Role of echocardiography in aortic atherosclerotic disease and stroke.

Patients with severe aortic atherosclerosis are at high risk for stroke. The risk is highest for those with atherosclerotic plaque measuring = or >4 mm in thickness. There is currently no proven medical therapy to reduce embolic risk in patients with aortic plaque. Antiplatelet therapy, smoking cessation, and management of diabetes and hypertension are important. Retrospective data support the use of statins to prevent stroke in patients with severe aortic plaque. Embolism from aortic atherosclerosis may occur spontaneously, or less commonly, as a complication of invasive or surgical cardiovascular procedures. Transesophageal echocardiography (TEE) is the procedure of choice for the characterization of plaque and the detection of superimposed mobile thrombi. Therefore, TEE is a useful tool to identify patients at high risk for stroke. For patients who are being evaluated for coronary artery bypass graft (CABG) surgery or coronary angiography, the risks and benefits of these procedures must be carefully weighed and alternate approaches should be considered in patients with severe plaque. Options include off-pump CABG or coronary angiography via a brachial (rather than femoral) approach.

Atheromas of the thoracic aorta: clinical and therapeutic update.

Atherosclerotic lesions of the thoracic aorta have recently been recognized as an important cause of stroke and peripheral embolization, which may result in severe neurologic damage as well as multiorgan failure and death. Their prevalence is approximately 27% in patients with previous embolic events. Transesophageal echocardiography is the modality of choice for the diagnosis of these atheromas, although computed tomography, magnetic resonance imaging and intraoperative epiaortic ultrasound are complementary. Two clinical syndromes account for the embolic phenomena, atheroemboli and, more commonly, thromboemboli. In addition to such superimposed thrombi, plaque thickness (especially > or =4 mm) also correlates with embolic risk. This risk is high, with 12% of patients having a recurrent stroke within approximately one year, and up to 33% of patients having a stroke or peripheral embolus. In addition, aortic atheromas (as seen with intraoperative transesophageal echocardiography and intraoperative epiaortic ultrasound) are an important cause of stroke during heart surgery requiring cardiopulmonary bypass. Such strokes occur during approximately 12% of cardiac operations employing cardiopulmonary bypass when aortic arch atheromas are seen with transesophageal echocardiography (six times the general intraoperative stroke rate). Although anticoagulant strategies have been reported with encouraging results in nonrandomized studies, prospective, randomized data must be developed before an effective and safe treatment strategy can be determined. This review details the current state of knowledge in this area, including the clinical and pathologic evidence that thoracic aortic atherosclerosis is an important embolic source, data which guide current therapy and future directions for clinical investigation.

Use of two-dimensional echocardiography during transseptal cardiac catheterization.

Inadvertent puncture of the intrapericardial aorta is a serious complication of transseptal catheterization. Two-dimensional echocardiography allows delineation and spatial resolution of the aorta and interatrial septum. Thirteen patients underwent transseptal catheterization with simultaneous monitoring of needle and catheter position using fluoroscopy and two-dimensional echocardiography. The interatrial septum was demonstrated in the short-axis and four chamber views, and clearly separated from the ascending aorta. The transseptal needle and catheter were visualized by echocardiography while the needle tip was manipulated into the fossa ovalis avoiding puncture of the aortic root. In some cases, under pressure from the needle tip just before puncture, the interatrial septum appears to bulge toward the left atrium. Saline solution contrast echocardiography helped to confirm the needle position in the right atrium, and in the left atrium after puncture. These data suggest that two-dimensional echocardiography is a useful adjunct to fluoroscopy during transseptal catheterization that may improve its safety and prevent complications.

Sterile, caseous mitral anular abscess.

Echocardiography identified three patients with a mitral anular mass. Fluoroscopy demonstrated a faint, homogeneous intracardiac calcific density in each patient. Cardiac catheterization and angiography were performed and showed no left ventricular inflow or outflow obstruction. One patient died suddenly and two patients had cardiac surgery (one for mitral regurgitation and another for constrictive pericarditis). Examination demonstrated that each mass was nonencapsulated, sterile and acellular and contained cholesterol, calcium and fatty acids. The clinical significance and cause of these masses are unclear at present.

Cardiac tamponade by loculated pericardial hematoma: limitations of M-mode echocardiography.

Three patients developed cardiac tamponade after heart surgery. Pericardial effusion was not identified by M-mode echocardiography. Two patients underwent two-dimensional echocardiography which showed compression of the right atrium by a localized mass. At reoperation, atrial compression by a loculated effusion or hematoma was found and successfully relieved. When cardiac tamponade is suggested by the clinical setting, but not supported by M-mode echocardiography, the presence of a loculated effusion should be considered and evaluated by a two-dimensional echocardiographic study.

Diastolic atrial compression: a sensitive echocardiographic sign of cardiac tamponade.

Nine patients with clinical and hemodynamic evidence of cardiac tamponade underwent M-mode and two-dimensional echocardiography. Pericardial effusion was documented in each patient. Four patients demonstrated respiratory variation in ventricular volumes in association with paradoxical pulse. Right ventricular compression was present in seven. In five patients, echocardiography demonstrated diastolic left atrial compression. In all nine patients, the apical four chamber view revealed diastolic right atrial compression. Drainage of 450 to 1,800 cc of pericardial fluid relieved the cardiac tamponade and eliminated the echocardiographic findings associated with this disorder. These observations suggest that the echocardiographic findings of atrial compression is a sensitive sign of cardiac tamponade.

Discrete atherosclerotic coronary artery aneurysms: a study of 20 patients.

The incidence, angiographic features and natural history of discrete atherosclerotic coronary aneurysms were evaluated in 20 patients with 22 aneurysms (0.2% of 8,422 patients referred for coronary angiography). Fifteen aneurysms (68%) were in the left anterior descending, four (18%) in the circumflex, two (9%) in the right and one (5%) in the left main coronary artery. Aneurysm diameter ranged from 4 to 35 mm (mean 8); 95% of aneurysms were adjacent to a severe obstruction. Seventy-five percent of patients had severe triple vessel disease that included severe left main disease in 15%. Total obstruction of one or two arteries was present in 75%. In patients with wall motion abnormalities, 78% of the abnormalities were in the distribution of the aneurysm. Follow-up (range 1 to 90 months [mean 30]) was obtained in all 20 patients. There were two cardiac and two noncardiac deaths; 12 patients had coronary bypass surgery and of 16 survivors, 13 were angina-free. In conclusion, discrete coronary aneurysms are much less common than diffuse ectasia. Unlike ectasia, they are never found in arteries without severe stenosis, and are most common in the left anterior descending coronary artery. Associated coronary artery disease is more severe in patients with discrete aneurysms than in those with diffuse ectasia. Discrete coronary aneurysms do not appear to rupture, and their resection is not warranted.

How useful is hand-carried bedside echocardiography in critically ill patients?

OBJECTIVES: The study compared a hand-carried echocardiography (HC) device with standard echocardiography (SE) in critically ill patients. BACKGROUND: Recently, small HC devices have been introduced, and early reports showed a good correlation with SE. METHODS: We used HC (SonoSite, Bothell, Washington) echocardiography to evaluate critically ill patients, and we compared the results with SE obtained with state-of-the-art equipment (Sonos 5500, Hewlett-Packard, Andover, Massachusetts). Each of 80 critically ill patients was studied twice (HC and SE). The studies were done and interpreted separately in blinded fashion. RESULTS: The HC device missed a clinical finding related to the reason for referral in 31% of patients. In 19% of patients a clinically important finding separate from the indication for echocardiography was also missed. The total number of patients with one or more missed findings was 36 (45%). Findings were missed by HC for several reasons. First, HC does not contain spectral Doppler, electrocardiographic, or M-mode capabilities. Two-dimensional imaging is superior on SE, with improved image processing. In addition, although HC does contain color power Doppler, it does not have true color flow Doppler imaging. Therefore, HC often failed to detect or accurately quantify valvular regurgitation. CONCLUSIONS: Although the HC device was able to provide important anatomic information, the device falls far short of SE in the evaluation of critically ill patients.

Left ventricular outflow obstruction: a complication of mitral valvuloplasty.

Thirty-two patients with severe mitral regurgitation underwent Carpentier mitral valvuloplasty. Postoperatively, three of these patients developed clinical and echocardiographic evidence of left ventricular outflow tract obstruction. None of these patients had asymmetric septal hypertrophy or preoperative echocardiographic demonstration of systolic anterior motion of the mitral valve. Outflow obstruction postoperatively was caused by systolic anterior motion of the mitral valve. Because this potential complication of Carpentier mitral valvuloplasty produced significant hemodynamic effects in two patients, echocardiography should be routinely performed after this operation.

Transesophageal echocardiography to detect atrial clots in candidates for percutaneous transseptal mitral balloon valvuloplasty.

Left atrial thrombi are common in patients with mitral stenosis. When percutaneous balloon mitral valvuloplasty is performed on such patients, there is a potential risk of thrombus dislodgment and embolization. In this study conventional transthoracic echocardiography and transesophageal echocardiography were performed for percutaneous balloon mitral valvuloplasty on 19 consecutive candidates (6 men, 13 women, 23 to 81 years old). In five patients (26%), transesophageal echocardiography revealed a left atrial thrombus; in only one of these was there a suspicion of left atrial thrombus on transthoracic echocardiography. Balloon mitral valvuloplasty was canceled in four of the five patients. Three underwent mitral valve surgery that confirmed the echocardiographic findings. Transesophageal echocardiography is better than conventional transthoracic echocardiography in detecting left atrial clots in candidates for balloon mitral valvuloplasty. Because of the potential risk of embolization, transesophageal echocardiography is recommended in all candidates for balloon mitral valvuloplasty.

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.

High risk for vascular events in patients with protruding aortic atheromas: a prospective study.

OBJECTIVES: The purpose of this study was to prospectively evaluate the risk of vascular events in patients with protruding aortic atheromas. BACKGROUND: Protruding atheromas of the thoracic aorta have been shown to be associated with embolic disease in previous retrospective studies. METHODS: During a 1-year period, 521 patients had transesophageal echocardiography. Of these, 42 patients had protruding atheromas and no other source of emboli. They were followed up for up to 2 years (mean follow-up 14 months) and compared with a control group without atheromas, matched for age, gender and hypertension. RESULTS: Of 42 patients with atheromas, 14 (33%) had 19 vascular events during follow-up (5 brain, 2 eye, 4 kidney, 1 bowel, 7 lower extremity). Of 42 control patients, 3 (7%) had vascular events (2 brain, 1 eye). Univariate analysis identified only protruding atheromas as significantly correlating with events (p = 0.003). There was no positive correlation of events with age, gender, hypertension, smoking, family history, atrial fibrillation, valve replacement, antithrombotic drug use, diabetes or coronary disease. Multivariate analysis showed that only protruding atheromas independently predicted events (p = 0.005, odds ratio 4.3, 95% confidence interval 1.2 to 15.0). Nine patients died in the atheroma group versus six in the control group, but this was not statistically significant (p = 0.39). CONCLUSIONS: Protruding atheromas seen on transesophageal echocardiography predict future vascular events.

Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography.

Protruding atheromas of the aortic arch identified by transesophageal echocardiography have been implicated as a cause of stroke in elderly patients. One hundred thirty patients greater than or equal to 65 years of age were studied with intraoperative transesophageal echocardiography to detect aortic arch protruding atheromas and determine if these patients were at higher risk for perioperative stroke. Protruding atheromas were identified in 23 (18%) of 130 patients. In 19 (83%) of these 23 patients, palpation of the aortic arch at operation did not identify significant abnormalities. Five patients (4%) had perioperative stroke. Logistic regression identified aortic arch atheroma as the only historical or procedural variable that was predictive of stroke (odds ratio 5.8, 95% confidence interval 1.2 to 27.9, p less than 0.03). A history of peripheral or cerebrovascular disease, presence of aortic calcification, cardiac risk factors, age and duration of cardiopulmonary bypass did not predict stroke. In contrast, patients with protruding atheromas with mobile components were at highest risk. There were 3 (25%) of 12 patients with a mobile atheroma who had a stroke versus 2 (2%) of 118 patients without a mobile atheroma (chi-square = 10.3, p = 0.001). Displacement and detachment of the frail, protruding atherosclerotic material by aortic arch cannulation or by the high pressure jet emanating from the cannula tip may play an important role in the creation of embolization and stroke.

Transesophageal echocardiography is superior to transthoracic echocardiography in the diagnosis of sinus venosus atrial septal defect.

The purpose of this study was to compare transthoracic and transesophageal echocardiography in the diagnosis of various types of atrial septal defects. Forty-one adult patients with the clinical diagnosis of atrial septal defect were studied by transthoracic and transesophageal echocardiography (30 women, 11 men; 18 to 81 years of age). Transthoracic echocardiography demonstrated the atrial septal defect in 33 patients (secundum type in 28, primum type in 3 and sinus venosus type in 2). Transesophageal echocardiography demonstrated the defect in all 41 patients. Thus, in 8 (20%) of 41 patients the atrial septal defect was demonstrated by transesophageal and not by transthoracic echocardiography. Six of the eight had a sinus venosus type atrial septal defect; the other two patients had a secundum atrial septal defect (one of these two had a technically poor transthoracic echocardiogram and the other had a small atrial septal defect). Transthoracic echocardiography, therefore, failed to demonstrate the sinus venosus defect in six (75%) of eight patients. An anomalous venous connection associated with the sinus venosus defect was visualized by transesophageal echocardiography in seven of the eight patients but was not seen on transthoracic echocardiography in any patient. Sinus venosus type atrial septal defects are frequently not visualized in adults by conventional transthoracic echocardiography. Transesophageal echocardiography is recommended when an atrial septal defect is clinically suspected but cannot be visualized by transthoracic echocardiography.

Long-term prognostic significance of dobutamine echocardiography in patients with suspected coronary artery disease: results of a 5-year follow-up study.

OBJECTIVES: This study sought to assess the long-term prognostic utility of dobutamine stress echocardiography in predicting fatal and nonfatal cardiac events. BACKGROUND: Although dobutamine stress echocardiography has improved sensitivity and specificity for detection of coronary artery disease, little is known of its predictive value for long-term cardiac events. Therefore, we followed up 120 consecutive patients who underwent dobutamine echocardiography for suspected coronary disease from March 1989 to August 1991. METHODS: All patients presenting for coronary angiography for chest pain were eligible for recruitment. Follow-up was 100% complete at 5 years (range 3.0 to 6.1). Cardiac events were defined as cardiac death or nonfatal myocardial infarction or the need for coronary revascularization (coronary angioplasty or bypass surgery). RESULTS: Positive (n = 78) and negative (n = 42) dobutamine test groups differed in their rates of coronary artery bypass graft surgery (37.2% vs. 9.5%, p < 0.001, respectively) and mortality. Of 26 total deaths, 22 occurred in the group with positive dobutamine test results (28% vs. 9.5%, p < 0.018); all 7 cardiac deaths occurred in this group as well (9% vs. 0%, p < 0.045). By multivariate regression analysis, positive results on dobutamine echocardiography remained independently predictive of future cardiac death after left ventricular ejection fraction and other clinical variables were accounted for. CONCLUSIONS: A positive finding on dobutamine echocardiography is an independent predictor of long-term cardiac mortality, whereas a negative finding confers a significantly reduced likelihood of cardiac death as much as 5 years from initial testing. We conclude that dobutamine stress echocardiography can be used to predict which patients with suspected coronary artery disease are at low risk for cardiac death and do not require concurrent nuclear or invasive testing.

Contrast echocardiography clarifies uninterpretable wall motion in intensive care unit patients.

OBJECTIVES: The study examined the value of contrast echocardiography in the assessment of left ventricular (LV) wall motion in intensive care unit (ICU) patients. BACKGROUND: Echocardiograms done in the ICU are often suboptimal. The most common indication is the evaluation of LV wall motion and ejection fraction (EF). METHODS: Transthoracic echocardiograms were done in 70 unselected ICU patients. Wall motion was evaluated on standard echocardiography (SE), harmonic echocardiography (HE), and after intravenous (IV) contrast echocardiography (CE) using a score for each of 16 segments. A confidence score was also given for each segment with each technique (unable to judge; not sure; sure). The EF was estimated visually for each technique, and a confidence score was applied to the EF. RESULTS: Uninterpretable wall motion was present in 5.4 segments/patient on SE, 4.4 on HE (p = 0.2), and 1.1 on CE (p < 0.0001). An average of 7.8 segments were read with surety on SE, 9.2 on HE (p = 0.1), and 13.7 on CE (p < 0.0001). Ejection fraction was uninterpretable in 23% on SE, 13% on HE (p = 0.14), and 0% on CE (p = 0.002 vs. HE; p < 0.0001 vs. SE). The EF was read with surety in 56% of patients on SE, 62% on HE (p = 0.47), and 91% on CE (p < 0.0001). Thus, wall motion was seen with more confidence on CE. More importantly, the actual readings of segmental wall motion and EF significantly differed using CE. CONCLUSIONS: CE should be used in all ICU patients with suboptimal transthoracic echocardiograms.

Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study.

OBJECTIVES: This study sought to determine the incidence of incomplete ligation of the left atrial appendage (LAA) during mitral valve surgery. BACKGROUND: Ligation of the LAA to prevent future thromboembolic events is commonly performed during mitral surgery. However, success in completely excluding the appendage from the circulation has never been systematically assessed. METHODS: Using transesophageal Doppler echocardiography, we studied 50 patients who underwent mitral valve surgery and ligation of the LAA. Thirty patients were studied immediately postoperative, and 20 patients were studied 6 days to 13 years after surgery. Incomplete ligation was detected by demonstrating a color jet traversing the separation between the left atrial body and appendage. RESULTS: Transesophageal echocardiography detected incomplete LAA ligation in 18 of 50 (36%) patients. The incidence of incomplete ligation was not significantly different between patients studied immediately postoperative and patients studied at various times after surgery. Type of mitral surgery (repair vs. replacement), operative approach (sternotomy vs. port access), left atrial size or degree of mitral regurgitation did not significantly correlate with the incidence of incomplete appendage ligation. However, the power to detect a significant difference in left atrial size was only 64%. Spontaneous echo contrast or thrombus was identified within appendages in 9 of 18 (50%) patients with incomplete ligation, while 4 of these 18 (22%) patients had thromboembolic events. CONCLUSIONS: Surgical LAA ligation is frequently incomplete. The similar incidence of incomplete ligation detected immediately postoperative and at various times thereafter suggest that this results from an intraoperative phenomenon rather than from gradual dehiscence of sutures over years. The incidence of incomplete left atrial ligation was unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events.

Valve strands are strongly associated with systemic embolization: a transesophageal echocardiographic study.

OBJECTIVES: We attempted to determine the prevalence of strands on native and prosthetic valves, as detected by transesophageal echocardiography, and to assess the relative risk for systemic emboli associated with these strands. BACKGROUND: Fine threadlike strands, seen on native and prosthetic valves by transesophageal echocardiography, have been implicated in systemic embolization. METHODS: During a 2-year period, 1,559 patients underwent transesophageal echocardiography at our center. Of these, 41 patients had strands and no other identifiable source of systemic emboli. They were matched for age, gender, history of hypertension and history of smoking with a control group of 41 patients without strands who also had no identifiable source of emboli. The risk of embolization in the two groups was compared. RESULTS: Of 1,559 patients studied by transesophageal echocardiography, 86 (5.5%) had strands. Strands were far more common on mitral valves than on aortic valves. Of the patients with strands, 38% had had an event consistent with a systemic embolus, whereas 62% had not. Of 597 patients with an embolic event, 63 (10.6%) had strands, whereas only 23 (2.3%) of 962 patients without emboli had strands. In the case-control study, 33 (83%) of the 41 patients with strands without another source of embolism had emboli compared with only 12 (29%) of the 41 control patients without another source (odds ratio 10.0, 95% confidence interval 3.6 to 27.8, p = 0.00001). CONCLUSIONS: Valvular strands visualized by transesophageal echocardiography are associated with systemic embolization.

Doppler echocardiography and computed tomography in diagnosis of left coronary arteriovenous fistula.

A 37 year old man with recurrent episodes of endocarditis was found to have a large left coronary arteriovenous fistula communicating with the right atrium. The origin and termination of the fistula were identified using computed tomography and two-dimensional Doppler echocardiography. Coronary angiography confirmed the diagnosis and the patient underwent a successful operation.

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.