Video Loops Research Articles

Quantitative evaluation of the echo intensity of the median nerve and flexor muscles of the forearm in the young and the elderly

Musculoskeletal structures often appear brighter on imaging in the elderly, which makes it difficult to accurately delineate a peripheral nerve during ultrasound-guided regional anaesthetic procedures. The echo intensity of skeletal muscles is significantly increased in the elderly. However, there are no data comparing the echo intensity of peripheral nerves in the young and the elderly, which this study was designed to evaluate. 13 healthy, young volunteers (aged <30 years) and 11 elderly patients (aged >60 years) who were scheduled to undergo orthopaedic lower limb surgery were recruited. The settings of the ultrasound system were standardised and a high-frequency linear array transducer was used for the scan. A transverse scan of the median nerve (MN) and the flexor muscles (FMs) at the left mid-forearm was performed and three video loops of the ultrasound scan were recorded for each subject. Still images were captured from the video loops and normalised. Computer-assisted greyscale analysis was then performed on these images to determine the echo intensity of the MN and the FMs of the forearm. The echo intensity of the MN and FMs of the mid-forearm was significantly increased in the elderly (p<0.005). There was also a reduction in contrast between the MN and the adjoining FM in the elderly (p = 0.04). Under the conditions of this study, the MN and the FMs in the forearm appeared significantly brighter than those in the young, and there was a loss of contrast between these structures in sonograms of the elderly.

False Tendons and Accessory Papillary Muscle in the Left Ventricle

False Tendons and Accessory Papillary Muscle in the Left Ventricle

Does the Disaster want to be Photographed?

While events of 9/11 may have been singed into collective psyche by now iconic video loops of collision and collapse of World Trade Center (WTC), for those who witnessed it firsthand photography would prove to be primary medium of experience. Within minutes of first impact, gift shops surrounding WTC reported selling out of disposable cameras. The manager of Duane Reade drugstore in vicinity of Towers claimed to have sold between sixty and one hundred cameras within first hour of attacks. (1) In response to this overwhelming demand, local deli owner even began handing them out for free. (2) The near universality of this desire among witnesses to take pictures of event and its aftermath is confirmed by archives such as Here is New York: A Democracy of Photographs, an overwhelmingly dense collection of over seven thousand amateur and professional photographs, which gives credence to characterization of 9/11 as the most photographed disaster in history. Admittedly, motivations behind impulse to take pictures in face of disaster are as varied as images produced. However, it is telling to find common thread running through accounts of those who either found themselves reaching for camera or witnessed this response from afar. For example, E. Ann Kaplan describes her own urge to photograph as a desire to make real what I could barely comprehend. (3) David Friend similarly attributes this collective response to realization that only rendering this act visually would confirm its reality. (4) Reflecting larger position within critical study of 9/11, these comments attribute resurgence of still image to collective need for clarity in face of an unfathomable event, desire to slow down and make sense of an event that happened too fast at time of its occurrence. Certainly photographs allow for kind of careful contemplation that disaster itself often does not. However, this possibility is often contingent upon an impoverishment of experience of event as it occurs. As Susan Sontag famously claimed in On Photography (1977), while photography allows for recording of moment for later scrutiny, act of taking photograph functions first and foremost as way of avoiding engagement with present. According to Sontag, as an instrument of nonintervention, camera effectively removes its operator intellectually and emotionally from reality before lens, dynamic that becomes especially disconcerting in face of human suffering. As she describes: Photographing is essentially an act of nonintervention. Part of horror of such memorable coups of photojournalism ... comes from awareness of how plausible it has become, in situations where photographer has choice between photograph and life, to choose photograph. The person who intervenes cannot record; person who is recording cannot intervene. (5) [ILLUSTRATION OMITTED] Bob Adelman's Birmingham, Alabama (1963) illustrates this inescapable binary between action and observation that often undergirds photographic practice in face of traumatic events. While at first glance female in center of triplet of figures in foreground appears to gaze directly at us, it doesn't take long for viewer to realize that desperation on her face is, in fact, addressed to photographer. Given context of Civil Rights Movement, it is significant that on other side of lens is white male, figure who would seem to wield very power that subject herself lacks. More recently, in 2009 Eagle Tribune photographer Marc Halevi took pictures of woman standing dangerously close to sea during Hurricane Bill, intending to capture human scale of highest tide Plumb Island, Massachusetts, had experienced in more than sixty years. However, as Julie Kredens describes, seconds later as he was looking through his viewfinder, [Halevi] saw wave crash against embankment on which [the woman] was standing, knocking down sand and pulling woman into water. …

Diagnostic performance of a pocket-sized ultrasound device for quick-look cardiac imaging

Background Although pocket-sized, simplified ultrasound devices have emerged to enable subjective point-of-care assessment, few data on their cardiac application exist. We sought to examine the image quality and the accuracy of subjective diagnosis of video loops obtained from a pocket-sized ultrasound device for 2 significant cardiac abnormalities, left ventricular systolic dysfunction and left atrial enlargement, obtained from a single, quick-look view. Methods Parasternal left ventricular long-axis images acquired with a miniaturized commercially available device (Acuson P10) were reviewed using subjective criteria for left ventricular systolic dysfunction and left atrial enlargement and were compared with M-mode measurements of left atrial systolic diameter and E-point septal separation from a fully featured echocardiograph in 78 inpatients referred for standard echocardiography. Interpretive confidence and image quality were evaluated with each interpretation. Results Of 78 inpatient studies, 19% of pocket ultrasound and 13% of standard studies were technically limited ( P = NS). Of 61 technically adequate studies, subjective interpretation of pocket ultrasound images had a sensitivity, specificity, and accuracy of 79%, 52%, and 64% for left atrial diameter more than 4 cm; 47%, 98%, and 82% for E-point septal separation more than 1 cm of; 83%, 62%, and 74% for either abnormality; and 92%, 82%, and 87% for either abnormality when interpretive confidence was present (n = 23). The pocket ultrasound image quality scores were significantly lower than the standard echocardiograph ( P < .001). Conclusion The pocket-sized device provided adequate imaging for screening of 2 significant cardiac entities. Subjective interpretation of a single parasternal view may help identify patients with cardiac disease.

A New Vascular Pattern for Idiopathic Juxtafoveal Telangiectasia Revealed by the Retinal Function Imager

The Retinal Function Imager (RFI) (Optical Imaging, Rehovot, Israel) is a novel method for assessing retinal blood flow characteristics and demonstrating the dynamics of fine retinal vasculature. The authors report a new pattern of retinal blood flow in five patients with idiopathic juxtafoveal telangiectasia (IJT) type 2. Retinal circulation is imaged using the RFI as a series of high-speed stroboscopically captured fundus photographs. Proprietary software aligns the images, allowing serial subtraction, and creates short video loops that show movement of red blood cells in the small and medium size retinal blood vessels. Ten eyes of five patients with IJT type 2 were examined. In all cases, the RFI demonstrated a common pattern of centripetal vascular flow in the region of telangiectasia. This pattern is unique in its configuration of vascular flow into the focus of the area of telangiectasia. This pattern could not be appreciated on fluorescein angiography. The RFI can detect the specific vascular pattern of the retinal blood flow in eyes of patients with IJT. The ability to characterize such blood flow patterns may aid in identification of ambiguous cases of IJT when the diagnosis is not straightforward.

Misinterpretation of a movable mass attached to the aortic valve imaged by transoesophageal echocardiography

Editor, Intraoperative transoesophageal echocardiography (TEE) is a useful tool not only for monitoring surgical patients but also for evaluating and diagnosing cardiac lesions during surgery and guiding surgical approaches. Several reports have described the incidental identification of cardiac lesions using TEE.1–3 This case alerts echocardiographers regarding the possible misinterpretation of an apparent movable cardiac mass. A 76-year-old man was scheduled for coronary artery bypass graft (CABG) surgery. He was admitted to our hospital and diagnosed with acute myocardial infarction 2 months prior to the scheduled surgery. Coronary angiography revealed total occlusion in segments 1 and 6 and significant stenosis (90%) in segment 13. The total occlusion in segment 1 was alleviated by percutaneous coronary intervention, resulting in nonsignificant stenosis (25%). Preoperative transthoracic echocardiography (TTE) revealed an ejection fraction of 67% with mild hypokinesis of the inferior wall, trivial mitral regurgitation and no abnormalities of the aortic valve. TEE was not performed preoperatively. After induction of anesthesia for the CABG surgery, TEE (ACUSON-CV70, Siemens, Tokyo, Japan), which was equipped with two-dimensional imaging with colour flow Doppler, was performed. A midoesophageal, modified long-axis view of the aortic valve revealed a 6.5 mm × 3.5 mm, high-echoic, mobile, pedunculated mass attached to the noncoronary cusp (Fig. 1 and Video Loop 1, https://links.lww.com/EJA/A1). The movement of the mass appeared to be synchronized with the aortic valve. Colour flow Doppler exhibited only trivial aortic regurgitation. The mass was visible in the wide range of the multiplane angle from the modified long-axis view to the true long-axis view of the aortic valve. A short-axis view of the aortic valve revealed mild hypertrophy of the noncoronary cusp at the level of the aortic valve (Fig. 2 and Video Loop 2, https://links.lww.com/EJA/A2). The view was unable to provide any clear images of the area proximal to the aortic valve due to the appearance of the basal left ventricle, and we were unable to detect the mass there. The movable mass was interpreted as likely representing a tumour, thrombus, vegetation or Lambl's excrescences. After detailed discussion with the cardiac surgeon regarding the movable mass and completion of distal anastomosis of CABG, the aorta was opened and the aortic valve was observed through the transaortic approach. Although no abnormal structures were attached to the aortic valve, part of the noncoronary cusp leaflet had yellowish degenerative bulging hypertrophy. After the aorta was closed and the cardiopulmonary bypass was completed, the aortic valve was again evaluated by TEE. The mass-like structure was still visible in the same view as it was during the pre-bypass period.Fig. 1Fig. 2Accurate diagnosis of the mass-like structure was necessary in this case because a pedunculated, movable mass carries the risk of life-threatening complications such as stroke, embolism and acute valvular dysfunction. TEE is a useful imaging modality for assessment of movable intracardiac masses. With TEE, optimal high resolution and proximity between the transducer and the heart sometimes provide superior evaluation of the characteristics of a movable cardiac mass compared with TTE. It has been reported that a fibroelastoma attached to the aortic valve was incidentally identified with intraoperative TEE although it was not shown by preoperative TTE.2,3 However, in our case, the hypertrophic region of the aortic valve leaflet was misinterpreted as a movable cardiac mass. It was postulated that the bulging hypertrophic region of the noncoronary cusp was imaged only during diastole, this being interpreted as a movable mass during the cardiac cycle. Misinterpretation of cardiac lesions by TEE has been reported.4,5 A mobile mass on a prosthetic mitral valve observed by TEE was reportedly misinterpreted as vegetation when it was actually a pannus.4 In our case, the hypertrophic region of the valve appeared to be a mass-like structure that moved with the cardiac cycle, as viewed by TEE. This is one possible pitfall of TEE. It is extremely important, though sometimes difficult, to differentiate mass-like structures attached to the aortic valve. This case has an important clinical message for the interpretation of a movable mass on the aortic valve with TEE.

To Sing Beside

OCTOBER 129, Summer 2009, pp. 133–142. © 2009 October Magazine, Ltd. and Massachusetts Institute of Technology. In time, something is always bound to happen—Mark Wallinger seems to be suggesting with Fly, the eleven-and-a-half minute video loop he realized in 2000— one only has to be patient. No setting could be less dramatic: an overcast sky, filmed with a motionless camera. There is very little wind, so the clouds are somewhat inert: no Sturm und Drang. At dead center of the image is an immobile fly. It takes a moment to realize that it must be dead. And since it has not fallen to the ground and does not look visibly flattened, one is ready to assume that it must be caught in between something like two (very clean) panes of a double-glazed window. The video’s sound consists of something like the cacophony produced by a cocktail party—in any case, a gathering with lots of different conversations going on at the same time, none of which are possible to make out. The only messages that intermittently emerge from the mumbling are those emitted by the radio (a few bars of music, a few snippets of news: “ . . . is released on bail to be questioned about the death of five hundred patients. They all died from methadone . . .”). The sound, in other words, is noise, both in the acoustic and the information-theory senses. As for the sky, it is, obviously, a neutral ground. No sooner has one reached the conclusion that this is all there is to it, than things start to happen: a fly—a live one this time—crawls from the bottom of the screen towards its upper edge; a plane high in the sky obliquely traverses the visual field, looking not much larger (sometimes even smaller) than the dead fly; a bird flaps by (the fastest of the three major kinds of travelers caught by the camera). These are the three most frequently recurring microand/or non-events in this phlegmatic ballet of nothingness. All in all, I counted fifteen planes crossing from right to left, and three from left to right (a distribution that, in certain circumstances, could be precious—say if you were a Scotland Yard operative trying to determine in which London suburb a hostage is being held captive); six complete ascents, always from the bottom up, by a fly; three interrupted ascents (the only occasion when this winged creature gathers speed, usually after a full stop:

Interactive TEE Review: Self-Assessment Examination (DVD).

Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia. william.whitley@emory.eduInteractive TEE Review: Self-Assessment Examination (DVD). By Robert M. Savage, M.D., Solomon Aronson, M.D., and Stanton K. Shernan, M.D. Philadelphia, Lippincott Williams &amp; Wilkins, 2008. Price: $229.00.The expanding interest of anesthesiologists in perioperative transesophageal echocardiography (TEE) has significantly changed the practice of anesthesia. Once an expensive toy for academic medical institutions, TEE now has achieved “standard of care” status for many cardiothoracic procedures. The Society of Cardiovascular Anesthesiologists initiated formal testing in perioperative TEE in 1998. Ten years later, nearly 3,000 physicians have successfully passed the examination.Parallel to this rise in interest has been the publishing of a large number of textbooks, atlases, and DVDs on perioperative TEE marketed to cardiovascular anesthesiologists. This year alone, three review books on the perioperative TEE examination have been introduced. Despite a large amount of competition, Interactive TEE Review: Self-Assessment Examination is the first of its kind.Most review books are “old school” paper and ink with static TEE images. Other DVDs have been designed as video atlases with a limited number of test questions. This DVD is the first interactive text that allows for extensive test review using “live” TEE loops and referenced answers. The timing of the new text is excellent. For the first time, the Perioperative TEE Exam will be completed at computer testing centers across the country in November 2009. This DVD format allows for an excellent simulation of the real test environment.Interactive TEE Review is composed of 420 test questions organized into 32 chapters. More than 600 videos and images are used in the text. The program interface allows the student to personalize the program by selecting the desired subject matter, the number of questions, and how the questions are answered, one by one or as a group.I found that the program was stable and ran quickly on my laptop. The video images have adequate resolution and can be expanded for closer inspection. I found most of the videos and image diagrams to have excellent quality and help clarify the explanations in the text.The subject matter is well organized and extensive. The subject chapters progress in complexity and question difficulty. Each group of 10 chapters roughly correlates with novice, intermediate, and advanced levels of expertise. The subject matter and format are well suited to the goal of testing TEE knowledge in preparation for the National Board of Echocardiography Perioperative TEE Exam.Unfortunately, I found this DVD text to have a few significant problems. Throughout several of the chapters, I encountered a large number of errors in the text and the video links for the questions. A few of the questions were confusing, and I struggled with the appropriate answer. Most of the explanations were excellent, but I noticed a small number of errors in the text of the answers (e.g. , speed of ultrasound in soft tissue was misquoted as 1,740 m/s). One answer merely stated “See Textbook.” A couple of the tables used were very complex and difficult to read.Some of the links seemed to be crossed with other videos in the same questions, which I found to be frustrating. Although most video loops were excellent, I found a small number of the video loops to be nonfunctional or to have poor resolution.Several of the advanced questions required a large number of images to complete the answer. One complex question had greater than 20 videos and images referenced in the question. I found my interest waning about halfway though the images, and I had to force myself to push on in the name of journalistic integrity.Overall, my impression is: Great idea! Great format! Great organization! But the questions and text need editing and proofreading. I was disappointed by the number of errors and would have been more disappointed if I were using the text to prepare for the Perioperative TEE Exam.Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia.william.whitley@emory.edu

Revisiting anaplastic astrocytomas II: Further characterization of an expansive growth pattern with visually enhanced diffusion tensor imaging

To seek to distinguish and visualize the different magnetic resonance imaging (MRI) growth patterns among malignant gliomas utilizing visually enhanced diffusion tensor imaging (DTI). Nineteen consecutive patients undergoing image-guided resection of a newly diagnosed malignant glioma underwent add-on acquisition of DTI data based on an Institutional Review Board (IRB)-approved imaging protocol during preoperative MRI scans for routine intraoperative image guidance. Tumor growth patterns were assigned to expansive or mixed/infiltrative classes as described in the companion article (24). Infiltrating tumors were WHO Grade IV astrocytomas and all expansive tumors were either WHO Grade III astrocytomas or WHO Grade II astrocytomas. DTI-based white matter tractography was conducted and the DTI data were fused with anatomical images using an in-house software package we developed to enhance the visualization of the tumor/fiber interface. In one case additional analysis was performed with 2D multivoxel (1)H-MRSI utilizing a 2D chemical shift imaging (CSI) technique to corroborate the nature of this interface. Out of the 19 tumor patients studied, 11 had infiltrative tumors and the other 8 had expansive tumors. While less clear with 2D axial diffusion color maps, visually enhanced 3D reconstructions of the tumor/fiber interface successfully corroborated distinctive growth patterns. This was particularly evident when viewed in 3D video loops of each tumor/fiber interface. We have successfully developed software that visually enhances the anatomic details of the tumor/fiber interface in patients with anaplastic astrocytomas. These data support the existence of a subgroup of patients within the WHO Grade III classification with expansive tumors and a significantly better prognosis.

Left Ventricular Mass: Intraoperative Transesophageal Echocardiography for Evaluation and Management

A 29-yr-old obese man with recent embolic stroke was brought to the operating room for resection of presumed intracardiac neoplasm suggested by preoperative imaging, including transthoracic echocardiography and cardiac magnetic resonance imaging. A significant history of cocaine use was revealed before surgery. The intraoperative transesophageal echocardiography (TEE) examination revealed mildly decreased left ventricular (LV) function (ejection fraction 45%) and confirmed a 25 15 mm mobile, pedunculated mass in the LV attached near the apex. A combination of mid-esophageal and transgastric views were used to image the mass, which was homogenous, noncalcified and noncavitated with higher echogenicity relative to myocardial tissue (Figs. 1 and 2). Regional wall motion abnormalities that were not described on initial studies were observed in the apex near the point of attachment of the mass. The apical anterior region was dyskinetic at the site of attachment with hypokinesis of the apical septal, lateral, and inferior segments (Video loop 1; please see video clip available at www.anesthesia-analgesia.org). The preoperative diagnosis of neoplasm was reconsidered in light of the regional wall motion abnormalities and the patient’s substance abuse history. A presumptive diagnosis of postmyocardial infarct (MI) associated thrombus was made, although the presence and extent of coronary artery disease had not yet been evaluated with coronary angiography. If significant coronary artery disease was present and coronary artery bypass grafting was indicated, a revascularization procedure could be performed at the time of thrombectomy. For this reason, the procedure was postponed and coronary angiography was performed the following day. This study demonstrated nonobstructive disease with luminal irregularities in the left anterior descending artery, consistent with the wall motion abnormalities observed by TEE. Although coronary revascularization was not indicated, thrombectomy was performed due to a high level of concern regarding additional embolic events. The procedure and postoperative course were uneventful; surgical pathology of the specimen confirmed the diagnosis of infarcted myocardium with associated thrombus. Echocardiography (transthoracic and TEE) remains the imaging modality of choice in the initial assessment of cardiac sources of emboli. In formulating the differential diagnosis of an intracardiac mass, the examiner must evaluate the size, shape, mobility, location, and myocardial attachment or infiltration in addition to considering the overall clinical scenario. Although pathologic intracardiac masses can be due to infectious processes or malignancy, thrombus is a common intraventricular mass. LV thrombi are usually located in the apex in association with an infarcted region. LV tumors tend to be intramural rather than pedunculated, and may alter the echogenic properties and regional contractile function of the tissue. Although LV thrombus was historically a frequent complication of MI, occurring in 20%– 60% of patients, the incidence has substantially decreased to approximately 4.3% since the advent of thrombolytic therapy and percutaneous interventions. Most thrombi develop within the first 14 days after an MI This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Use of Transesophageal Echocardiography in the Evaluation and Surgical Treatment of a Patient with an Aneurysmal Interatrial Septum and an Intracardiac Thrombus Traversing a Patent Foramen Ovale

A 77-yr-old women presented to an outside hospital complaining of shortness of breath and transient diploplia. A transthoracic echocardiogram revealed an intracardiac mass and, due to the high risk of systemic embolization, she was transferred to our institution for emergency surgical removal. In the operating room, after induction of general anesthesia, transesophageal echocardiography (TEE) was performed, revealing a large serpentine mass in the right atrium extending across an aneurysmal interatrial septum into the left atrium through a patent foramen ovale (PFO). The end sections of this horseshoe-shaped mass repeatedly descended into both ventricles during diastole and then flipped back into the atria before atrioventricular valve closure and ventricular systole. (Figs. 1 and 2, Video clips 1–4; please see video loop at www. anesthesia-analgesia.org). TEE was used to guide placement of a left subclavian central line and bicaval cannulation. During placement of these devices, a bicaval view revealed that neither the central line wire nor the venous cannulae entered the right atrium and interfered with the thrombus. The proximal pulmonary arteries were examined in the midesophageal ascending aortic short axis view, and no thrombus was seen. The thrombus was removed and the PFO was closed. Postoperatively, the patient was neurologically intact and was discharged 7 days after admission. Of interest, the patient’s symptom of dyspnea was due to distal pulmonary artery emboli (unseen on TEE) from deep venous thromboses. We think the pulmonary emboli increased right atrial pressure and thereby facilitated right-to-left flow and “trapping” of the large thrombus in the PFO. Aneurysmal interatrial septums occur with a prevalence of 1%–2.2% and are associated with a PFO in 50%–89% of patients. Patients with an aneurysmal interatrial septum and a PFO constitute a high-risk group with a risk of recurrent paradoxical cerebral embolus 3–5 times more than patients with a PFO alone. An aneurysmal interatrial septum is a thin, highly compliant sail-like septum that moves back and forth between the atria with increased excursion compared with a normal septum. The exact amount of excursion that constitutes an aneurysmal interatrial septum varies between 6 and 15 mm, but most authors use a cutoff of 10 mm of excursion. Motion mode (M-mode) can be helpful when measuring excursion, which should be measured from the maximal point of the bulging to an imaginary line connecting the nonaneurysmal segments of the septum primum at the base of the aneurysm. Aneurysmal interatrial septums may contribute to paradoxical emboli by three mechanisms:

Elephant Trunk Prosthesis Kinking: Transesophageal Echocardiography Diagnosis

A patient underwent aortic arch replacement by the elephant trunk technique as the first part of treatment of a Stanford type A aortic dissection with retrograde extension into the aortic arch. The aortic arch was approached through a median sternotomy and was replaced because of extended dissection to left subclavian artery. Cardiopulmonary bypass (123 min) and deep hypothermic circulatory arrest at 18°C (34 min) allowed both anastomosis of the elephant trunk and cerebral protection. An intimal tear was clearly identified 50 mm after the origin of left subclavian artery. The proximal end of a 22-mm aortic prosthesis (Polythese, LPI France) was sutured to the ascending aorta 10 mm distal to the sinotubular junction. Then, the innominate and left common carotid arteries were implanted directly onto the graft. The left subclavian artery was transposed onto the left common carotid artery. The length of the inserted prosthesis was 150 mm. A large portion of intimal flap was resected as far as possible into the aorta (leaving at least 1 cm on both sides of the membrane to avoid injury to the aorta) to allow insertion of the distal part of the prosthesis. The final result of the procedure is described on Figure 1. After placement of several clips to facilitate radiologic visualization, the distal end of the prosthesis was introduced and left free in the descending thoracic aorta. A major enlargement of the mediastinum appeared 28 days after surgery on chest radiograph with the upside-down position of metallic clips marking the distal part of the aortic prosthesis. A pressure gradient between the arm and leg was then noted (125/65 and 85/45, respectively) 28 days after surgery. Our patient’s clinical examination was normal and there was no sign of organ failure. A transesophageal echocardiography (TEE) examination was then performed showing on a descending aorta short-axis view (desc aorta SAX) a double-lumen aspect of the distal part of the prosthesis. A descending aorta long-axis view revealed a complete kinking of the prosthesis with the distal end in cephalad direction (Fig. 2). A high velocity (yellow) and turbulent color Doppler flow pattern (mosaic) was noted at the kinking level and at the distal end of the prosthesis (please see video loop at www.anesthesia-analgesia.org). Further TEE examination showed that the prosthesis was positioned inside the false lumen without intimal membrane in the initial part of descending aorta. Swirling echo reflections indicative of low flow were noted in the false lumen. Complete examination of the descending aorta revealed that the intimal membrane was preserved in the distal part of the aneurysm with false This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Aorto–Atrial Fistula: An Important Complication of Aortic Prosthetic Valve Endocarditis

Aorto–Atrial Fistula: An Important Complication of Aortic Prosthetic Valve Endocarditis

Absent Right Superior Vena Cava and Persistent Left Superior Vena Cava: The Perioperative Implications

A 22-yr-old female patient was admitted for repair of tetralogy of Fallot. Preoperative transthoracic echocardiography revealed large subaortic ventricular septal defect, 50% aortic over-ride, severe valvular and subvalvular pulmonary stenosis, persistent left superior vena cava (PLSVC), and a large coronary sinus (CS). After anesthetic induction, central venous cannulation of the right internal jugular vein was attempted with a 20-guage cannula using Seldinger’s technique. Despite free flow through the cannula, the guidewire could not be advanced beyond 8 cm; therefore, a pediatric (8 cm, 5.5F) triple-lumen catheter was inserted. Intraoperative transesophageal echocardiography (TEE) imaging of the midesophageal (ME) bicaval view with the transducer steered through 90–120° suggested absence of the right superior vena cava (RTSVC) (Figs. 1a and b) (please see video loops available at www.anesthesia-analgesia.com). However, a large PLSVC and CS (Fig. 2) (see video loop) were seen midway between the ME four-chamber and a deep four-chamber view; the probe was slightly rotated counterclockwise. The absent RTSVC was evident on opening the pericardium. After aortic and inferior vena cava cannulation and institution of cardiopulmonary bypass a separate cannula was inserted extrapericardially in the PLSVC. The surgical repair and postoperative course were uneventful. An absent RTSVC is always associated with a PLSVC, with a reported incidence of 0.1% (1). It should be suspected when the chest radiograph does not show its characteristic shadow, particularly with an extra shadow (PLSVC) above the aortic knob (1). On TEE examination, the RTSVC is usually well visualized in the ME bicaval view. Agitated saline administered centrally appears as contrast in the RTSVC and right atrium (RA). With an absent RTSVC, contrast appears in the RA via the CS and can be viewed just below the ME four-chamber view and in bicaval view; however, if the CS is unroofed [absence of common wall between CS and left atrium (LA)], the contrast appears in both the LA and RA. A PLSVC descends along the left paramediastinal structures, anterior to the aortic arch and left pulmonary artery. It then passes inferiorly; in its course receives its tributary the hemiazygos vein, and then descends medially between the left pulmonary veins and left atrial appendage joining the CS in the atrioventricular groove (Fig. 3) causing an enlarged CS. Enlargement of the CS ( 1 cm) may indicate right atrial hypertension, an anomalous systemic venous channel draining through it (e.g., connection of PLSVC, hepatic veins, inferior vena cava), fistulous communication with coronary arteries and total or partial anomalous pulmonary venous connection. A PLSVC can be seen in ME views in the vicinity of the left atrial appendage and left upper pulmonary vein with the probe rotated counterclockwise, and can be traced to its entry into the CS. Occasionally, a PLSVC can be misdiagnosed as descending thoracic aorta, however, it can be differentiated from the descending thoracic aorta by pulse-wave Doppler assessment that shows continuous flow in the PLSVC and pulsatile flow in the descending thoracic aorta. The diagnosis of PLSVC is classically made by injecting contrast into the left-sided brachiocephalic veins and demonstrating contrast appearance in the PLSVC, CS, and RA (in that sequence). In 10% of patients, a PLSVC may drain into the LA either directly or via an unroofed CS; in such a situation, contrast first appears in the LA. Because of the PLSVC draining into the LA (right to left shunt) the arterial blood gas analysis or pulse oximetry will show desaturation. Although, this finding will not help evaluation of cyanotic patients, it can create a diagnostic and management dilemma in patients with acyanotic lesions. This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Fetal Sex Assignment by Sonographic Evaluation of the Pelvic Organs in the Second and Third Trimesters of Pregnancy

The purpose of this study was to determine the feasibility and reliability of fetal sex assignment by prenatal sonography of the pelvic organs in the second and third trimesters. A prospective study, on an axial pelvic image with the umbilical arteries in cross section at the midpoint of the bladder, measured the distance between the posterior wall of the bladder and the anterior wall of the rectum. The bladder interface was scored as concave, flat, or convex. Endometrium visualization was recorded. A video loop of the pelvis was obtained. Each case was read by a second reader aware of only the gestational age. The study population included 205 fetuses. The primary reader was 98.8% accurate in identifying true female fetuses and 100% accurate in identifying true male fetuses. The intraclass correlation coefficient for axial measurement was 0.99. Video loop analysis achieved 96% inter-reader concordance. In the second trimester, measurements in 100% of male fetuses were less than 3.3 mm, and those in 94% of female fetuses were greater than 3.3 mm. In the third trimester, measurements in 96% of male fetuses were less than 4.7 mm, and those in 100% of female fetuses were greater than 4.7 mm. Ninety-eight percent of all fetuses with concave interfaces were female. The endometrium was visualized in 74%. The additional time per examination was less than 5 minutes in 87.7%. Internal pelvic fetal sex assignment is a reliable additional method for fetal sex determination. A numerical discriminatory level can be used to distinguish between male and female internal genitalia. Larger numbers will be required to further refine these values.

Echocardiographic Evidence of the Brockenbrough???Braunwald???Morrow Sign After Mitral Valve Repair

The Brockenbrough–Braunwald–Morrow sign was first described in 1961 (1) in individuals with hypertrophic cardiomyopathy and dynamic left ventricular (LV) outflow tract (LVOT) obstruction worsened by conditions associated with increased myocardial contractility. The sign was characterized by an increase in peak-systolic gradient combined with a decrease in pulse pressure after an extrasystolic beat (2). The increased contractile performance in the postextrasystolic beat was explained by postextrasystolic potentiation from 1) persistence of the positive inotropic effect and 2) rest potentiation from an increased strength of contractility immediately after a period of rest (3). The pathophysiology underscoring the Brockenbrough– Braunwald–Morrow sign was demonstrated echocardiographically after repair of the mitral valve. A 58-yr-old female patient with severe mitral regurgitation from myxomatous degeneration underwent mitral valve repair that included a sliding quadrangular resection of the P2 (middle) segment of the posterior mitral valve leaflet and a 34-mm mitral ring annuloplasty (Model 4450, Edwards Life Sciences). Preprocedural transesophageal echocardiography (TEE) revealed a mitral valve with advanced myxomatous degeneration, redundant tissue of both leaflets and severe, central mitral regurgitation. After repair, color flow Doppler in the TEE midesophageal-aortic valvelong axis view demonstrated turbulent flow in the LVOT and mild mitral regurgitation consistent with systolic anterior motion (SAM) of the mitral valve (Fig. 1; also please see video loop available at www.anesthesiaanalgesia.org). Continuous-wave Doppler examination in the TEE transgastric mid-LV-long axis view measured a LVOT peak gradient of 60 mm Hg in the absence of aortic stenosis or septal hypertrophy. The presence of SAM ultimately led to a return to cardiopulmonary bypass and revision of the mitral valve repair (please see video loop available at www.anesthesiaanalgesia.org). In addition to SAM, further evidence for dynamic LVOT obstruction was captured on continuous-wave Doppler examination (Fig. 2). In this image, a premature complex led to a poor ejection and a reduced gradient. However, the postextrasystolic beat led to an increased LVOT gradient (VMAX 4.2 m/s; peak gradient 67.2 mm Hg; mean gradient 33.2 mm Hg). Continuouswave Doppler-derived measurements, taken immediately before the premature complex, demonstrated a consistent This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Severe Acute Aortic Regurgitation due to Aortic Dissection

CASE DESCRIPTION Aortic insufficiency (AI) occurs frequently in patients with acute Type A aortic dissection. Exacerbation of this AI due to prolapse of the dissection flap is rare (1). A 68-year-old man presented to an outside hospital with sudden onset of severe back pain and numbness in his right leg. A Stanford Type A thoracic aortic dissection was diagnosed by a computed tomography scan. He was transferred via helicopter to our hospital for emergency aortic surgery. To expedite the care of this patient, he was transported directly to the operating room from the helipad. After induction of general anesthesia, transesophageal echocardiography (TEE) confirmed the diagnosis of an ascending aortic aneurysm with a dissection in the ascending aorta that progressed through the aortic arch into the distal descending aorta. In the midesophageal long axis view of the aorta, a definite, undulating dissection flap was seen as a mobile echogenic structure with a pattern of motion different than the aortic wall. Color flow imaging revealed an entry site into the false lumen in the ascending aorta and demonstrated blood flow in both the true and false lumens. The aortic valve was trileaflet. Color Doppler revealed severe AI because of incomplete leaflet closure from a dilated sinotubular junction. This AI was exacerbated by the back and forth movement of the dissection flap from the ascending aorta into the left ventricular outflow tract, further preventing coaptation of the aortic valve leaflets (Fig. 1). The midesophageal short axis view of the ascending aorta revealed a starfish-like appearance of the circumferential dissection flap (Fig. 2). In our patient, although it was not clear if the dissection involved the coronary arteries, both the left and right ventricles were normal in size and function, with no regional wall motion abnormalities. (TEE video loops are available online at www.anesthesia-analgesia.org.) The patient was placed on cardiopulmonary bypass and his ascending aorta and aortic valve were replaced with a 25-mm Carboseal valve conduit with reimplantation of the coronary arteries. Circulatory arrest under deep hypothermia was used for a portion of the procedure. TEE examination after weaning from cardiopulmonary bypass revealed a mechanical aortic valve prosthesis functioning normally and an ascending aortic graft with no evidence of leak. The dissection flap now seen in the aortic arch continued into the descending thoracic aorta. The patient was discharged home on the eighth day in satisfactory condition.

Left Ventricular Outflow Tract to Right Atrial Fistula Diagnosed by Intraoperative Transesophageal Echocardiography

A 68-yr-old male with increasing shortness of breath and a history of aortic stenosis was admitted. A transthoracic echocardiographic examination (TTE) revealed an aortic valve (AV) area of 0.62 cm2. The patient was subsequently scheduled for an AV replacement (AVR). Cardiac catheterization performed on the morning of surgery demonstrated single vessel coronary artery disease involving the right coronary artery. The patient underwent an uncomplicated AVR (#23 Carpentier-Edwards Magna) with a single vessel coronary artery bypass graft. His initial postoperative course was uncomplicated, but on postoperative day 3 he became febrile to 38.7°C. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated. TTE at that time was inconclusive, however transesophageal echocardiography (TEE) performed in the intensive care unit on postoperative day 7 was interpreted as a fistulous communication between the aorta and right atrium (RA) associated with a periannular abscess in the vicinity of the AVR. The patient returned to the operating room where intraoperative multiplane TEE demonstrated that the fistula actually communicated between the left ventricular outflow tract (LVOT) and the RA. In the midesophageal four-chamber view at 0° rotation, the diameter of this tract was approximately 0.5–0.8 cm. (Fig. 1 Top). Color flow Doppler in the midesophageal (Fig. 1 Bottom) and deep transgastric long-axis (Fig. 2) views confirmed the presence of turbulent flow from the LVOT to the RA just above the tricuspid valve (see video loop for midesophageal TEE views available at www.anesthesia-analgesia.org). Therefore, the surgical approach was changed to a replacement of the original AV prosthesis and aortic root with a #22 homograft (LifeNet), and the fistula closed by sewing bovine pericardial patches to both sides of the tract. The patient was discharged from the hospital in good condition after a subsequent uneventful postoperative course.Figure 1.: Top: Midesophageal four-chamber transesophageal echocardiographic (TEE) view at 0° rotation demonstrating a fistula (→) from the left ventricular outflow tract (LVOT) to the right atrium (RA). Bottom: Midesophageal four-chamber TEE view at 0° rotation with color flow Doppler showing turbulent flow from the LVOT into the RA.Figure 2.: Deep transgastric transesophageal echocardiographic (TEE) view at 0° rotation showing a communication between the left ventricular outflow tract (LVOT) and right atrium (RA). Turbulent flow from the LVOT into the RA at the level of the tricuspid valve is demonstrated (→).Communications between the LVOT and RA are mostly congenital and are known as “Gerbode's defect” (1). This anomaly accounts for <1% of all congenital heart lesions. Similar acquired shunts may develop after chest trauma, mitral and AV replacement, or infective endocarditis (2). The communication results from a defect in the interventricular septum, inferior to the crista supraventricularis. Patients with this lesion can present with hemodynamic deterioration, myocardial injury, prosthetic valve dysfunction, or perivalvular leaks. Symptoms of right-sided heart failure dominate the clinical picture and depend on the magnitude of the shunt as a reflection of the size of the defect. Physical findings include a harsh holosystolic murmur and right ventricular heave. Only patients with small shunts remain asymptomatic. Collateral injury associated with a perivalvular infection can involve the subannular region and membranous interventricular septum (3). TTE often fails to identify the involvement of these subaortic structures (4). The creation of a TTE window to visualize the membranous septum can be technically challenging because of patient anatomy and beam orientation. An overlying aortic prosthesis that overshadows the lesion can also complicate transthoracic imaging. Therefore, a comprehensive TEE examination using two-dimensional and color flow Doppler imaging can be useful for delineating the location of the pathology and for guiding the surgical procedure.

Unexpected Periaortic Cavity During Heart Surgery

A 43-year-old man was referred to our institution for surgical correction of aortic valvular disease discovered in the context of new onset aortic insufficiency with acute pulmonary edema. The patient had no medical history of cardiac disease besides an “innocent” heart murmur since youth, which had never been investigated. Of note, he had an acute episode of glomerulonephritis with secondary renal insufficiency and systemic hypertension 6 mo before, and septicemia from an infected percutaneous hemodialysis catheter 5 mo before admission. The patient was afebrile, appeared nonseptic at the time of admission for surgery. Preoperative transthoracic echocardiography (TTE) revealed Grade IV aortic insufficiency and moderate aortic stenosis. There were no other abnormalities described. Intraoperative transesophageal echocardiography (TEE) examination revealed a pulsatile cavity on the mitral-aortic intervalvular fibrosa in the mid-esophageal long-axis view, close to the noncoronary cusp of a bicuspid aortic valve. The cavity had pronounced systolic enlargement (Fig. 1). Systolic flow in the cavity was apparent using color flow Doppler (Fig. 2; video loop can be accessed at www.anesthesia-analgesia.org).Figure 1.: Mid-esophageal long-axis view in end systole. The left ventricular outflow tract pseudoaneurysm (arrow) is at maximal size.Figure 2.: Mid-esophageal long-axis view displaying M-mode of the left ventricular outflow tract showing the holosystolic filling (white arrow) and diastolic emptying of the pseudoaneurysm.Visual inspection of the aortic valve showed no evidence of endocarditis. The presence of this undiagnosed cavity was confirmed by the surgeon, who isolated it from the left ventricle by means of an autologous pericardial patch. After aortic valve replacement, TEE showed significant reduction of flow in the cavity. The postoperative course was uneventful. A subsequent TTE study failed to show any residual cavity. Left ventricular outflow tract (LVOT) pseudoaneurysms, or pseudoaneurysms of the mitral-aortic intervalvular fibrosa, are rare complications of infective aortic endocarditis, trauma, and aortic valve replacement surgery. This is the first case of LVOT abscess that we have encountered in a 13-year-TEE database of approximately 8500 examinations. The incidence of fistulas or pseudoaneurysm complicating aortic annular abscesses is estimated to be 11% (1). Pseudoaneurysms associated with infective endocarditis of the aortic valve can occur anywhere from the left ventricle to more distal arteries, such as the superior mesenteric artery. Echocardiographic criteria of an LVOT pseudoaneurysm include a pulsatile nature (with systolic enlargement, easily diagnosed using M-mode) and communication with the LVOT (2). These can be associated with aortic regurgitation and rarely, mitral regurgitation. In one small study, it was shown that pseudoaneurysms of the LVOT are more readily observed with TEE than with TTE or aortography (3). In this case, the bicuspid aortic valve may have predisposed the patient to infective endocarditis, which may have been effectively treated with antibiotic therapy of his infected dialysis catheter. The pseudoaneurysm may have developed shortly thereafter.

Dynamic Left Ventricular Inflow Obstruction Associated with a Left Atrial Myxoma

A 49-year-old female presented with lower extremity weakness, worsening dyspnea, stigmata of systemic embolism, and an acute episode of dysarthria. Brain computed tomography and magnetic resonance imaging demonstrated small embolic strokes while transthoracic echocardiographic examination showed a large left atrial (LA) mass. The patient was scheduled for surgical excision of the mass. Intraoperative two-dimensional and three-dimensional transesophageal echocardiography (TEE) (Siemens Sequoia, Mountain View, CA and Tom Tek Corporation, Boulder, CO) demonstrated a 4 × 6 cm2 pedunculated LA mass attached by a pedicle to the superior fossa of the interatrial septum [Fig. 1 and Video Loop 1 (Please see video loops available at www.anesthesia-analgesia.org)]. During diastole, the mass prolapsed through the mitral valve resulting in a turbulent color flow Doppler pattern (Video Loop 2). Continuous wave doppler revealed mild to moderate left ventricular (LV) inflow obstruction, with calculated mean and peak pressure gradients of 6 mm Hg and 9 mm Hg, respectively (Fig. 2). In general, mild mitral obstruction is suggested by a mean pressure gradient <6 mm Hg, moderate obstruction by a mean pressure gradient of 6–10 mm Hg, and severe obstruction by a gradient >10 mm Hg. Proximal isovelocity surface area can provide information about the degree of obstruction, but the asymmetry of the proximal isovelocity surface area hemisphere in this case may have resulted in an inaccurate estimate of the diminished LV inflow area. The use of pressure half-time is also commonly used to estimate the severity of mitral obstruction, however, this technique has not been validated in patients with dynamic LV inflow obstruction.Figure 1.: Intraoperative two-dimensional transesophageal mid-esophageal four-chamber view demonstrating the left atrial myxoma (arrow) prolapsing through the mitral valve during diastole. LA: left atrium; LV: left ventricle; RV: right ventricle.Figure 2.: Intraoperative continuous wave Doppler image from the transesophageal mid-esophageal four-chamber view demonstrating the left ventricular inflow velocity profile along the prolapsing left atrial myxoma. Pressure gradients (ΔP) calculated from the modified Bernoulli Equation (ΔP = 4V 2; V = peak velocity), were obtained from values averaged over three cardiac cycles. The calculated mean (6 mm Hg) and peak (9 mm Hg) pressure gradients are consistent with mild-to-moderate obstruction.A complete excision of the LA mass and its atrial septal attachment was performed and the resultant atrial septal defect was closed with pericardial patches. After cardiopulmonary bypass, TEE confirmed an intact interatrial septum. Pathologic examination confirmed the mass to be a myxoma. The patient recovered uneventfully and was discharged home on postoperative Day 5. Seventy-five percent of myxomas are found in the LA, but 10–20% originate in the right atrium, and 5% in either ventricle. In contrast to this report, LA myxomas typically attach via a narrow base to the interatrial septum at the border of the fossa ovalis, and are rarely invasive. Patients with myxomas who become symptomatic usually present with congestive heart failure (67%) because of LV inflow obstruction, signs of tumor embolization (29%), or constitutional symptoms (41%) (1,2). Intraoperative TEE is used for identifying satellite tumors and confirming the structural integrity of the interatrial septum after surgical excision of a myxoma (3). Three-dimensional TEE may be helpful for delineating the extent of the myxoma's attachment, thereby permitting more accurate surgical planning.