Transesophageal Doppler Color Flow Research Articles

症例 超高速CTと経食道心エコー・ドプラー法にて診断し得た左房内に瘤状拡張を呈する右冠動脈左房瘻の1 例

症例 超高速CTと経食道心エコー・ドプラー法にて診断し得た左房内に瘤状拡張を呈する右冠動脈左房瘻の1 例

Initial Experience With a Novel Percutaneous Left Atrial Appendage Exclusion Device in Patients With Atrial Fibrillation, Increased Stroke Risk, and Contraindications to Anticoagulation

Atrial fibrillation (AF) increases by fivefold a patient's risk for thromboembolic stroke. The main source of emboli in AF is the left atrial appendage (LAA). Therefore, LAA closure could reduce the risk for thromboembolic events in AF. The investigators report the first United States experience with a novel percutaneous LAA closure device, the Lariat snare device, and its outcomes in 21 patients with AF, CHADS2 scores ≥2, and contraindications to anticoagulation. The LAA was closed with a snare containing suture from within the pericardial space. The intraoperative success of the procedure was confirmed by left atrial angiography and transesophageal echocardiographic color Doppler flow. The effectiveness of the procedure was evaluated by follow-up transesophageal echocardiography. The incidence of periprocedural and short-term complications was assessed by reviewing medical records. Twenty patients (100%) had successful LAA exclusion that was preserved at 96 ± 77 days. No patient had a stroke during an average of 352 ± 143 days of follow-up. One patient had right ventricular perforation and tamponade that required surgical exploration and repair. Two patients required prolonged hospitalization: 1 because of pericardial effusion that required repeat pericardiocentesis and 1 because of noncardiac co-morbidities. Three patients developed pericarditis <1 month after the procedure, of whom 1had associated pericardial effusion that required drainage. In conclusion, percutaneous LAA exclusion can be achieved successfully and with an acceptable incidence of periprocedural and short-term complications. Further studies are needed to determine whether LAA exclusion lowers the long-term risk for thromboembolic events in patients with AF and contraindications to anticoagulation.

The Enemy of Good …

The Enemy of Good …

Comparison of Transthoracic and Intraoperative Transesophageal Color Flow Doppler Assessment of Mitral and Aortic Regurgitation

Background: We examined the agreement between transthoracic echocardiography (TTE) and intraoperative prepump transesophageal echocardiography (TEE) in the assessment of left-sided regurgitant lesions and echocardiographic variables associated with grading discrepancies. Methods: The TTE and prepump TEE studies of 54 patients undergoing aortic-valve replacement for aortic stenosis were reviewed. Agreement and correlation in assessment of aortic (AR) and mitral regurgitation (MR) severity were evaluated. Results: There was no significant difference between mean TTE and prepump TEE grading of MR (0.23 ± 0.19 vs. 0.21 ± 0.15 jet area/area of the left atrium, p = 0.49), but the correlation between the two methods was weak (r = 0.40, p = 0.003), with an exact agreement of 54%. Prepump TEE tended to grade AR as more severe (mean grade 1.43 ± 0.94 vs. 1.24 ± 0.75, p = 0.058). The correlation between the two methods in AR assessment was fair (r = 0.70, p = 0.0001) with an agreement of 59%. For MR and AR grading, no significant correlations between valvular regurgitation severity and blood pressure differences between preoperative TTE and prepump TEE were found. In 17% of cases, discrepancies in identifying severe mitral or aortic valve regurgitation could have affected patient management. Conclusions: There is modest agreement in MR and AR assessment between TTE and prepump TEE. Cardiologists, cardiac surgeons, and anesthesiologists must be aware of differences between these methods when using prepump TEE to guide intraoperative decisions.

Aortic dissection with aorto-left atrial fistula formation soon after aortic valve replacement: A lethal complication diagnosed by transthoracic and transesophageal echocardiography

Fistulas between the aorta and left atrium are a rare manifestation of aortic dissection and are infrequently diagnosed premortem. We report the case of a 70-year-old man who exhibited this condition soon after aortic valve replacement and eventually died from rapidly developing refractory congestive heart failure. The diagnosis was indicated by transthoracic echocardiography and was ultimately made with transesophageal echocardiography and color flow Doppler imaging. Transesophageal echocardiography is the procedure of choice for establishing the correct diagnosis and leading to prompt surgical repair of this lethal condition. (J Am Soc Echocardiogr 2002;15:1409-11.)

Aortic dissection with fistula to left atrium: Diagnosis by transesophageal echocardiography with successful repair

The aorta-atria fistula is an infrequent complication of aortic dissection, and it is rarely diagnosed before death. A 41-year-old man who 8 years previously had undergone prosthetic aortic valve replacement had an aortic dissection complicated by aorta-left atrial fistula. This patient had acute left heart failure associated with a systolic and diastolic murmur at the lower left sternal border suggesting an aortic prosthetic malfunction. The cardiac diagnosis was made with transesophageal echocardiography and Doppler color flow imaging; it was notable that the cardiac lesions were not detected by transthoracic echocardiography. On the basis of the echocardiographic findings, the patient underwent successful emergency replacement of the dissecting ascending aorta with closure of the aorta-left atrial fistula. Transesophageal echocardiography is the procedure of choice for defining this abnormality. In this case a prompt surgical repair consisting of replacement of the affected segment of the aorta with the prosthesis and closure of the fistula provided optimum resolution of the clinical situation.

Medida de la anchura del jet en su origen en la valoración de la regurgitación protésica mitral. Influencia de la disposición espacial del jet

The study was performed to test the influence of the jet spatial disposition on the correlation degree between the measurement of the jet width at its origin and the severity of mitral prosthetic regurgitation by transesophageal Doppler color flow imaging. In 165 patients with mitral valve prosthesis which were submitted for transesophageal echocardiography examination due to suspected prosthetic dysfunction, we studied 126 with pathological mitral regurgitation. On these patients, studies of jet spatial disposition, maximum width in its origin and severity quantification by means of maximum regurgitation area were performed. For the free jet group of patients (90), jet width at its origin correlated with maximal regurgitation area (r = 0.75); whereas for the wall jet group (36), the correlation degree was 0.59. We observed a relationship (p < 0.05) between severe mitral regurgitation assessed by maximal regurgitant jet size and jet width > or = 5 mm in both groups: the sensitivity and specificity of 72.7% and 95% respectively for free jets, and 70.7% and 64.4% for wall jets. The correlation between the area measurement and the width in its origin is better for free jets than for wall jets. A statistically significant relationship between the presence of severe mitral regurgitation and width in its origin > or = 5 mm could be observed, independently of the jet spatial disposition.

A case of cor triatriatum in an eighty-year-old man: Transesophageal echocardiographic observation of multiple defects

An 80-year-old man was admitted to the hospital because of recurrent syncope caused by sick sinus syndrome. Conventional transthoracic echocardiography showed a membranelike echo-dense structure across the left atrium. Subsequently we confirmed the diagnosis of cor triatriatum with multiple defects and shunt flows across the membrane by transesophageal color flow Doppler echocardiography. There were no other associated congenital anomalies. The patient recovered well and was discharged from the hospital after implantation of a permanent VVI pacemaker for sinus node dysfunction. No other cardiac intervention for the cor triatriatum was done except follow-up with echocardiography. About 1 year after discharge, he died of massive cerebral infarction. The cardiac autopsy findings were compatible with the transesophageal echocardiogram. This is a rare case of uncorrected cor triatriatum in an elderly patient. (J Am Soc Echocardiogr 1997;10:185-88.)

Biplane transesophageal color-flow doppler imaging in assessing severity of mitral regurgitation: Influence of hemodynamic circumstances and mechanism of regurgitation

To determine the value of biplane transesophageal echocardiography in the assessment of severity of mitral regurgitation compared with left ventricular angiography. Prospective study of consecutive patients. Two university hospitals, one community hospital. Thirty-seven patients with angiographically proven mitral regurgitation. Transthoracic and biplane transesophageal echocardiography. In 19 patients, transesophageal echocardiography was performed during general anesthesia. The largest mitral regurgitation jet area and longest jet as obtained with Doppler color-flow mapping from transthoracic and biplane transesophageal echocardiography and pulsed-Doppler pulmonary venous flow characteristics. Sensitivity and 100-minus-specificity were plotted to constitute receiver operating characteristics (ROC) curves. Areas under ROC curve for transverse, longitudinal, and biplane jet area were 0.77, 0.75, and 0.81, and for jet length, 0.82, 0.84, and 0.88, respectively; this was for biplane jet area in conscious patients; 0.99 compared with 0.72 in anesthetized patients (p < 0.05). Biplane measurements identified severe mitral regurgitation slightly more reliably than the transverse or longitudinal measurements alone. In conscious patients, jet area was an excellent test for estimating severity of mitral regurgitation. In anesthetized patients, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted angiographic severity of mitral regurgitation. In anesthetized patients, the optimal cut-off value for jet area to distinguish between moderate and severe mitral regurgitation was lower than in conscious patients. In the total population, regardless of hemodynamic and technical variations, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted the severity of mitral regurgitation.

Ventricular pacing: A cause of reversible severe mitral regurgitation

Transesophageal color flow Doppler assessment of degree of mitral valve regurgitation during open heart surgery is increasingly used as an on-line guide for surgical intervention. Factors that influence the degree ofmitral regurgitation, such as alteration in preload and afterload fluctuations, are routinely accounted for in the assessment of the mechanisms and severity of mitral regurgitation. The case reported here underscores the magnitude ofventricular pacemaker-related mitral regurgitation, which is not readily anticipated in the intraoperative evaluation of mitral regurgitation. A 71-year-old woman (166 cm; 89 kg) with a history of valvular heart disease was scheduled for coronary artery bypass grafting and mitral valve repair or replacement. She had intermittent chest pain during dally activities and progressive shortness of breath. She had a history of systemic hypertension and a type II diabetes but no previous myocardial infarction. She also had a pacemaker of unknown model (VVI mode) with a ventricular lead implanted in 1989 (in Russia) because of syncope. Syncopal episodes did not reoccur after pacemaker implantation. Preoperative medications included captopril, digoxin, furosemide, potassium, and insulin. An electrocardiogram showed sinus rhythm, complete atrioventricular block, and a ventricularly paced rhythm. Cardiac catheterization revealed a cardiac output of 2.8 L/min, right atrial pressure of 26 mmHg, pulmonary artery pressures 78/34 mmHg and pulmonary capillary wedge pressure of 42 mm Hg. Coronary angiography demonstrated luminal narrowing of the left anterior descending coronary artery and left circumflex coronary artery and total midvessel occlusion of the right coronary artery. Left ventricular ejection fraction was 30%. Mitral regurgitation was classified as severe. Immediately after contrast left ventriculography, pulmonary edema developed. Transthoracic echocardiography

Fatal Paradoxical Cerebral Embolization during Bilateral Knee Arthroplasty

NEUROLOGIC complications of knee and hip arthroplasty range from mild delirium to coma and death. 1 The pathogenesis and operative events that lead to acute neurologic injury during joint arthroplasty are not completely understood but are thought to be a consequence of the fat embolism syndrome. 1-3 The syndrome often is accompanied by pulmonary, circulatory, hematologic, and neurologic derangement. According to one hypothesis, procedures that increase intramedullary pressure promote the entry of marrow fat or other debris into the central venous circulation through the medullary veins. 3,4 These emboli accumulate within the lung, causing increases in the pulmonary vascular resistance and pulmonary artery pressure. The consequent increase in right atrial and pulmonary artery pressures favor right-to-left shunt flow via a patent foramen ovale (atrial septal defect) or intrapulmonary shunt increasing the risk of paradoxical cerebral embolization. In the following report, intraoperative hemodynamic monitoring, carotid artery ultrasonography, and electroencephalography (EEG) were used to detect the sequence of operative events that led to paradoxical cerebral embolization causing fatal neurologic injury during bilateral knee arthroplasty.

712-3 Predictive Value of Intraoperative Transesophageal Color Doppler Flow Imaging During Mitral Valve Repair

To assess the predictive value of Residual Mitral Regurgitation (RMR) after valve repair for severe MR, we performed transesophageal color (TEE) Doppler flow imaging intraoperatively, after 3 months and 1 year at similar loading conditions in a prospective study of 178 patients (pts). Intraoperative grading of RMR on a 4 point scale in 159 pts showed no RMR in 77 pts, grade I in 45, grade II in 29 and grade III in 8 pts. Univariate analysis of preoperative and surgical characteristics showed that a history of chronic lung disease (Relative Risk (RR) 1.88 * ), increased leaflet mobility (RR 1.50 * ) and normal leaflet mobility (RR 1.51 * ) at TEE, coronary artery disease (RR 1.38), and a Duran annular ring (RR 1.97 * ) were associated with an increased risk of intraoperative RMR. In the 8 pts with grade III RMR, immediate valve replacement (VR) was advised and performed in all but one pt, who underwent VR 2 months later. After 3 months, increase of RMR (of at least one grade) was present in 63%, reduction in 8% and no change in 29% of the pts. Compared to three months, no increase or decrease of RMR was seen at 1 year. During the one year follow-up VR was performed in another 7 pts; all but one pt (no RMR) with intraoperative RMR grade I-II. Intraoperative RMR grade I-II was associated with a higher risk of VR (RR 6.51 * ) and thromboembolic events (RR 6.51 * ) in relation to absence of RMR, during this one year follow-up. (1) RMR increases in most pts within 3 months postoperatively and is stable thereafter. (2) Intraoperative RMR is associated with a substantial reoperation rate and risk of thromboembolic events. 131 RMR S grade II does not exclude a redo during one year follow-up. * = P &lt; 0.05.

Intraoperative Evaluation of Valvular Function Using Transesophageal and Epicardial Echocardiography

Objectives and Background. Intraoperative transesophageal echocardiography (TEE) and epicardial echocardiography (ECE) offer the opportunity to assess valvular function before and after cardiopulmonary bypass. Valve reconstruction offers many advantages over prosthetic valve replacement. The purpose of this study was to assess the utility of TEE and ECE during the surgical treatment of mitral, aortic, and tricuspid valve diseases. Methods. Intraoperative echocardiography was performed in 50 patients undergoing surgery for valvular heart disease. In 21 recent patients, concurrent TEE with Doppler color flow mapping was performed. The severity of mitral stenosis (MS) was assessed by the intraoperative echocardiographic mitral valve area (MVA) and morphologic findings of the mitral apparatus. The severity of mitral regurgitation (MR) was visually graded on a semiquantitative scale of 0-4+ according to the ratio of the maximal regurgitant jet area to the left atrial area (JA/LAA) indicated by transesophageal and epicardial Doppler color flow mapping. The severity of aortic regurgitation (AR) was similarly graded on a scale of 0-4+ according to the ratio of the maximal regurgitant jet area to the left ventricular area (JA/LVA) in end diastole. The severity of tricuspid regurgitation (TR) was similarly graded on a scale of 0-4+ according to the ratio of the maximal regurgitant jet area to the right atrial area (JA/RAA). These criteria for the severity of valvular regurgitation were compared with conventional nonsimultaneous angiographic criteria and operative criteria according to fluid injection into the flaccid ventricles. Tricuspid annulus diameter during systole was measured before and after tricuspid annuloplasty. Results. There was a good correlation (r = 0.78, P &lt; 0.001) between intraoperative two-dimensional echocardiographic MVA and operative MVA by direct measurement. Epicardial two-dimensional MVA and transthoracic MVA measured by mitral pressure half time method were similar (r = 0.88, P &lt; 0.005). Mitral commissurotomy was performed in 4 (27%) of 15 patients with MS. Comparison of mitral JA/LAA measurements as assessed by epicardial and transesophageal color flow mapping revealed an excellent correlation between the techniques (r = 0.94, P &lt; 0.001). Intraoperative TEE and ECE assessment of the severity of MR showed good agreement with preoperative angiographic gradings and with operative gradings. Mitral valve repair was performed in 10 (48%) of 21 patients with MR. Postrepair intraoperative Doppler studies showed satisfactory surgical results in all. No significant residual MR (grade &gt; 2+) was identified in this series. Comparison of aortic JA/LVA measurements as assessed by epicardial and transesophageal color flow mapping showed an excellent correlation between the techniques (r = 0.96, P &lt; 0.001). Intraoperative echocardiographic assessment of the severity of AR showed good correlation with preoperative angiographic assessment. Aortic valve repair was performed in 1 (11%) of 9 patients with AR. There was a good correlation (r = 0.77, P &lt; 0.005) between tricuspid JA/RAA ratios as assessed by epicardial color flow mapping and operative gradings for TR. Tricuspid annulus diameter during systole measured by epicardial technique was significantly (P &lt; 0.001) decreased after tricuspid annuloplasty. Conclusions. Both intraoperative TEE and ECE are useful for the evaluation of valvular function in the mitral, aortic, and tricuspid positions. Doppler color flow mapping is a reliable method of assessing valve regurgitation. Combined intraoperative use of transesophageal and epicardial techniques is recommended.

Anomalous Origin of the Right Coronary Artery from the Pulmonary Trunk:

Anomalous origin of the right coronary artery from the pulmonary trunk is a rare congenital anomaly, which may be detected noninvasively by echocardiography. We report a case of definitive diagnosis of this anomaly using transesophageal echocardiography and Doppler color flow mapping in a 36‐year‐old woman. Of special interest is the fact that the most prominent echocardiographic feature was turbulent flow in the region of the interventricular septum streaming into the dilated RCA.

Assessment of mitral regurgitation by biplane transesophageal color Doppler flow mapping

To test the role of recently developed biplane transesophageal color Doppler echocardiography in the assessement of severity of mitral regurgitation, we examined 51 patients undergoing cardiac catheterization and left ventriculography. Transesophageal color Doppler flow imaging detected mitral regurgitation in all 32 patients proved to have this lesion. In 10 of 16 patients without mitral regurgitation by angiography, mitral regurgitation signals were detected by transesophageal color Doppler flow imaging. Thus, the sensitivity and specificity of transesophageal color Doppler echocardiography for the detection of mitral regurgitation were 100% and 38%, respectively. There was some correlation between the regurgitation jet area from the longitudinal plane and angiographic grading. An improved angiographic correlation was achieved with the regurgitant jet area from the transverse plane. The best correlation with angiography was obtained when the maximum regurgitant jet area from two planes (the greater of the two measurements, each from a different plane) was considered. There was a significant difference in the maximum regurgitant jet area between none and mild ( p < 0.01), mild and moderate ( p < 0.001), and moderate and severe ( p < 0.01) mitral regurgitation. The maximum regurgitation jet area of less than 1.5 cm 2 predicted the angiographic grading as none with a sensitivity and specificity of 88% and 94%, respectively. The maximum regurgitant jet of between 1.5 and 4 cm 2 predicted the angiographic grading as mild with a sensitivity and specificity of 82% and 95%, respectively. The maximum jet area of between 4 and 7 cm 2 predicted moderate mitral regurgitation by angiography with a sensitivity and specificity of 100% and 95%, respectively, whereas the maximum jet area of more than 7 cm 2 predicted severe mitral regurgitation with a sensitivity and specificity of 83% and 100%, respectively. Thus, biplane transesophageal color Doppler flow imaging is a useful technique that not only is highly sensitive in identification of mitral regurgitation but also provides an accurate estimation of its severity.

Ruptured Sinus of Valsalva Detected by Biplane Transesophageal Echocardiography

This case illustrates the importance of biplane transesophageal echocardiography and color flow Doppler imaging in detecting a sinus of Valsalva aneurysm and fistula. It also demonstrates how endocarditis can be a complication of this condition.

Transesophageal Color Doppler Flow Imaging in the Evaluation of Prosthetic Cardiac Valves

Transesophageal Color Doppler Flow Imaging in the Evaluation of Prosthetic Cardiac Valves

The Diagnosis of Thoracic Aortic Dissection by Noninvasive Imaging Procedures

Background and Methods This study was designed to assess the safety and reliability of new noninvasive imaging methods as compared with aortography in the diagnosis of dissection of the thoracic aorta. One hundred ten patients with clinically suspected aortic dissection followed a diagnostic protocol that included transthoracic and transesophageal color-flow Doppler echocardiography (TTE and TEE), contrast-enhanced x-ray computed tomography (CT), and magnetic resonance imaging (MRI). Imaging results were compared in a blinded fashion and validated independently against intraoperative findings in 62 patients, autopsy findings in 7, and the results of contrast angiography in 64. Results The sensitivities of MRI, TEE and x-ray CT for detecting dissection were similar, at 98.3, 97.7, and 93.8 percent, respectively; TTE had a sensitivity of only 59.3 percent (P<0.005). The specificities of both TTE (83.0 percent) and TEE (76.9 percent) were lower than those of x-ray CT (87.1 percent) and MRI (97.8 percent; P<0...

Magnetic resonance imaging: computed tomography, and transesophageal color-flow Doppler echocardiography were sensitive and specific for diagnosing thoracic aortic dissection

Source Citation Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med. 1993 Jan 7;328:1-9.

The relationship between “Normal” transesophageal color-flow doppler-defined tricuspid regurgitation and thermodilution right ventricular ejection fraction measurements

Twenty coronary artery revascularization patients, aged 58 ± 15 years, were studied intraoperatively to define the impact of Doppler-defined tricuspid regurgitation on measurement of thermodilution right ventricular ejection fraction (50 msec response pulmonary artery catheter). Right ventricular function was also estimated using a measurement technique independent of flow patterns across the tricuspid valve (transesophageal two-dimensional echocardiographic 5.0 MHz phased-array transducer). Measurements included transverse plane long- and short-axis planimetered area ratio, respectively, and tricuspid annular plane systolic excursion ratio (ratio = end-diastolic minus end-systolic value divided by end-diastolic value). Data were expressed as thermodilution-echocardiographic gradients, ie, thermodilution ejection fraction minus long-axis planimetered area ratio, short-axis planimetered area ratio, and tricuspid annular plane systolic excursion ratio, respectively. Tricuspid regurgitation was quantified by color-flow Doppler perimetry of maximal regurgitation jet area and analysis of transduced right atrial pressure waveform. Doppler estimates were expressed as absolute values and as a function of corresponding atrial area (tricuspid regurgitation index = planimetered jet area divided by right atrial area). Data were obtained following endotracheal intubation, sternotomy, pericardiotomy, cardiopulmonary bypass, and chest closure. Data were evaluated by regression analysis, with separate analyses performed for each time period. Profiles were unassociated with right atrial pressure waveform abnormalities. There was no significant relationship between thermodilution ejection fraction variance values and tricuspid regurgitation jet area or regurgitation index, respectively. In each measurement period, thermodilution-echocardiographic gradients were also unrelated to the tricuspid regurgitation estimates. These findings suggest that transesophageal color-flow Doppler evidence of tricuspid regurgitation, without atrial pressure waveform abnormalities, does not invalidate thermodilution right ventricular ejection fraction data.