting in prolapse into the left ventricular outflow tract. Another valve replacement was performed with patient survival. Echocardiography appears to be a useful adjunct to established roentgenographic procedures in the diagnosis of major dehiscence of prosthetic aortic valves.

Radiolucent holder for echocardiographic recordings during fluoroscopy and exercise.

The design and function of a device that holds an ultrasound transducer against the chest wall in a stationary position is described. This holder is useful for obtaining echocardiograms during cinefluoroscopic procedures, various positional maneuvers, and exercise testing.

Echocardiography in the diagnosis of Lutembacher syndrome.

In two patients with Lutembacher syndrome cardiac catheterization demonstrated a large atrial septal defect but no diastolic gradient across the mitral valve. Echocardiography was compatible with right ventricular volume overload and mitral stenosis. Surgical exploration of the mitral valve at the time of atrial septal defect correction is warranted when the echocardiogram is suggestive of mitral stenosis.

Ultrasonic evaluation of thrombosis of Björk-Shiley aortic valve prosthesis.

Recognition of thrombosis of a Björk-Shiley aortic valve prosthesis 4 years after insertion in a patient was based upon sudden clinical deterioration, loss of prosthetic sounds, and development of new stenotic and regurgitant murmurs. Thrombotic fixation was confirmed by diagnostic alterations on the echocardiogram. All manifestations reverted to normal after successful surgical debridement of the prosthesis. Echocardiography is a valuable noninvasive adjunct in the differential diagnosis of prosthetic valve malfunction.