Suprasternal Echocardiography Research Articles

Suprasternal echocardiography: an essential incidence in emergency room

Suprasternal echocardiography: an essential incidence in emergency room

The utility of limited trans-thoracic echocardiography in the stratification of pulse pressure variation: A feasibility study in major open abdominal surgery.

Background and Aim:Limitation in use of pulse pressure variation (PPV) in predicting fluid responsiveness (FR) in hypotensive patients is encountered when values are in the “gray zone” (8–13%). Dynamic arterial elastance (Eadyn= PPV/SVV) can be used in such situations to predict arterial pressure response to volume expansion (VE). In our study, we used respiratory variation of ascending aorta velocity time integral (AoVTI) calculated from suprasternal window as a surrogate of stroke volume variation (SVV). Fluids/vasopressors were administered to hypotensive patients intraoperatively based on value of Eadyn. Aim was to assess feasibility and utility of suprasternal echocardiography in the above-mentioned subset of patients.Materials and Methods:Hemodynamic data were monitored and respiratory variation in AoVTI was recorded using suprasternal echocardiography at all time points when patients developed hypotension (systolic blood pressure <90 mm Hg/<20% of baseline for 5 min) and at randomly selected time intervals when hemodynamic stability was maintained. VE with 250 ml of Ringer lactate (RL) was done in hypotensive patients with PPV value of 8–13% and Eadyn>0.9. Increase of >15% in AoVTI after VE defined “fluid responsiveness.”Results:Twenty-eight patients were enrolled, but three were excluded in view of left ventricular systolic dysfunction detected during preinduction echocardiography. Hemodynamic and echocardiographic data were recorded at 538 observation points in 25 adults. Hypotension occurred in 247 data sets, and in 168 data sets, value of PPV was 8–13%. VE was carried out in only those 131 data sets in which the value of Eadyn was >0.9. Area under the curve (AUC) for VE as an intervention in the indeterminate (PPV 8–13%) group was 0.574 (0.49–0.68, 95% CI, P < 0.049), and in the observation set with PPV >13, the AUC value was 0.7 (0.59–0.98, 95% CI, P < 0.01).Conclusions:Echocardiography using the suprasternal window in the operating room during abdominal surgery is feasible, but the utility of Eadyn in stratification of patients with PPV 8–13% is inconclusive.

Suprasternal echocardiography and aortic dissection

Suprasternal echocardiography and aortic dissection

Suprasternal echocardiography and aortic dissection

Suprasternal echocardiography and aortic dissection

Suprasternal notch echocardiography determination of right pulmonary artery lesions

Objective To evaluate the value of suprasternal long axis view in echocardiography for right pulmonary artery (RPA) lesions.Methods Echocardiography was performed in 31 patients with clinical suspicion of pulmonary vascular disease.Through suprasternal long axis view,RPA,right superior pulmonary artery and right inferior pulmonary artery were identified,and the vessel wall,intraluminal echoes,and location of the lesion were obtained.Blood flow in pulmonary artery was detected with color Doppler flow imaging.The results of echocardiography were compared with those of computer tomography of pulmonary angiography (CTPA) and clinical diagnosis.Results With suprasternal notch echocardiography,RPA lesions were identified in 27 patients.H owever,RPA could not be clearly identified in four patients.There were 22 patients with moderate or low echo mass in RPA,and five patients with intimal thickening and artery stenosis/obliteration.In the 27 patients with detected lesions,20 lesions were located in RPA,seven lesions were located in distal RPA or its branches.Among the results obtained with echocardiography,25 were in accordance with CT results,6 were not in accordance with CT results.Conclusions The suprasternal long axis view of RPA can be an important alternative imaging modality in identification of pulmonary vascular diseases. Key words: Echocardiography; Pulmonary artery; Suprasternal notch view; Pulmonary vascular disease

Validity of echocardiography in non-invasive diagnosis of acute pulmonary embolism (author's transl)

M-mode echocardiography was used in 66 consecutive patients with a clinical suspicion of acute pulmonary embolism. It could be ascertained in 30 patients using pulmonary angiography and in 19 using lung scintigraphy. When pulmonary embolism had effects on haemodynamics, an end-diastolically enlarged right ventricle, a diminished left ventricle, reduced closing velocity of the anterior mitral valve cusp and paradox septum movement were seen in precordial echocardiography (n = 18). The relation of end-diastolic diameter of the right ventricle to the left ventricle correlated with the angiographic severity of pulmonary embolism (r = 0.78). In patients with acute pulmonary embolism and pulmonary hypertension a significant enlargement of the right pulmonary artery was found in the suprasternal beam direction when compared with patients without pulmonary hypertension (14.7 +/- 2.2 mm/m2 body surface vs 11.0 +/- 1.2 mm/m2 body surface; P less than 0.01). The index width of the right pulmonary artery of all patients correlated with the mean pulmonary artery pressure (r = 0.84). In one patient a thrombus in the right pulmonary artery could be demonstrated by suprasternal echocardiography. Haemodynamically effective pulmonary embolisations in patients without cardiopulmonary history can be diagnosed using echocardiography.

Double Aortic Arch, Tetralogy of Fallot with Pulmonary Atresia and Atrioventricular Septal Defect

A double aortic arch is usually an isolated abnormality. We describe a case with a previously undescribed combination of tetralogy of Fallot with pulmonary atresia, complete atrioventricular septal defect, and left patent arterial duct in association with a double aortic arch. A complete diagnosis was made by echocardiography. Meticulous suprasternal echocardiography must be employed to avoid overlooking an unsuspected aortic arch abnormality.

Altered Hemodynamic Response to Isosorbide Dinitrate in Essential Hypertension

Relaxation produced by nitrates on venous, arteriolar, and large arterial vessels is well known but has never been studied in human hypertensive aortas studied in vivo. In this investigation, the effects of acute oral administration of 20 mg of isosorbide dinitrate were evaluated in 12 patients with sustained essential hypertension and nine normotensives of the same age. Noninvasive measurements of systolic, diastolic, and mean arterial pressure, carotid-femoral pulse wave velocity and aortic-arch diastolic diameter using suprasternal echocardiography were determined before and 3 hours after drug administration. In normal subjects, isosorbid dinitrate significantly decreased systolic blood pressure and pulse pressure but did not affect diastolic and mean arterial pressure. In contrast, in hypertensives, the same dosage of isosorbid dinitrate decreased together systolic, diastolic mean, and pulse pressure. In both populations, pulse wave velocity decreased significantly whereas aortic arch diastolic diameter increased markedly. The increase was observed mainly in normal subjects. The study provided evidence that (1) both in normal subjects and hypertensives, isosorbide dinitrate caused an increase in aortic diameter together with an increase in arterial distensibility; and (2) the changes in mean arterial pressure were significant only in hypertensives, indicating that the altered vasodilator response in essential hypertension is not endothelium-mediated.

Coarctation of the Aorta: Quantitative Analysis by Transesophageal Echocardiography

SummaryTransesophageal echocardiography and standard two‐dimensional echocardiography were performed in 15 patients with suspected coarctation of the aorta. Aortic diameters and crosssectional areas were determined by means of TEE and compared with clinical findings and catheterization data. The isthmus of the aorta could be imaged in all patients using TEE, but in only seven patients using standard suprasternal echocardiography. Compared with controls, aortic diameters were narrowed in 9 of 15 patients, and cross‐sectional areas were reduced in 13 of 15. There was a satisfactory correlation between TEE data and angiographic and hemodynamic data. TEE is a promising method of a diagnosing and quantifying coarctation of the aorta, and is more sensitive than conventional two‐dimensional and Doppler echocardiography.

Abnormal position of the brachiocephalic vein

With the advent of suprasternal echocardiography, both normal and abnormal systemic venous drainage can be delineated noninvasively. 1,2 Persistence of the left superior caval vein (SCV) is readily identified and can be differentiated from a left vertical vein in patients with anomalous pulmonary venous connection. 2,3 Similarly, the absence of a bridging brachiocephalic vein (innominate vein) in the presence of a left SCV is reliably recognized. 1 The left brachiocephalic vein invariably runs in front of the aorta to its point of communication with the right-sided brachiocephalic vein. Rarely, the left brachiocephalic vein has a subaortic course running beneath the aortic arch. 4–6 This study describes cross-sectional echocardiographic features in 7 patients in whom the left brachiocephalic vein ran beneath the aortic arch before communicating with the right brachiocephalic vein. In the normal patient, in the suprasternal long-axis projection, the left brachiocephalic vein can be seen at its point of communication with the right to form the SCV (Fig. 1a). With anticlockwise rotation the azygous vein can be visualized, just above the SCV right atrial junction (Fig. 1b).

Suprasternal echocardiography-angiographic correlations in the young.

Twenty five young patients were studied by M-mode echocardiography from the suprasternal notch. The findings were compared with the angiographic findings. Good visualisation of the aorta, and right pulmonary artery was obtained in all patients by suprasternal echocardiography. while the left atrium was well visualised in twenty patients. Strong correlation was found between the ultrasonic and angiographic lumen measurements of the aorta, right pulmonary artery and the left atrium in the superoinferior axis. We conclude that suprasternal M-mode echocardiography is a useful and reliable noninvasive method of studying the great vessels and the left atrium.

Invasive and noninvasive assessment of pulmonic regurgitation: clinical, angiographic, phonocardiographic, echocardiographic, and Doppler ultrasound correlations.

Three patients with pulmonic regurgitation and no evidence of pulmonary hypertension were investigated. These patients had low pitched diastolic murmurs which increased on inspiration, evidence of connective tissue disease as manifested by lax joints and hyperextensible skin, and marked hilar dance which extended up to the peripheral vessels. Suprasternal echocardiography revealed dilatation and increased systolic expansion of the right pulmonary artery (RPA) (25% and 28%, respectively) in two patients; the third patient had a normal RPA dimension in diastole and a marked increase in diameter (88%) in systole. Thus, these three patients demonstrated hyperdistensibility of the RPA. The spectral signal from the pulsed doppler echocardiograph showed evidence of turbulent blood flow in diastole (wide dispersion of the dots) in the right ventricular outflow tract in all three patients. This pattern was indicative of pulmonic regurgitation. In summary, the combined use of echocardiography and Doppler ultrasound is useful in the evaluation of patients with pulmonic regurgitation.

Estimation of pulmonary arterial pressure by measuring the size of the right pulmonary artery in the suprasternal echocardiogram.

We studied 175 patients within 24 hr before cardiac catheterization with suprasternal echocardiography to evaluate whether pulmonary arterial hypertension can be derived by measuring the size of the right pulmonary artery. Group I consisted of 103 patients without pulmonary arterial hypertension (enddiastolic less than or equal to 12 mm Hg; mean pressure less than 20 mm Hg) and group II consisted of 72 patients with pulmonary arterial hypertension. The right pulmonary artery could be imaged in 91.2% of the patients studied. The size of the right pulmonary artery at the end of diastole in group I measured 17.9 +/- 0.2 mm (mean +/- SEM) and correlated best to the body surface area in this group (r = 0.63; p less than 0.001). The respective index size amounted to 9.9 +/- 0.1 mm/m2, and was different from that in group II with 14.1 +/- 0.4 mm/m2 (p less than 0.001). The systolic percent expansion of the right pulmonary artery in group I was 21.2 +/- 0.8% and in group II 9.2 +/- 0.8% (p less than 0.001). The index size of the right pulmonary artery for both groups correlated best to the pulmonary enddiastolic pressure (r = 0.82; p less than 0.001). The systolic per cent expansion showed a negative log linear relationship to the pulmonary enddiastolic pressure (r = 0.67; p less than 0.001). Thus, pulmonary arterial pressure can be derived by measuring the size of right pulmonary artery with suprasternal echocardiography.

Echocardiographic Control of Swan-Ganz Catheters

In 68 patients, subxiphoidal, percordial, and suprasternal echocardiography was used to trace the Swan-Ganz catheter during its passage to the pulmonary artery and to localize its position. The localization of the catheter could be exactly identified in 62 out of 68 patients in whom we managed to obtain a suprasternal echocardiogram. In one patient, the catheter was found (by chest x-ray film) in the left pulmonary artery (LPA) and was regarded to be in the right pulmonary artery according to suprasternal echocardiography. In two patients, the catheter could not be localized by suprasternal echocardiography although it was positioned in the LPA. In three patients, the catheters could not be advanced to the pulmonary circulation and were visualized within the right ventricular cavity by precordial and subxihpoid echocardiogarphy. Thus, echocardiography, particularly the suprasternal approach, has proven a safe, reliable, and easy way for position control of Swan-Ganz catheters.

Echocardiography in assessing acute pulmonary hypertension due to pulmonary embolism

Eighteen patients with acute pulmonary embolism were studied with right heart catheterization and M mode echocardiography. No patient had evidence of preexisting cardiopulmonary disease; pulmonary embolism was documented with pulmonary angiography. The mean pulmonary arterial pressure correlated with the angiographic severity index of embolic obstruction (r = 0.61, p <0.001). The size of the right pulmonary artery was evaluated with suprasternal echocardiography and corrected for body surface area (index size). In patients with elevated mean pulmonary arterial pressure (greater than 20 mm Hg) the index size was increased (mean ± standard error of the mean 15.1 ± 0.6 mm/m2, p <0.001) over values in a control group of 25 normal subjects with a mean normal pulmonary arterial pressure (9.6 ± 0.9 mm/m2) and in 5 patients with acute pulmonary embolism and a mean normal pulmonary arterial pressure (10.9 ± 0.4 mm/m2). For all measurements the index size of the right pulmonary artery correlated with the mean pulmonary arterial pressure (r = 0.84, p <0.001). Precordial echocardiography revealed that the right ventricular dimension was increased in 13 of 16 patients and the left ventricular dimension decreased in 10 of 15 patients. Thus, the right ventricular end-diastolic/left ventricular end-diastolic ratio was above normal in 14 of 15 patients when compared with the value in 25 normal subjects. This ratio correlated well with the angiographic severity index of embolic obstruction (r = 0.83, p <0.001). The E–F slope of the anterior mitral leaflet was reduced in 12 of 16 patients. In eight patients an abnormal pattern of septal motion was observed, exhibiting a posterior motion during diastole. Suprasternal and precordial echocardiography seems to be a valuable noninvasive technique in the assessment of acute pulmonary hypertension in patients with acute pulmonary embolism with no known prior cardio-pulmonary disorder. Eighteen patients with acute pulmonary embolism were studied with right heart catheterization and M mode echocardiography. No patient had evidence of preexisting cardiopulmonary disease; pulmonary embolism was documented with pulmonary angiography. The mean pulmonary arterial pressure correlated with the angiographic severity index of embolic obstruction (r = 0.61, p <0.001). The size of the right pulmonary artery was evaluated with suprasternal echocardiography and corrected for body surface area (index size). In patients with elevated mean pulmonary arterial pressure (greater than 20 mm Hg) the index size was increased (mean ± standard error of the mean 15.1 ± 0.6 mm/m2, p <0.001) over values in a control group of 25 normal subjects with a mean normal pulmonary arterial pressure (9.6 ± 0.9 mm/m2) and in 5 patients with acute pulmonary embolism and a mean normal pulmonary arterial pressure (10.9 ± 0.4 mm/m2). For all measurements the index size of the right pulmonary artery correlated with the mean pulmonary arterial pressure (r = 0.84, p <0.001). Precordial echocardiography revealed that the right ventricular dimension was increased in 13 of 16 patients and the left ventricular dimension decreased in 10 of 15 patients. Thus, the right ventricular end-diastolic/left ventricular end-diastolic ratio was above normal in 14 of 15 patients when compared with the value in 25 normal subjects. This ratio correlated well with the angiographic severity index of embolic obstruction (r = 0.83, p <0.001). The E–F slope of the anterior mitral leaflet was reduced in 12 of 16 patients. In eight patients an abnormal pattern of septal motion was observed, exhibiting a posterior motion during diastole. Suprasternal and precordial echocardiography seems to be a valuable noninvasive technique in the assessment of acute pulmonary hypertension in patients with acute pulmonary embolism with no known prior cardio-pulmonary disorder.

Scanning suprasternal echocardiography.

Scanning suprasternal echocardiography was performed in 280 patients with a variety of cardiac anomalies. By using the special suprasternal transducer on the suprasternal notch, the aortic arch, right pulmonary artery, and left atrium were recorded superoinferiorly. From this reference position various scanning techniques were made to record the main pulmonary artery, pulmonary valve, ascending aorta, aortic valve, and distal aortic arch, wherever possible. These scans made it possible to assess (a) the integrity and size of right pulmonary artery and main pulmonary artery in pulmonary atresia, stenosis of origin of right pulmonary artery, pulmonary artery banding, kinked Waterston anastomosis, and aneurysm of pulmonary artery; (b) relative positions of aortic valve and pulmonary valve in malposition complexes; (c) the position and size of the aortic arch in tetralogy of Fallot and aortic coarctation. Measurements of the left atrium made by suprasternal echocardiography were consistently larger than those made by praecordial echocardiography. Changes in relative sizes of aortic arch, right pulmonary artery, main pulmonary artery, and left atrium were also documented in the various cardiac anomalies. The atrial baffle after Mustard repair for d-transposition of the great arteries and the atrial membrane in cor triatriatum were also demonstrated. The introduction of scanning techniques has thus widened the scope of suprasternal echocardiography.

Diagnosis of dissecting aortic aneurysm with suprasternal echocardiography

A 33 year old woman with Marfan's syndrome and aortic root dissection was studied with precordial and suprasternal echocardiography. The precordial approach revealed some typical features of aortic root dissection. With suprasternal echocardiography it was possible to visualize the characteristic diagnostic feature of this disease: within the aortic lumen an m-shaped pattern—the aortic intimal flap—moving downward to the posterior aortic wall during systole. The diagnosis was confirmed with aortic cineangiography and intraoperative findings. Thus, Suprasternal echocardiography can be a useful method of detecting aortic root dissection, especially in patients with aortic arch dissection alone.