Prognostic significance of spontaneous echo contrast in the thoracic aorta: relation with accelerated clinical progression of coronary artery disease.

OBJECTIVES: The purposes of this study were to identify the incidence of aortic smoke in an unselected cohort of patients and to determine the utility of this measurement as a clinical marker for future coronary events and long-term cardiac prognosis. BACKGROUND: Although spontaneous echo contrast detected within the cardiac chambers has been associated with an increased risk of thromboembolism, less is known about "smoke" within the thoracic aorta and its relation to progression of coronary artery disease. METHODS: We prospectively assessed 118 unselected, consecutive male patients (mean age 67 years, range 29 to 86) who underwent transesophageal echocardiography (TEE). The presence of aortic smoke was identified by swirling echodense shadows distinct from high gain artifact. A positive result required confirmation by two of three independent observers. RESULTS: Aortic smoke without dissection was found in 25 of the patients (21%). Indications for TEE, coronary risk factors, the incidence of reduced left ventricular ejection fraction and mitral insufficiency and known coronary artery disease severity collectively did not differ significantly at baseline between the groups with and without smoke. Follow-up averaged 20.4 months (range 18 to 24) and was 100% complete for mortality and 98% complete for morbidity. The presence of aortic smoke was an independent predictor of myocardial infarction (16.0% vs. 2.2%, p < 0.005) and cardiac death (20.0% vs. 1.1%, p < 0.0001). These statistics remained significant after covarying for age, ejection fraction < 50%, hypertension, diabetes, aortic dimension, the presence of an atheromatous plaque and smoke in the left atrium. CONCLUSIONS: Spontaneous echo contrast detected within the thoracic aorta by transesophageal echocardiography is a common and important clinical marker that is strongly associated with an increased risk for future myocardial infarction and cardiac mortality. Future studies will attempt to define the pathophysiology of this relation and assess whether aggressive revascularization strategies and antithrombotic therapy may aid in the reduction of this risk.

Misplaced Greenfield filter: diagnosis by transesophageal echocardiography.

A case of accidental placement of a Greenfield filter in the right atrium is described. Transthoracic echocardiography demonstrated the filter but was unable to provide details regarding the exact location of the filter. Transesophageal echocardiography showed the filter to be fixed to the tricuspid anulus. This finding, which was confirmed during surgery, was used to guide the subsequent surgical management.

Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique.

Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction after Carpentier-type mitral reconstruction with ring annuloplasty has led some surgeons to abandon an otherwise successful repair or to avoid use of a rigid ring. To assess the long-term significance of such motion, we studied 439 patients undergoing Carpenter mitral reconstruction at our institution between March 1981 and June 1990. The hospital mortality rate was 4.8% (21/439) overall and 3.7% (9/243) for isolated mitral reconstruction. Systolic anterior motion was found in 6.4% (28/438) after the operation, and 2.3% (10/438) had a coexisting left ventricular outflow tract gradient (mean 53 mm Hg). Of the 28 patients with systolic anterior motion, 27 (96.4%) had leaflet prolapse, 17 (60.7%) had undergone more than a 3 cm resection of the posterior leaflet, and two (7.1%) had preexisting idiopathic hypertrophic subaortic stenosis. All patients were treated medically, 14 with negative inotropic agents. Follow-up echocardiograms at a mean of 32 months demonstrated the disappearance of systolic anterior motion in 13 of 28 patients (46.4%) and resolution of the outflow tract gradient in 10 of 10 (100%). At follow-up only one patient was in New York Heart Association class III or IV and required reoperation for rheumatic mitral insufficiency. These data demonstrate that systolic anterior motion after Carpentier mitral reconstruction with ring annuloplasty is not prevalent and should be managed medically in most cases. Associated left ventricular outflow tract obstruction resolves with medical treatment.

Echocardiographic diagnosis of secondary coarctation complicating the repair of a traumatic pseudoaneurysm of the aorta.

An 18-year-old patient underwent repair of traumatic aortic pseudoaneurysm. Postoperatively, the physical examination showed hypertension with 30 mm Hg gradient between the upper and lower extremities. Doppler echocardiographic evaluation demonstrated a new (secondary) aortic coarctation at the site of the repair. Transesophageal echocardiography revealed the detailed anatomy and the cross-sectional area of the coarctation.

Comparison of cardiac catheterization and Doppler echocardiography in the decision to operate in aortic and mitral valve disease.

Clinical decisions utilizing either Doppler echocardiographic or cardiac catheterization data were compared in adult patients with isolated or combined aortic and mitral valve disease. A clinical decision to operate, not operate or remain uncertain was made by experienced cardiologists given either Doppler echocardiographic or cardiac catheterization data. A prospective evaluation was performed on 189 consecutive patients (mean age 67 years) with valvular heart disease who were being considered for surgical treatment on the basis of clinical information. All patients underwent cardiac catheterization and detailed Doppler echocardiographic examination. Three sets of two cardiologist decision makers who did not know patient identity were given clinical information in combination with either Doppler echocardiographic or cardiac catheterization data. The combination of Doppler echocardiographic and clinical data was considered inadequate for clinical decision making in 21% of patients with aortic and 5% of patients with mitral valve disease. The combination of cardiac catheterization and clinical data was considered inadequate in 2% of patients with aortic and 2% of patients with mitral valve disease. Among the remaining patients, the cardiologists using echocardiographic or angiographic data were in agreement on the decision to operate or not operate in 113 (76% overall). When the data were analyzed by specific valve lesion, decisions based on Doppler echocardiography or catheterization were in agreement in 92%, 90%, 83% and 69%, respectively, of patients with aortic regurgitation, mitral stenosis, aortic stenosis and mitral regurgitation. Differences in cardiac output determination, estimation of valvular regurgitation and information concerning coronary anatomy were the main reasons for different clinical management decisions. These results suggest that for most adult patients with aortic or mitral valve disease, alone or in combination, Doppler echocardiographic data enable the clinician to make the same decision reached with catheterization data.

Doppler echocardiographic flow velocity measurements in the superior vena cava during the Valsalva maneuver in normal subjects.

The hemodynamic manifestations of the Valsalva maneuver are in part the result of changes in the venous return accompanying changes in intrathoracic pressure. Doppler echocardiography was performed during Valsalva maneuver in 13 normal subjects. Superior vena cava flow velocities and flow velocity integrals were measured in all 13 subjects. In the 5 subjects in whom the superior vena cava was clearly visualized throughout the maneuver, vena cava diameter was also analyzed. The superior vena cava flow velocity integral at rest was 17 +/- 2 cm. It diminished significantly, disappeared or reversed (-13 +/- 6 cm, p less than 0.001) with phase I of the maneuver. During the maintenance phase (phase II), the flow velocity integral increased significantly (31 +/- 2 cm, p = 0.05 vs baseline and phase I) and was associated with a decrease in superior vena cava lumen diameter at the time of Valsalva and continuing throughout the strain. With release of the maneuver (phase III), there was a sudden significant increase in flow velocity integral (61 +/- 2 cm, p = 0.005 vs phase II) and superior vena cava lumen diameter. Subsequently, superior vena cava flow velocity integral returned to baseline values. This study suggests that one of the ways in which the Valsalva maneuver leads to decreased venous return may be by direct external compression of the superior vena cava.

The anatomy of the interatrial septum: a transesophageal echocardiographic study.

Transesophageal echocardiography provides a unique view of the IAS. We reviewed results of 119 transesophageal studies (1) to study the detailed anatomy of the IAS, and (2) to determine the thickness of the IAS at different times during the cardiac cycle, (3) the effect of age, and (4) the thickness of the IAS in relation to various disease states. From the transesophageal view the IAS extends from the right posteriorly toward the left and anteriorly. The more inferior aspect of the septum courses in a more direct posteroanterior direction and is more difficult to accurately visualize. The IAS is thickest peripherally and gradually narrows toward the more centrally located fossa ovalis. A region of constant thickness is frequently present between the most peripheral aspect of the IAS and the fossa ovalis. We standardized the measurement of the thickness of the septum by measuring it only at this region of constant thickness in the plane that visualized the fossa ovalis. The mean thickness at this point was 6 +/- 2 mm. The thickness correlated weakly with the age of the patient. These results agree with previously published autopsy findings. Thickness was not affected by the presence of significant disease of the atrioventricular valves, atrial fibrillation, or an atrial septal defect. However, the thickness increased to 7 +/- 2 mm with atrial contraction during sinus rhythm (p less than 0.0001). The mean thickness of the septum primum covering the fossa ovalis was 1.8 +/- 0.7 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic and hemodynamic characteristics of atrial septal defects created by percutaneous valvuloplasty.

Twenty-nine patients were studied by pulsed, continuous wave, and color Doppler before and after percutaneous transseptal valvuloplasty. New atrial septal defects were detected in 14 patients, and the patients were monitored for up to 320 days after the procedure. The diameter of the defect, best evaluated by the transesophageal approach, was 3 to 15 mm. A narrow, high velocity (1.4 to 3.1 meters per second) left-to-right shunt jet was detected in 13 of 14 patients. The shunt jet was continuous in nine of 14 patients, late systolic-holodiastolic in four patients, and bidirectional in one patient. Cardiac catheterization in nine patients confirmed the Doppler findings and demonstrated a peak pressure gradient of 10 to 32 mm Hg between the left and right atria. Oximetry revealed a calculated pulmonary to systemic flow ratio ranging from 2.3:1 in the patient with the largest atrial septal defect by echocardiography to 1:1 (no oxygen saturation step-up) in the patient with the smallest atrial septal defect. In the three patients who underwent cardiac surgery, the operative findings confirmed those of echocardiography. We concluded that atrial septal defects are common after transseptal valvuloplasty. Usually, their relatively small size and the underlying valvular disease that produces high left atrial pressure are responsible for the high pressure gradient between the left and right atria. This results in the high velocity and continuous shunt jet detected by Doppler echocardiography.

Echocardiographic diagnosis of atrioventricular septal perforation caused by an aortic valve vegetation.

A case of aortic valve endocarditis is presented in which a vegetation eroded through the atrioventricular septum and extended into the right atrium. This was diagnosed by echocardiography and confirmed at surgery.

Noninvasive diagnosis of left ventricular outflow tract obstruction caused by a porcine mitral prosthesis.

A patient developed shortness of breath 8 years after mitral valve replacement with a porcine prosthesis. Doppler echocardiography revealed left ventricular outflow tract obstruction created by a protruding prosthesis.