Usefulness of unipolar electrograms to detect isthmus block after radiofrequency ablation of typical atrial flutter.

BACKGROUND: RS morphology of the unipolar electrogram is associated with propagation of the wave front through the exploring electrode, whereas positive uniphasic (R) unipolar electrograms are characteristic of the end of activation. METHODS AND RESULTS: Unipolar electrograms were recorded in 45 consecutive patients with atrial flutter who were undergoing radiofrequency ablation (RFA). Bidirectional cavotricuspid isthmus (CTI) block was achieved in 44 patients. The unipolar electrogram obtained before RFA at the low anterolateral right atrium during coronary sinus pacing changed from RS, rS, or QS to R or Rs in all patients after clockwise CTI block was obtained. The morphology of unipolar electrograms recorded close to the coronary sinus during pacing from the low anterolateral right atrium changed from RS or rS to R or Rs in all but 4 patients after counterclockwise CTI block. In the patient in whom CTI block was not achieved, the RS morphology of the unipolar electrogram remained unchanged. In 18 patients, the results of the RFA were assessed with only the unipolar electrogram. The unipolar electrogram correctly predicted 100% and 89% of the cases of clockwise and counterclockwise CTI block, respectively. CONCLUSIONS: The creation of CTI block is associated with an easily detectable loss of negative components and development of an R or Rs pattern of the unipolar electrogram recorded close to the ablation line while pacing at the opposite side of the CTI.

Effects of dobutamine on Doppler echocardiographic indexes of aortic stenosis.

OBJECTIVES: This study sought to assess the diagnostic implications of the flow dependence of Doppler echocardiographic indexes of aortic valve stenosis. BACKGROUND: Although valve area has been shown to change with alterations in flow rate, the diagnostic consequences of this phenomenon remain unknown. Valve resistance has been suggested as a more stable index for evaluating aortic stenosis. METHODS: A low dose dobutamine protocol was performed in 35 patients with aortic stenosis. Hemodynamic indexes were obtained by Doppler echocardiography at baseline and at each dobutamine dose. RESULTS: As a result of the shortening of the systolic ejection period, flow increased from (mean +/- SD) 164 +/- 48 to 229 +/- 102 ml/s (p < 0.0001). At peak flow, valve area increased by 28% (from 0.5 +/- 0.2 to 0.6 +/- 0.3 cm2, p < 0.0001), whereas valve resistance decreased by 4% (from 498 +/- 252 to 459 +/- 222 dynes.s.cm-5, p = 0.04). This observed change in resistance was smaller than that for valve area (p < 0.01). The flow dependence of valve area varied among individual patients (p < 0.0001). Multivariate analysis identified calcific degenerative etiology (beta 0.29, p = 0.002), left ventricular velocity of fiber shortening (beta 0.22, p = 0.01), baseline flow (beta -0.28, p = 0.04) and amount of flow increased induced by dobutamine (beta 0.90, p < 0.0001) as factors related to valve area flow dependence. CONCLUSIONS: Although all Doppler echocardiographic indexes of aortic stenosis are affected by flow, valve resistance is more stable than valve area under dobutamine-induced hemodynamic changes. Baseline valve area may be unreliable in patients with calcific degenerative aortic stenosis and low output states.

Predictors of left atrial spontaneous echo contrast and thrombi in patients with mitral stenosis and atrial fibrillation.

The purpose of this study was to investigate the independent factors associated with the presence of left atrial (LA) spontaneous echo contrast (SEC) and thromboembolic events in patients with mitral stenosis (MS) in chronic atrial fibrillation (AF). Factors independently associated with LASEC, thrombi, and embolic events have been mainly investigated in patients with nonvalvular AF or inhomogeneous populations with rheumatic heart disease. Transesophageal and transthoracic echo studies were performed in 129 patients with MS in chronic AF. Previous embolic events were documented in 45 patients, 20 of them within 6 months, and 65 patients were receiving long-term anticoagulation. The intensity of LASEC and mitral regurgitation, the presence of thrombi and active LA appendage flow (peak velocities > or = 20 cm/s), and LA volume as well as other conventional echo-Doppler determinations were investigated in every patient. The prevalences of significant LASEC (degrees 3+ and 4+), thrombus, active LA appendage flow, and significant mitral regurgitation (>2+) were: 52% (67 patients), 29.5% (38 patients), 32% (41 patients), and 36% (47 patients), respectively. Multivariate analysis showed that decreasing mitral regurgitation severity, absence of active LA appendage flow, and mitral valve area were the independent correlates of LASEC (odds ratio [OR] 3.7, 5.4, and 0.17, respectively; all p <0.02). Active LA appendage flow and anticoagulant therapy were associated negatively, whereas the severity of LASEC was associated positively with the finding of LA thrombus (OR 9.6, 3.9, and 1.6, respectively; all p <0.05). The intensity of LASEC and previous anticoagulant therapy (OR 1.74 and 4.5, respectively; p <0.005) were the independent covariates of thrombi and/or recent embolic events. In conclusion, the severity of mitral regurgitation and lack of active LA appendage flow were, respectively, the strongest independent correlates of significant LASEC and thrombus in patients with MS in chronic AF. LASEC remains the cardiac factor most strongly associated with thrombus and/or recent embolic events in these patients.

[Massive myocardial infiltration by lymphoma of tonsilar origin simulating left ventricular hypertrophy: diagnosis using echocardiography]. / Infiltración miocárdica masiva por linfoma de origen amigdalar que simula hipertrofia ventricular izquierda: diagnóstico mediante ecocardiografía.

We present the first described case in the literature of isolated left anterior hemiblock, in the setting of massive myocardial invasion by a primary tonsilar lymphoma. Such process evolved with a morphologic pattern mimicking left ventricular hypertrophy of unequal distribution. An hemodynamic behaviour of an infiltrative cardiomyopathy, with both systolic and diastolic important ventricular dysfunction, was observed. An early presumptive diagnosis of severe lymphomatous myocardial invasion was established by echocardiography. The pathologic examination confirmed it subsequently.

[Diagnostic usefulness of 2-dimensional echocardiography in eosinophilic endomyocardial disease (Loeffler disease)]. / Utilidad diagnóstica de la ecocardiografía bidimensional en la enfermedad endomiocárdica eosinofílica (enfermedad de Löffler).

We present an uncommon case of idiopathic hypereosinophilic syndrome with cardiac involvement (fibroplastic parietal endocarditis --Löffler's disease--) in a 48-year-old female with congestive heart failure and hypereosinophilia. The 2-D echo findings (biventricular apical obliteration by echogenic endomyocardial proliferations with normal systolic inward motion) were the clue for the diagnosis that was hemodynamically and pathologically confirmed subsequently. We emphasize the diagnostic value of two-dimensional echocardiography in this condition and review the literature on it.

[Transesophageal echocardiography in the assessment of coronary artery anatomy and blood flow]. / Ecocardiografía transesofágica en la valoración de la anatomía y flujo de las arterias coronarias.

Proximal coronary artery anatomy and coronary blood flow was evaluated by transesophageal echocardiography in 41 consecutive patients without coronary artery disease. The left main coronary artery was visualized in 37 patients (90%), the left anterior descending coronary artery in 20 (48%), the left circumflex artery in 16 (39%) and the right coronary artery in 7 (17%). The image quality was optimal in 58% of patients in left main coronary artery, 29% in left anterior descending coronary artery, 24% in left circumflex artery and 5% in right coronary artery. Transesophageal Pulsed Doppler echocardiography evaluation of blood flow velocity in the left coronary artery was obtained in 37% of patients. Velocity flow pattern was biphasic with greater diastolic component and smaller systolic one (average peak flow velocity of 47.5 +/- 16.6 cm/seg during diastole and 23.1 +/- 9.5 cm/seg during systole). Coronary blood flow was detected by transesophageal color Doppler echocardiography in 51% of patients in left main coronary artery, 24% in left anterior descending coronary artery, 19% in left circumflex artery and 2% in right coronary artery. We conclude that transesophageal echocardiography provides better and more accurate visualization of proximal coronary arteries than transthoracic echocardiography, but technical limitations still remain to detect and evaluate coronary artery anatomy and coronary blood flow in a large number of patients.

[Usefulness of carotid sinus massage for Doppler quantification of mitral stenosis in sinus rhythm]. / Utilidad del masaje del seno carotídeo en la cuantificación por técnica Doppler de la estenosis mitral en ritmo sinusal.

The quantification of mitral stenosis by pressure half-time method may be difficult in sinus rhythm with short deceleration slopes. To evaluate the usefulness of carotid sinus massage (CSM) for measuring mitral valve area by pressure half-time, 80 consecutive patients with mitral stenosis in sinus rhythm underwent a echo-Doppler study at basal heart rate and during right CSM. In both situations we measured: heart rate, mitral area by pressure half-time and E-F interval (time from E peak velocity to onset of atrial contraction). In 38 consecutive patients we also determined the mitral area by planimetry. The study group was divided into patients with basal E-F interval < or = 150 ms and a HR > or = 75 bpm (group A, 28 patients [35%]) and those with a basal E-F interval > 150 ms who showed a heart rate < 75 bpm (group B, 52 patients). In the group A, the values obtained at basal heart rate vs after CSM were: heart rate, 86 +/- 9 vs 61.6 +/- 10.5 lpm; E-F interval, 109 +/- 33 vs 372 +/- 136 ms; mitral area, 1.88 +/- 0.5 vs 1.23 +/- 0.29 cm2 (p < 0.001). In the group B, these values were: 69.7 +/- 6.6 vs 53 +/- 11 bpm, 253 +/- 60 vs 510 +/- 212 ms y 1.34 +/- 0.3 vs 1.18 +/- 0.32 cm2, respectively (p < 0.01). Mean differences in Doppler mitral areas between both situations for groups A and B were: 0.63 +/- 0.3 cm2 and 0.17 +/- 0.1 cm2, respectively (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Transesophageal echocardiography study of the left atrium and the mitral valve plane after heart transplantation]. / Estudio mediante ecocardiografía transesofágica de la aurícula izquierda y del plano valvular mitral tras el trasplante cardíaco.

To assess the anatomy of the left atrium and mitral plane after heart transplantation, we performed a transesophageal echocardiographic study to 37 consecutive transplant patients. After heart transplantation no patient was under anticoagulant treatment and no case of atrial fibrillation was documented. The transesophageal approach allowed us to measure the left atrial free wall suture which was: less than 15 mm in 14 patients, between 15 and 25 mm in 16 patients, and more than 25 mm in 7 patients. In those patients with a left atrial free wall suture greater than 15 mm, blood flow turbulences within the "niche" underneath the protruding suture as well as blood flow acceleration at the rim of that suture were noted. In 4 patients a "pseudoaneurysm" of the interatrial septum was observed. Two patients had mitral valve prolapse. Mitral regurgitation was noted in 17 patients (46%) by color Doppler transesophageal echocardiography and graded as mild in 15 patients and moderate in 2 cases. In 16 patients (43%) spontaneous echo contrast within the left atrium was detected by transesophageal echocardiography. Both major and minor axis as well as left atrial area in patients with and without dynamic echoes were, respectively: 72.5 +/- 12.2 mm vs 56.9 +/- 5.9 mm (p < 0.001), 48.3 +/- 7.1 mm vs 39 +/- 7.9 mm (p < 0.001), and 35.4 +/- 7.1 cm2 vs 24.4 +/- 5.2 cm2 (p < 0.001). Atrial thrombi were not detected. After a mean follow-up of 15 +/- 10.7 months there was no arterial thromboembolism in patients with spontaneous contrast.(ABSTRACT TRUNCATED AT 250 WORDS)

[Usefulness of transesophageal echocardiography in the critical patient]. / Utilidad de la ecocardiografía transesofágica en el paciente crítico.

To assess the usefulness and safety of transesophageal echocardiography in critically ill patients, we analysed the transesophageal echocardiography studies in 60 of such cases (age: 58 +/- 11 and 38 males). Every patient underwent a previous transthoracic echocardiogram, that was considered inadequate for diagnostic purposes. Thirty patients (50%), were on mechanical ventilation and 17 patients (28%) showed hypotension and/or shock. Forty patients (66%) were at special care units and in 31 (52%) of them, pulmonary and systemic pressures, and continuous analysis of venous pressure of oxygen were available. Indications for study were: 17 patients with clinical suspicion of aortic dissection (confirmed in 5 cases): 9 patients infective endocarditis (4 cases showed valvular vegetations); 6 patients with mitral prosthesis dysfunction (confirmed in 4 cases); complicated acute myocardial infarction (MI) in 8 patients (2 cases with mitral insufficiency, 3 with left ventricular dysfunction, 1 with right ventricular MI, 1 with left ventricular pseudoaneurysm and other with isolated inferior MI); in 11 patients the study was performed to evaluate the result of cardiac transplantation immediately (< 4 h) and it showed 2 cases of left ventricular dysfunction; 3 patients were studied for severe cardiac dysfunction of unknown etiology (a dilated cardiomyopathy was confirmed in one and ruled out in the other, and one patient showed signs of restrictive situation); there were other causes in the rest. The procedure could be completely performed in all cases. In conclusion in critically ill patients the transesophageal echocardiography has a great usefulness and minimal complications.

[The syndrome of mid-ventricular obstruction with apical aneurysm in hypertrophic myocardiopathy: presentation of a case]. / El "síndrome" de obstrucción medioventricular con aneurisma apical en la miocardiopatía hipertrófica: presentación de un caso.

We report an 81-year-old woman with hypertrophic cardiomyopathy, midventricular obstruction and associated apical aneurysm partially dyskinetic. At admission she showed a lateral acute myocardial infarction with sustained episodes of uniform ventricular tachycardia and subtle cardiac physical findings. Old apical infarction was suggested by resting thallium defects in the absence of obstructive coronary disease. The ECG revealed persistent ST elevation in the anteroapical leads without Q waves at discharge. This case report represents a rare example, in a previously asymptomatic elderly woman, of a distinct syndrome within the wide clinical spectrum of hypertrophic cardiomyopathy.

[The accuracy and applicability of different methods in the Doppler technic for the quantification of mitral stenosis]. / Precisión y aplicabilidad de los diversos métodos en técnica Doppler para la cuantificación de la estenosis mitral.

INTRODUCTION AND OBJECTIVES: We analyse the applicability and accuracy of the various Doppler methods for quantification of mitral stenosis as well as the value of combining measurements. PATIENTS AND METHODS: The study comprised 74 patients with reliable planimetry of mitral orifice. The following Doppler methods were tested: a) pressure half-time; b) color jet width at the mitral valve orifice in the apical long-axis view (short diameter) and its width in the 90 degree rotated view (long diameter), assuming an elliptic mitral orifice; c) proximal isovelocity surface area from the 4-chamber view assuming a hemispheric surface, and d) the continuity equation. The mean value of mitral valve area estimates from all applicable Doppler methods was calculated in each patient. RESULTS: The rates of applicability of each method were, respectively: 85, 97, 97 and 53% (p < 0.01). The correlations--r (SEE)--between each method and planimetry were: 0.86 (0.17 cm2), 0.81 (0.19 cm2), 0.74 (0.21 cm2) and 0.83 (0.18 cm2), respectively. The highest correlation was found with the mean value (r = 0.90; SEE = 0.14 cm2), and only this parameter was selected by stepwise multiple regression analysis (r = 0.93; SEE = 0.12 cm2). CONCLUSIONS: The continuity equation method has the lowest level of obtainable results owing to the high incidence of mitral regurgitation. The mean value of mitral area estimates from all applicable methods in each patient showed the closest correlation with planimetry, thus the performance of these Doppler methods provides improved accuracy in the quantification of mitral stenosis.

[The mitral valve apparatus in hypertrophic myocardiopathy: observations by transesophageal echocardiography]. / El aparato valvular mitral en la miocardiopatía hipertrófica: observaciones por ecocardiografía transesofágica.

INTRODUCTION AND OBJECTIVES: We analyzed the characteristics of mitral valve apparatus by transesophageal echocardiography in a consecutive series of patients with hypertrophic cardiomyopathy. METHODS: We performed a transesophageal study in 60 patients; 35 of them had intraventricular obstruction at basal state. The following measurements and observations were made in the frontal long-axis transesophageal plane: a) length of both mitral leaflets and dimensions of left ventricular outflow tract that were compared with those obtained from 25 normal subjects; b) structure involved in the systolic anterior mitral motion; c) mechanism of mitral regurgitation, and d) sequence of systolic events. RESULTS: Compared with control subjects (anterior mitral leaflet: 2.86 +/- 0.3 cm, posterior mitral leaflet: 1.62 +/- 0.2 and 1.7 +/- 0.2 cm, respectively; the mitral leaflets were longer in patients with and without subaortic obstruction (anterior leaflet: 2.3 +/- 0.1; posterior leaflet: 1.07 both, p < 0.01). Systolic anterior motion was observed in 49 patients, with mitral leaflet-septal contact in 87% of patients with obstruction and in 11% of nonobstructive patients (p < 0.01). Structures participating in this phenomenon were: distal portion of the anterior mitral leaflet (77.5%), of both mitral leaflets (18.4%) and anomalous chordae (4.1%); in 5 patients the obstruction was located at a more distal level. Mitral regurgitation was observed in 43 patients; in 37 of them the jet was posteriorly directed in late systole. Patients with hypertrophic cardiomyopathy have longer mitral leaflets with frequent associated abnormalities suggesting that this disease is not confined to myocardium and that leaflet length is not the sole determinant of the obstruction; 2) in almost 80% of patients the systolic anterior motion was produced by the distal anterior mitral leaflet resulting in incomplete coaptation in mid-systole; 3) the sequence of systolic events was ejection/obstruction/leak.

[The usefulness of transesophageal echocardiography in general intensive care units]. / Utilidad de la ecocardiografía transesofágica en las unidades de cuidados intensivos generales.

BACKGROUND AND OBJECTIVES: It's well known the utility of transesophageal echocardiography in the evaluation of cardiological patients that are critically ill. However, there is less experience about this usefulness in non-cardiological critically ill patients. METHODS: To assess the utility and safety of the method we analyzed 51 correlative studies of patients admitted to our general Intensive Care Unit. Forty-seven patients (92%) were on mechanical ventilation and in 24 patients (47%) continuous assessment of the hemodynamic variables were available. RESULTS: The most frequent diagnoses on admission were sepsis (23.5%) and shock status (17.6%). The indications were: suspicion of endocarditis (15 patients), hemodynamic instability (11 cases), cardiac source of embolus (10), suspicion of cardiac tamponade (4), suspicion of aortic dissection (4) and other causes in 7. The study confirmed the clinical suspicion in 31 cases (60.8%), excluded it in 15 (29.4%) and established a new, non-suspected, diagnosis in 5 patients (9.8%). There were major diagnostic changes in 16 patients (31.6%) and minor changes in 17 (33.3%) comparing the results of the transesophageal and transthoracic approaches. It was also assessed the influence of the result on the clinical management of the patient: in 32 cases (62.8%) there were a significant change in the treatment; in 5 patients (9.8%) cardiac surgery was prompted by echocardiography. Only in 3 patients hypertensive reactions and tachycardia were detected, without posterior consequences. CONCLUSIONS: Transesophageal echocardiography can be safely performed and has a definite role in the diagnosis (showing sometimes non-suspected abnormalities) and management of non-cardiological critically ill patients.

[Transesophageal echocardiography in mitral prosthesis dysfunction: usefulness and limitations in the evaluation of mitral insufficiency]. / Ecocardiografía transesofágica en la disfunción protésica mitral: utilidad y limitaciones en la valoración de la insuficiencia mitral.

This study was performed to test the usefulness of transesophageal echocardiography in the diagnosis and assessment of pathological mitral regurgitation in patients with mitral valve prostheses. Doppler color flow imaging by transesophageal echocardiography was compared to the transthoracic echocardiography and angiographic and surgical assessment. We analyzed the influence of the spatial configuration of the jet on the semiquantitative assessment of mitral regurgitation. We studied 71 patients with prostheses in mitral position which were submitted for transesophageal echocardiography examination. 51 of these patients were found to have a pathological prosthetic regurgitation that was confirmed in 21 cases by left ventriculography and in 4 during cardiac surgery. Transesophageal echocardiography Doppler color flow imaging identified a regurgitant jet in 31 patients (60.7%). There was complete agreement with the quantitative assessment of regurgitation by angiography or surgery in 36% of the cases. All patients with prosthetic insufficiency observed by angiography or during cardiac surgery were confirmed by transesophageal echocardiography. Complete agreement in grade of severity by transthoracic echocardiography was found in 84% of cases. There was a difference in grade of severity of mitral regurgitation in only 4 patients. Regurgitant jets were classified by transesophageal echocardiography color Doppler in two groups: free jets and impinging wall jets. 21 cases presented a free jet and 31 excentrically directed impinging wall jet of mitral regurgitation. There was complete agreement with hemodynamic assessment of severity in all patients with regurgitant free jets (11/11). In presence of jet wall there was understimation of mitral regurgitation in 28.5% (4/13).(ABSTRACT TRUNCATED AT 250 WORDS)

[The echocardiographic assessment of wall regurgitant jets in prosthetic mitral valves: the superiority of multiplanar transesophageal sections over standard sections]. / Valoración ecocardiográfica de los jets regurgitantes de pared en válvulas protésicas mitrales: superioridad de las secciones transesofágicas multiplanares sobre las secciones estándares.

OBJECTIVES: The purpose of this study was to determine whether multiplanar (MP) transesophageal echocardiographic views were superior to standard views (ST), in the evaluation of mitral prosthesis regurgitation (MR), particularly in presence of wall regurgitant jets. METHODS: We studied all mitral prostheses (n = 43) in which pathological mitral regurgitation had been detected by multiplanar TEE between January 1993 and March 1994. Regurgitant prostheses were classified in two groups according to the presence of wall regurgitant jets and maximum turbulent color flow areas (Amax.) were measured on standard (0 and 90 degrees) and MP (0 to 180 degrees) views. RESULTS: The Amax. detected on ST views were 5.80 +/- 4.60 cm2 and on MP 7.42 +/- 5.13 cm2. Student's test was used to compare both areas and significant differences were found: 1.61 cm2; 95% confidence interval from 0.94 to 2.28 cm2; p = 0.000025. The sample was divided in two groups, A (n = 33): with wall jets and B (n = 10): without wall jets. The Amax. for group A was 5.64 +/- 4.30 cm2 in ST views, and 7.51 +/- 5.12 cm2 in MP. The difference was statistically significant: 1.86 cm2, 95% c.i. from 1.04 to 2.68 cm2; p = 0.00009. Differences for group B were also statistically significant: 0.68 cm2; p = 0.0172. MP views detected a bigger regurgitant area in 26 of the 43 cases (60%). The difference between ST and MP views was significantly bigger for group A than for group B: mean 1.18 cm2; p = 0.0176. MP views detected a severer degree of MR, classified as mild moderate and severe according to the color flow area, than ST views in 8 patients. All of them had wall regurgitant jets. Three had been considered normal on ST views. CONCLUSION: We conclude that MP transesophageal views are significantly superior to ST in the assessment of regurgitant prosthetic mitral valves, particularly in presence of wall regurgitant jets. Our data strongly suggest that multiplanar TEE is the procedure of choice in the assessment of wall regurgitant mitral prostheses.

[Accuracy and clinical applicability of the echocardiographic automated endocardial boundary detection system: correlation and bias analysis]. / Precisión y aplicabilidad clínica del sistema ecocardiográfico de detección automática de bordes endocárdicos: análisis de correlación y de sesgo.

INTRODUCTION AND OBJECTIVES: Automated edge detection of endocardial borders is a new echo system that permits on-line delineation and tracking of blood-tissue interface and offers promise for measuring cyclic changes in cavity area and the assessment of left ventricular function on-line. Its accuracy has only been analyzed by linear regression and its applicability in unselected patients is not clearly established. METHODS: We analyzed the accuracy and clinical applicability of the system in 150 patients. Its accuracy was assessed not only by linear regression but also by bias analysis by comparing the results of the system with those obtained by manual tracing from parasternal short-axis and apical 4 chamber views. RESULTS: We obtained satisfactory studies with this system in at least one of the two echo views in 66% of patients: 47% from 4-chambers view, 43% from parasternal short-axis view and 24.6% from both echo views. A visual semiquantitative assessment of left ventricular function could be performed in 88.6% of patients (p < 0.001). On-line and hand-traced left ventricular areas there well correlated, but fractional area change values from both methods correlated less closely. 95% limits of agreement between both methods were: 2.8 +/- 5.5 cm2 (end-diastolic area), 1 +/- 4.4 cm2 (end-systolic area) and 1.2 +/- 23% (fractional area change) in short-axis parasternal view; in apical 4-chambers view these limits were: 1.16 +/- 6.4 cm2,--1.1 +/- 6 cm2 and 7.3 +/- 16%, respectively. CONCLUSIONS: Although the correlations between left ventricular areas from both methods were close the limits of agreement exceeded our acceptable range of reproducibility. Fractional area change showed only moderate correlations and a lack of agreement with off-line method. Poor image quality of the conventional echo still limits the clinical applicability of the current automated edge detection system.

[Perforation of the mitral valve: transesophageal echocardiographic diagnosis in 3 cases]. / Perforación de la válvula mitral: diagnóstico por ecocardiografía transesofágica en 3 casos.

We submit 3 cases of perforation of the mitral valve leaflet as a consequence of infectious endocarditis. In the first of this cases, perforation was the result of the impact of the regurgitant jet of an aortic insufficiency affected by bacterial endocarditis of the anterior mitral leaflet in a young female presenting various congenital malformations. Both the transthoracic and transesophageal echocardiography showed that the regurgitant jet affected the area where the lesions were later detected. In the other 2 cases the perforation appeared in valves previously affected by endocarditis. In these cases, only the transesophageal echocardiography showed the lesions. Surgery was performed in all 3 cases with satisfactory results, confirming the echocardiographical findings. We wish to emphasize the role of transesophageal echocardiography in the diagnosis of this rare process that may be the primary effect of the destructive action of the endocarditis, or a secondary effect, on dissemination by means of affected valves, on previously unaffected valvular leaflets.

[The progression of a postinfarct interventricular communication: an echocardiographic follow-up]. / Progresión de una comunicación interventricular postinfarto: seguimiento ecocardiográfico.

An 80-year-old female patient presented rupture of the interventricular septum as complication of acute anteroseptal myocardial infarction. Serial echocardiographic studies documented progressive increase in size of the apical defect over 16 hours. This observation highlights a potential hazard if surgical repair is deferred to "stabilize" hemodynamically the patient before the intervention.

[A pulsed Doppler transesophageal echocardiographic study of pulmonary venous flow in mitral regurgitation jets in the parietal direction]. / Estudo Doppler pulsado do fluxo venoso pulmonar por ecocardiografia transesofágica em jactos de regurgitação mitral de direcção parietal.

OBJECTIVE: Transesophageal echocardiographic analysis of the degree of severity of mitral regurgitation eccentric wall jets by color Doppler and pulsed Doppler interrogation of the pulmonary venous flow. DESIGN: Transesophageal echocardiographic prospective study. SETTING: consecutive out and in patients referred to the Echocardiographic Laboratory of Gregorio Marañon General Hospital, Madrid, Spain. MATERIAL AND METHODS: We studied 90 consecutive patients with the clinical and echocardiographic diagnosis of valvular mitral regurgitation. In each patient through pulsed Doppler transesophageal echocardiographic technique, we measured the peak velocities and areas of systolic forward flow and systolic reversed flow of the left superior pulmonary vein. By pulsed color Doppler transesophageal echocardiographic technique, we calculated total area, severity and spatial direction of the mitral regurgitant jet. MAIN RESULTS: There were 80% (72/90) of patients included in the JC group and 20% (18/90) in the JP group. The color Doppler maximal area in the JC group was 484 +/- 118 mm2 and 445 +/- 79 mm2 (p = NS) in the JP group. Mild mitral regurgitation was present in 32% (23/72) and 55% (10/18) of the patients in the JC and JP groups (p < 0.01) respectively. Severe mitral regurgitation was present in 29% (21/72) and 0% (0/18) of the same groups (p < 0.0001). Peak velocity of pulsed Doppler pulmonary venous systolic forward flow in JC and JP groups was 47 +/- 7 cm/sec and 29 +/- 8 cm/sec respectively (p < 0.01). Maximal area of pulmonary venous flow wave in JC and JP groups was 1215 +/- 140 mm2 and 568 +/- 176 mm2 (p < 0.001) respectively. Peak velocity of reversed systolic pulmonary venous flow in JC and JP groups was 28 +/- 10 cm/sec and 46 +/- 8 cm/sec (p < 0.01) respectively. Maximal area of reversed pulmonary venous flow of JC and JP groups was 124 +/- 30 mm2 and 389 +/- 40 mm2 (p < 0.001) respectively. CONCLUSIONS: Color Doppler echocardiographic evaluation of mitral regurgitation wall jets, is not an exact method to quantify their degree of severity. In the assessment of extreme eccentric mitral regurgitation jets that interact with the atrial wall, the color Doppler quantification criteria is not sufficient. In these cases of mitral regurgitation wall jets, pulmonary venous pulsed Doppler flow criteria can be useful.

[A transesophageal color-coded pulsed Doppler echocardiographic study of the spatial distribution of mitral regurgitation jets]. / Estudo ecocardiográfico Doppler pulsado codificado a cor transesofágico da distribuição espacial dos jactos de regurgitação valvular mitral.

OBJECTIVE: Transesophageal echocardiographic analysis of color Doppler characteristics of mitral valvular regurgitation jets. DESIGN: Transesophageal echocardiographic prospective study. SETTING: Ambulatory patients referred to Echocardiographic Laboratory of Gregorio Marañon General Hospital, Madrid, Spain. MATERIAL AND METHODS: We studied a group of 100 consecutive patients with mitral regurgitation diagnosis. In each patient we calculated the degree of severity, percentage of wall intersection, maximal traced area, axis direction, atrial depth, maximal transversal diameter, perimeter and angle of the mitral regurgitation jet. We divided the entire population in three different groups according to the jet direction in central (CJ), eccentric (EJ) and wall jets (WJ). MAIN RESULTS: The direction of the mitral regurgitation jet was central in 49%, eccentric in 33% and impinging the left atrial wall in 18%. The mitral regurgitation jet angle was in the CJ 80 +/- 11 degrees, EJ 33 +/- 10 degrees and WJ 6 +/- 7 degrees. Maximal mitral regurgitant traced area in CJ was 732 +/- 104 mm2, EJ was 593 +/- 110 mm2 and WJ was 267 +/- 80 mm2. Maximal regurgitant jet depth in CJ was 36 +/- 17 mm, EJ 30 +/- 15 mm and WJ 49 +/- 14 mm. The perimeter of the mitral regurgitation jet in the CJ was 87 +/- 22 mm, EJ was 68 +/- 22 mm and WJ was 92 +/- 30 mm. CONCLUSIONS: Color Doppler quantification criteria are not useful in all patients with mitral regurgitation jets. The presence of atrial walls close to the mitral regurgitation jet area is an important factor in the mitral regurgitation color Doppler evaluation.