Absence Of Obstruction Research Articles

PROSPECTIVE COMPARISON OF NONENHANCED HELICAL COMPUTERIZED TOMOGRAPHY AND DOPPLER ULTRASONOGRAPHY FOR THE DIAGNOSIS OF RENAL COLIC

We evaluate the accuracy of nonenhanced helical computerized tomography (CT) and Doppler ultrasonography for the diagnosis of renal colic. Our study includes 109 patients, with 218 kidneys, who presented with unilateral flank pain. All patients underwent nonenhanced helical CT, Doppler ultrasonography and excretory urography (IVP). CT was evaluated for the presence of ureteral stones and manifestation of ureteral obstruction. For Doppler ultrasonography the renal resistive index was measured for the left and right kidneys in each patient, and change in resistive index between ipsilateral and contralateral kidneys was calculated and considered positive for ureteral obstruction with values 0.04 or greater. As a reference standard, absence of obstruction was considered if IVP was negative and the cause of flank pain was confirmed not to be urological. Obstruction was diagnosed not only by positive IVP, but also by patient followup until passage or retrieval of ureteral stones. Results of CT and change in resistive index were compared with those of the reference standard. Unilateral ureteral obstruction was confirmed in 52 patients, while no obstruction was found in 57. Of the 57 patients without ureterolithiasis the change in resistive index results was negative in all patients with a specificity of 100%, while CT was negative in 55 with a specificity of 96%. Of the 52 patients with ureteral obstruction CT was positive in 50, and change in resistive index was positive in 47 with a sensitivity of 96% and 90%, respectively, with a difference of no significant value. Nonenhanced helical CT and change in resistive index are sensitive and specific tests that can contribute significantly to the diagnosis of acute unilateral renal obstruction. They can replace IVP, particularly in situations in which it is undesirable.

Reliability of color Doppler ultrasound urodynamics in the evaluation of bladder outlet obstruction

Objectives. To analyze the intrarater and interrater reliability of a newly developed noninvasive urodynamic technique based on color Doppler ultrasound for the evaluation of bladder outlet obstruction. We previously demonstrated the feasibility of this new technique. Methods. Color Doppler ultrasound urodynamic evaluations were performed on 31 men with and without bladder outlet obstruction. An ultrasound image-directed Doppler system with a 3.75-MHz probe operated by a remote control robotic manipulator was used to obtain color scale data using the transperineal approach in men during voiding. We measured the flow velocities in the distal prostatic (V1) and membranous urethra (V2) and used them to obtain the velocity ratio (VR = V1/V2). Combining this information with simultaneous uroflowmetry, the functional cross-sectional area of the distal prostatic urethra (A1) was calculated. These parameters were independently reinterpreted by an inexperienced investigator using the color image data stored in a personal computer. The intrarater and interrater reliability for VR were assessed using a classification based on cutoff values previously shown to indicate the presence or absence of obstruction. Results. The retest correlation using Spearman’s rho for VR in terms of intrarater and interrater reliability was 0.95 and 0.57, respectively; that for A1 was 0.97 and 0.64, respectively. Using a VR of less than 1.1 (to indicate the absence of obstruction) and a VR greater than 1.6 (to indicate the presence of obstruction) for classification, intrarater and interrater agreement occurred in 93.6% to 96.8% and 77.4% to 83.9% of cases, respectively. Conclusions. The color Doppler ultrasound urodynamic technique for noninvasive evaluation of bladder outlet obstruction can be performed with reasonable reliability.

Detection of positional airway obstruction in neonates by acoustic reflection.

In neonates intubated with an uncuffed endotracheal tube (ETT), positional changes of the head may induce obstruction (side position-related ETT obstruction [SPRO]) due to abutment of the beveled distal ETT orifice against the tracheal wall. We studied whether the acoustic reflection (ACR) method, a 4-s measurement that maps cross-sectional area as a function of the distance along the ETT and the airways, could detect SPRO. Eleven preterm newborns intubated with 2.5-mm ETTs and clinically suspected of having SPRO were studied with the head oriented to the left and to the right. In all patients there was a marked decrease in the ACR-measured area beyond the distal tip of the ETT in the presence of obstruction (decrease = 38 +/- 22% [mean +/- SD] of the ETT inside area), while the ACR-measured area increased markedly in the absence of obstruction (increase = 49 +/- 17%). For six of the 11 infants, we also recorded the maximal flow produced by a set mechanical inflation pressure. This maximal flow decreased in the presence of obstruction (decrease = 47 +/- 18%), and was constantly associated with a decrease in ACR-measured area beyond the ETT. In conclusion, ACR measurement is an efficient method for diagnosing positional ETT obstruction in intubated newborns.

Use of diuretic renogram in evaluation of patients before and after endopyelotomy

Objectives. Endopyelotomy is a widely accepted alternative in the treatment of ureteropelvic junction (UPJ) obstruction, with success rates between 63% and 88%. However, various methods have been used to evaluate patients with UPJ obstruction, making it difficult to compare results. Diuretic renography has the potential to unify the evaluation if performed in standard ways. In this report, we present a standardized protocol for diuretic renography. Methods. Nineteen endopyelotomies were performed by one surgeon (E.B.K.) at our institution. The 16 patients were evaluated with technetium 99m MAG-3 diuretic renography. The presence or absence of obstruction was classified according to the differential renal function, time activity curves, and T max to T 1/2max time. Three patients had a postoperative Whitaker’s test. Results. Eight patients had pre- and postoperative diuretic renograms at our institution. This group was stratified by their differential renal function. Among 4 patients with differential renal function greater than 35%, 3 of 4 showed progressive improvement in renal function postoperatively, 4 of 4 had a T max to T 1/2max time less than 10 minutes, and 3 of 4 had unobstructed time activity curves. Five patients had postoperative renograms only. Of these 5 patients, 4 had differential renal function greater than 35% and 3 of 5 had normal-appearing curves and normal T max to T 1/2max time. Three patients required a second endopyelotomy and 2 of these underwent a dismembered pyeloplasty. Conclusions. Standardized diuretic renography should be used as an objective test for the evaluation of patients with UPJ obstruction. The successful outcome of an endopyelotomy depends on the preoperative renal function of the involved kidney. Whitaker’s test may be used for equivocal cases.

Accurate Determination of Prostate Size Via Digital Rectal Examination and Transrectal Ultrasound

Previously, prostate size did not play a significant role in the choice of treatment for benign prostatic hyperplasia (BPH). It has been postulated that prostate size does not correlate with symptom severity, flow rate, or the presence or absence of obstruction. However, in a published study of community-dwelling men, the odds of having moderate to severe symptoms were five times higher for men with enlarged prostates than for those with normal prostates. Response to certain types of BPH therapy, especially finasteride, depends on actual prostate volume. Therefore, it is important to have a simple way to accurately determine if a patient’s prostate is enlarged. In an analysis of four studies, there was a distinct underestimation of prostate size by digital rectal examination (DRE) when compared with transrectal ultrasound (TRUS) measurement. The underestimation of prostate volume increased with increasing TRUS volume, particularly if the volume was greater than 30 mL. The average underestimation was between 9% and 12% for prostate volumes 30 to 39 mL and between 17% and 27% for prostate volumes 40 to 49 mL. Because of these results, a prospective study is currently in progress to develop models or visual aids to assist physicians in more accurately predicting a threshold prostate volume via DRE.

Long-term follow-up of childhood duodenal ulcers

Purpose: This study reports the long-term results in children who have duodenal ulcers diagnosed by endoscopy who were treated with H2-receptor antagonist. Methods: The medical records of 32 children admitted into The Queen Mary Hospital with endoscopically proven duodenal ulcers between 1975 and 1988 were reviewed to evaluate the long-term outcome of childhood duodenal ulcers after initial treatment with H2-receptor antagonist (H2RA). Follow-up details were updated and patients who had been lost to follow-up were recalled. The age of the 22 boys and 10 girls at the time of diagnosis of the ulcers ranged from 3 to 16 years (mean, 11.8 yrs). The duration of follow-up ranged from 8.5 to 21 years (mean, 11.6 yrs). Results: Their primary presentations included epigastric pain (n = 9, 28.0%); nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB, n = 6, 18.7%); unprovoked GIB (n = 12, 37.5%); perforation (n = 4, 12.5%); and pyloric obstruction (n = 1, 3.0%). All 13 patients who had NSAID-induced ulcers (pain and bleeding) responded to H2RA therapy and required no further treatment. All 14 patients who had unprovoked ulcers who presented with pain or bleeding did not respond to H2RA treatment. Ulcer healing was achieved only after eradication of Helicobacter pylori with antibiotics (n = 8) or definitive surgery involving either truncal vagotomy and pyloroplasty (VP, n = 4) or proximal gastric vagotomy (PGV, n = 2). The patient who had gastric outlet obstruction had vagotomy and antrectomy. All four patients who had perforation were initially treated with patch repair, but two had persistent ulceration despite H2RA treatment and required PGV. Complications developed in none of the four patients who had PGV, whereas two of the four patients with VP had problems (diarrhea, n = 1; bezoar obstruction, n = 1). Conclusions: Unprovoked childhood duodenal ulcer is associated with significant long-term morbidity and requires continued follow-up. The majority of the ulcers are resistant to H2RA treatment alone and ultimately require either eradication of H pylori or surgery. In the absence of obstruction, PGV may be enough to resolve the ulcer diathesis.

Anuric renal failure from massive bilateral renal hematoma following extracorporeal shock wave lithotripsy

We report a case of large bilateral perirenal and intrarenal hematoma formation leading to prolonged anuria in the absence of obstruction following extracorporeal shock wave lithotripsy. With conservative management, including the need for hemodialysis support, renal function gradually returned. A mechanism for this patient's anuric renal failure is postulated and caution is advised when considering simultaneous bilateral extracorporeal shock wave lithotripsy in patients with a potential risk of bleeding.

The value of Doppler resistive index and peak systolic velocity in the evaluation of porcine renal obstruction.

We evaluated the use of Doppler resistive indexes and systolic velocities as diagnostic tools in a partially obstructed animal model. We studied 12 normal pigs by Doppler sonography, which served as control units. In 9 subjects partial ureteral obstruction was then created surgically, and 3 continued as controls. The presence or absence of obstruction was confirmed by ultrasound, antegrade nephrostography and intrapelvic pressure monitoring. Doppler parameters were measured 1 hour to 21 days postoperatively. Resistive index, and angle corrected peak and mean systolic velocities were measured bilaterally from samplings of interlobar and arcuate arteries. An average of 4 samplings per kidney was obtained at each session. Data from the control and obstruction groups were compared for statistical differences. In controls mean resistive index was 0.53, and peak and mean systolic velocities were 0.38 and 0.26 m. per second, respectively. In the subacute period after obstruction (defined as days 4 to 21) mean resistive index was 0.54, and peak and mean systolic velocities were 0.33 and 0.22 m. per second, respectively. Compared to control data there was no significant change in resistive index after obstruction (p = 0.6). However, peak and mean systolic velocities showed significant downward trends (p < 0.05). Known small sequential changes in renal blood flow after ureteral obstruction are reflected in flow velocities, as measured by duplex Doppler sonography. However, resistive indexes are not useful in assessing these changes in renal blood flow, and they do not correlate with the presence or absence of obstruction in this animal model.

The Value of Doppler Resistive Index and Peak Systolic Velocity in the Evaluation of Porcine Renal Obstruction

Purpose We evaluated the use of Doppler resistive indexes and systolic velocities as diagnostic tools in a partially obstructed animal model. Materials and Methods We studied 12 normal pigs by Doppler sonography, which served as control units. In 9 subjects partial ureteral obstruction was then created surgically, and 3 continued as controls. The presence or absence of obstruction was confirmed by ultrasound, antegrade nephrostography and intrapelvic pressure monitoring. Doppler parameters were measured 1 hour to 21 days postoperatively. Resistive index, and angle corrected peak and mean systolic velocities were measured bilaterally from samplings of interlobar and arcuate arteries. An average of 4 samplings per kidney was obtained at each session. Data from the control and obstruction groups were compared for statistical differences. Results In controls mean resistive index was 0.53, and peak and mean systolic velocities were 0.38 and 0.26 m. per second, respectively. In the subacute period after obstruction (defined as days 4 to 21) mean resistive index was 0.54, and peak and mean systolic velocities were 0.33 and 0.22 m. per second, respectively. Compared to control data there was no significant change in resistive index after obstruction (p = 0.6). However, peak and mean systolic velocities showed significant downward trends (p less than 0.05). Conclusions Known small sequential changes in renal blood flow after ureteral obstruction are reflected in flow velocities, as measured by duplex Doppler sonography. However, resistive indexes are not useful in assessing these changes in renal blood flow, and they do not correlate with the presence or absence of obstruction in this animal model.

The Abrams-Griffiths nomogram.

The treatment of benign prostatic hyperplasia and the definition of bladder-outlet obstruction has preoccupied urologists and researchers in recent years. Bladder-outlet obstruction can be defined only by pressure-flow measurement. Various methods of analysis of pressure-flow data have been proposed. The Abrams-Griffiths nomogram is an easy method of classifying these data to distinguish between the presence or absence of obstruction. Using the values for the maximal flow and the corresponding voiding detrusor pressure a point can be plotted on the nomogram that determines whether the bladder outlet is obstructed, unobstructed, or equivocally obstructed. For those that fall in the equivocal zone, further criteria for the mean slope of the pressure-flow plot and the minimal voiding detrusor pressure are used to determine whether there is obstruction or not. The nomogram's prognostic value in predicting the outcome of prostatectomy has been studied and found to be excellent. The Abrams-Griffiths nomogram can be modified by assigning an Abrams-Griffiths number to each set of pressure-flow data. This number is easy to calculate and use and gives a continuous variable that can be used to evaluate the effects of therapy. Although the Abrams-Griffiths nomogram and number are somewhat simplistic, none of the more complex methods of pressure-flow analysis have been shown to be better predictors of treatment outcome to date.

The Assessment of Obstruction in the Newborn with Unilateral Hydronephrosis by Measuring the Size of the Opposite Kidney

We measured the size of the normal kidney opposite a unilateral hydronephrotic kidney in infants to determine if compensatory changes occurred and could be used as a diagnostic test for defining or excluding obstruction. Comparison of subgroups of neonates with unilateral hydronephrosis or multicystic renal dysplasia to normal controls demonstrated that compensatory changes do occur in the normal kidney. Normal kidneys opposite obstructed hydronephrotic kidneys requiring surgery became larger than normal for age. Normal kidneys opposite nonob- structed poorly functioning hydronephrotic kidneys whose function rapidly improved were smaller than normal for age. These changes in renal growth by the normal newborn kidney reflect renal counterbalance, which is exaggerated in this age group and which may be used to corroborate rapid changes in renal function caused by the presence or absence of obstruction. By plotting serial measurements of normal renal length on a renal growth chart, the diagnosis of obstruction in newborn hydronephrosis can be facilitated and the clinical management of the patient improved.

Pseudodiverticulosis: unusual appearance for metastases to the ureter.

A rare pseudodiverticular pattern of metastatic malignancy to the ureter is reported along with pathologic findings at postmortem examination in three patients. There was no clinical or pathological obstruction. This pattern is due to malignancy-induced edema in the subepithelial connective tissues and muscularis propria causing displacement of these layers into the ureteral lumen resulting in an undulating epithelial surface. The epithelium itself is normal. Metastases to the ureter is uncommon in life unless associated with ureteral obstruction. Ureteral pseudodiverticulosis found in vivo in a nonobstructed patient with known metastatic malignancy is likely due to inflammatory causes and usually reversible with antibiotic and medical therapy. A patient with widespread malignancy showing nonreversibility of the ureteral pseudodiverticular pattern, even in the absence of obstruction, should be considered a candidate for impending obstruction and followed closely for ureteral stent placement.

Focal and segmental glomerulosclerosis in children with reflux nephropathy.

A histological review of 86 pediatric nephrectomy specimens from patients with vesicoureteric reflux (with or without apparent obstruction at the vesicoureteric junction) investigated the relationship between the presence and extent of focal and segmental glomerulosclerosis (FSGS) and coexisting renal hypoplasia and postnatally acquired cortical damage. FSGS was found in 18 patients, 9 of whom were less than 5 years old. There was no significant association between the presence (or grade) or absence of FSGS and age at nephrectomy, gender, presence or absence of obstruction, and severity of hypoplasia and/or postnatally acquired cortical loss. FSGS was absent from 18 hypoplastic kidneys without vesicoureteric reflux (although of relatively young age), 40 normally developed kidneys age-matched with the index population, and 72 nephrectomy specimens without vesicoureteric reflux (except in 2 known cases of focal segmental glomerulonephritis). Within the index population FSGS was significantly (P < .01) associated with hypertension, and hypertension was significantly associated with proteinuria (P < .001) but not with an abnormal contralateral kidney. There was no significant association between FSGS, proteinuria, and an abnormal contralateral kidney. Our results were unexpected when interpreted within a pathogenesis for FSGS of glomerular "hyperfiltration." They may, at least in the pediatric age group, indicate a possible role for other mechanisms in the development of FSGS.

MR cholangiography: clinical evaluation in 40 cases.

To determine the reliability and efficacy of magnetic resonance (MR) cholangiography in demonstrating the site and extent of stricture. In 40 patients with obstructive jaundice, three-dimensional MR cholangiography was performed with a sequence of mirrored fast imaging with steady-state precession and was compared with conventional cholangiography in 39 cases. The level of obstruction was determined by examining all imaging data available. Diagnostic MR cholangiograms were acquired in 39 patients; absence of obstruction was confirmed in three, and obstruction was seen in 36. The level of obstruction or absence of obstruction was accurately shown in 36 of 40 patients with MR cholangiography and in 37 of 39 patients with conventional cholangiography. The peripheral biliary tree was shown more completely with MR cholangiography than with endoscopic retrograde cholangiography in all 32 patients undergoing diagnostic studies with both modalities. Three-dimensional MR cholangiography shows particular promise for the assessment of complex strictures, in which conventional cholangiography carries a higher risk of sepsis, for planning optimal drainage before intervention.

Variability of mitral valve area by Gorlin formula after replacement by a caged-ball prosthesis

The hemodynamically effective orifice size for valve prostheses is calculated using the modified Gorlin formula 1,2 in the same way as for native valves. The comparison of hemodynamic performance of different types of biological and mechanical prostheses has relied on the values obtained in this way, 3,4 although there are obvious anatomic and flow pattern differences with the native valves. Caged-ball prostheses have a fixed, nondistensible, maximal anatomic orifice area and therefore are generally thought to have also a constant Gorlin mitral area. Considerable variability of the Gorlin mitral area in patients with these prostheses is difficult to explain in the absence of obstruction by tissue or thrombus and provokes questions in regard to the use of this calculation for assessment of the performance of the mechanical valves. It is conceivable that the mitral area calculated by the Gorlin formula is variable and dependent on flow in mechanical ball prostheses. We tested this hypothesis by determining the Gorlin mitral area of mechanical mitral prostheses at rest and after an increase in transvalvular flow.

Management of primary non-refluxing upper urinary tract dilation: an analysis of 219 pediatric patients

Antenatal ultrasound (US) examinations have changed the diagnostic approach to and management of malformative uropathies. Primary non-refluxing upper urinary tract (UUT) dilation is one of the urinary malformations that has undergone significant evolution in recent years. From January 1972 to June 1991, 219 children with primary non-refluxing megaureter (caliber more than 10 mm on radiologic examination) were admitted to our pediatric surgical department; 37 (16.8%) had bilateral UUT dilatation, an overall 256 renal units. The patients were divided into two groups: from January 1972 to June 1985 and from July 1985 to June 1991. In the latter period there was a considerable and progressive increase in admissions of infants in whom a prenatal US diagnosis of UUT dilation was made. A total of 186 renal units in 166 patients were operated upon; the success rate was 92%. A total of 70 megaureters (17 bilateral) in 53 patients were managed conservatively. The percentage of conservatively managed cases has increased in recent years; in almost all these patients the diagnosis was made antenatally. Our criteria for conservative management have been absence of obstruction and normal renal function as assessed by dynamic diuretic DTPA renography. These patients were carefully followed by serial US examinations and diuretic DTPA renograms. The follow-up of these 53 patients ranged from 6 months to 16 years with an average of 3 years 6 months; 47 have had a minimum follow-up of 18 months. In all these patients there has been progressive, spontaneous reduction or normalization of the dilation and no deterioration of renal function. In the authors opinion less than 50% of infants with grossly dilated non-refluxing megaureter diagnosed prenatally should be considered candidates for surgery, while the majority can be successfully managed without surgery.

Wheezing triggered by dorsal decubitus: pulmonary function changes.

In 23 subjects with chronic obstructive pulmonary disease (COPD) who wheezed when changing their position from sitting to dorsal decubitus (DD), we recorded lung volumes and flow volume loops in sitting (S1), DD and immediately after resuming sitting (S2). We found three main patterns of ventilatory changes associated with wheezing in DD: (1) acute obstruction (AO) in 14 subjects characterized by FEV1 > or = -10% and %FEV1/FVC > or = -3%; functional residual capacity or residual volume was increased, decreased or unchanged; (2) acute restriction (AR) in 7 subjects characterized by absence of obstruction spirographically and FVC and/or FRC > -10%; (3) indeterminate response (IR) in 2 subjects. Except for 3 subjects, the changes recorded in DD returned to baseline in S2. Both AO and AR responses in DD and their rapid resolution in S2 were reproducible (11 subjects). (1) in COPD, DD may trigger wheezing; (2) the physiologic changes during DD wheezing are reproducible, rapidly reversible when the sitting position is resumed and unlike those recorded during bronchoprovocation, heterogeneous.

Renal hypoplasia and postnatally acquired cortical loss in children with vesicoureteral reflux.

We reviewed histologically 86 nephrectomy specimens from patients with vesicoureteral reflux (with or without ureterovesical obstruction) to investigate the relationship between coexisting hypoplasia and postnatally acquired cortical damage. Hypoplasia was assessed independently of the acquired cortical loss using medullary ray glomerular counting. Severe hypoplasia (glomerular number < 25% of normal) was detected in 47 of 86 patients. These patients underwent nephrectomy at a significantly younger age than those with minimal or no hypoplasia (P < 0.01). There was no significant relationship between the severity of hypoplasia and the presence or absence of obstruction. Severe acquired cortical loss was found in 68 of 86 patients. There was no significant association between the severity of cortical loss and the presence or absence of obstruction, age at nephrectomy or degree of coexisting hypoplasia. The findings suggest a strong association of hypoplasia and vesicoureteral reflux. Therefore, early postnatal presentation with minimal renal function need not necessarily reflect a failure of management but rather a pre-existing limitation of renal capacity. Furthermore, in a significant proportion of fetuses with ultrasonographic evidence of urinary tract abnormality, renal pathology may be present prior to the time at which in utero surgical intervention may be considered.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting.

It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal micro-organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.

Patterns of anomalous pulmonary venous connection/drainage in hypoplastic left heart syndrome: Diagnostic role of Doppler color flow mapping and surgical implications

Differentiation between anomalous connection and anomalous drainage of the pulmonary veins in hypoplastic left heart syndrome is important before either the Norwood procedure or heart transplantation is performed. To determine the prevalence of echocardiographically detected anomalous connection or drainage, or both, of pulmonary veins in patients with this syndrome, preoperative two-dimensional echocardiographic and Doppler color flow mapping studies of 317 patients who underwent the stage I Norwood procedure were reviewed. The term “connection” was used to describe the precise anatomic attachment of the pulmonary veins and the term “drainage” to describe the physiologic end point of pulmonary venous flow.Twenty patients (6.3%) had anomalous connection or drainage, or both, of the pulmonary veins by preoperative echocardiographic and Doppler examination. The subcostal and suprasternal scans best showed the anatomic details of the pulmonary veins. All these patterns were confirmed intraoperatively and could be grouped as follows: 1) partial anomalous connection and drainage (two patients); 2) total anomalous connection and drainage (eight patients); 3) normal connection with total anomalous drainage (eight patients); and 4) normal connection with partial anomalous drainage (two patients). The advantage of adding Doppler color flow mapping to two-dimensional echocardiography and conventional Doppler study was clearly demonstrated in the detection of small accessory vertical veins, their course and the presence or absence of obstruction. Doppler color flow mapping was especially helpful in detecting anomalous drainage of the right pulmonary veins to the right of the superior attachment of the septum primum.