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.

Acute pericardial distension in pigs: effect of fluid conductance on body surface electrocardiogram QRS size.

OBJECTIVES: Pericardial effusion has long been associated with low voltage of the surface electrocardiogram and its clinical utility is well known. The cause of this reduced QRS voltage has usually been attributed to short circuiting of the impulses by the pericardial fluid, but its precise mechanism has not been clearly elucidated. Therefore, we investigated this phenomenon by instilling various fluids with different resistances in increasing volumes into the pericardial space to finally produce acute cardiac tamponade. METHODS: Acute cardiac tamponade was produced 65 times in 25 closed chest pigs with a mean weight of 57(SEM 1.2) kg. A sufficient quantity (mean = 200 ml) of plasma, saline, blood, and blood with varying packed cell volume was introduced into the pericardial space in 60 ml increments to decrease systemic and pulmonary pressures to 50% of control to produce cardiac tamponade. At that point intrapericardial pressure had increased to 15-20 mm Hg. Resistivity values for the instilled fluids are 150 omega-cm for blood, 60 omega-cm for plasma, and 50 omega-cm for saline. RESULTS: Mean limb and precordial lead QRS voltage fell significantly, with no significant differences among these fluids. Electrocardiograph recordings from a unipolar electrode catheter in the right ventricle showed an increase in R wave voltage, but body surface recordings of stimuli introduced into the right atrium via a bipolar electrode catheter showed no amplitude change. CONCLUSIONS: In considering possibilities such as internal shunting of cardiac currents by intrapericardial fluid, distance of the heart from body surface electrodes, and change in cardiac position, the results are best explained by a reduction of cardiac volume and size during cardiac tamponade. This conclusion confirms Brody's hypothesis.

A two-bag system for continuous measurement of oxygen uptake.

Collection of mixed expired gas in a bag has been a classic method for the estimation of VO2 during the steady state but has not been employed during unsteady state exercise in part because there is a need for suspending the acquisition of data during the period of gas analysis unless many bags are used. In this study a two-bag system is described in which one bag fills while the other is analyzed. Bag volume is under the control of the operator, and we employed volumes of 30 to 50 L. Thirty-one subjects were studied with this circuit in a progressive treadmill test. Although VO2 could be falsely elevated during periods of overbreathing, this source of error could be identified and its effect reduced if VO2 was plotted against both ventilation and power requirement. Plateau values of VO2 were identified only in six subjects and the ventilatory threshold in 16.

Atrial natriuretic hormone. Predictive of the hypokalemic response to thiazide therapy in essential hypertension.

Thiazide diuretics cause hypokalemia in some, but not all patients. Adding a second diuretic with a different mechanism of action greatly increases the chance of inducing hypokalemia. Suggestive causative factors include hyperaldosteronism, acid-base status, and the degree of natriuresis. Atrial natriuretic hormone (ANH), a circulating peptide secreted primarily by the heart in response to changes in intravascular volume, induces a natriuresis by a mechanism distinct from the thiazides. It was previously shown that furosemide and thiazide diuretics can increase plasma ANH levels in some patients, but reduce ANH levels in others. This phenomenon was investigated in 26 patients with uncomplicated essential hypertension to observe the relationships between ANH and changes in serum potassium (K+) in response to chronic hydrochlorothiazide therapy (HCTZ, 50 mg/day for 1 month). Regression analysis demonstrated significant correlations between K+ level after HCTZ and initial ANH (r = 0.68, P less than .001), change in K+ level and initial ANH (r = 0.40, P less than .05), K+ level after HCTZ and change in ANH (r = -0.64, P less than .001), and change in K+ levels and change in ANH levels (r = -0.38, P less than .05). By multivariate analysis, initial ANH level, but not the plasma aldosterone level, was significantly (P less than .05) related to the change in K+ after HCTZ. These results suggest that initial plasma ANH levels are a marker predictive for diuretic-induced hypokalemia.

Superior vena caval blood flow velocities in adults: a Doppler echocardiographic study.

Superior vena caval blood flow velocity was measured in 30 normal adults (age 20-65, mean 36 yr). The flow velocities were measured by pulsed Doppler echocardiography, using a Duplex system with the transducer at the right supraclavicular fossa, approximating a 0 degrees Doppler angle. Four distinct flow waveforms were found during each cardiac cycle: A, a small retrograde flow during right atrial contraction (peak flow velocity 12.4 +/- 2.2 cm/s); B, a small antegrade flow during right atrial relaxation (15.7 +/- 5.0 cm/s); S, a large antegrade flow during ventricular systole (35.2 +/- 7.3 cm/s); and D, a large antegrade flow during ventricular diastole (23.2 +/- 3.1 cm/s). The wave duration was inversely related to heart rate. The peak flow velocities of the S and D waves were inversely related to the patients' ages. This study provides recognition of the pattern and range of normality essential to extension of this noninvasive technique to the diagnosis of pathological conditions.

Lower frequency (5 MHZ) intracardiac echocardiography in a large swine model: imaging views and research applications.

Our previous investigation indicated that, in the 50-114-kg weight range, the swine model provides transeosophageal echocardiographic normal values for cardiac structures comparable to those found in human adults. Intracardiac echocardiographic imaging using a 12.5-MHz ultrasound catheter is limited, due to ultrasonic attenuation. Transesophageal echocardiographic imaging of the right heart is also limited with its anterior anatomic location. To further study the utility of intracardiac imaging, we placed a 5-MHz (30 Fr) multiplane transducer at the junction of the superior vena cava and right atrium, in the right atrium and right ventricle in 8 closed-chest swine (weight 129 +/- 61 kg). In each animal, complete whole heart imaging was obtained, with tomographic views including the cardiac 4-chamber, right atrium, right ventricle and outflow, left atrium and ventricle, and basal great vessels. Major intracardiac anatomic landmarks (i.e., crista terminalis, right atrial appendage, coronary sinus orifice, interatrial septum, tricuspid valve, right ventricular outflow, pulmonary veins, mitral valve and left ventricular papillary muscles) were visualized in every swine. Thus, this 5-MHz multiplane transducer, as a prototype for a steerable low-frequency intracardiac ultrasound catheter, improved both whole heart and individual cardiac structure imaging from a single intracardiac location. Further technological development and refinement is needed for routine use in research and clinical imaging practice.

Clinical applications of two-dimensional/Doppler echocardiography.

The number of clinical applications for which Doppler echocardiography can, or could, be used is substantial. We must acknowledge that in our institution, the use of pulsed Doppler echocardiography is relatively routine, and we are enthusiastic about its contributions to diagnostic echocardiography. Having used Doppler echocardiography in our laboratory for a number of years, we are impressed that the study of intracardiac flow disturbances helps us understand clinical cardiac disorders more fully, and we believe the technique will become more widespread over the next few years. At present, we believe pulsed Doppler to be a useful and often necessary part of the echocardiographic evaluation of patients with valvular and congenital heart disease. Moreover, the prospects for using Doppler echocardiography to quantitate volume flow and ventricular function appear intriguing and promising. Other potential applications which we discussed, though only speculative at present, may well be realized as future technologic improvements occur. Thus, the future of pulsed Doppler echocardiography appears exciting.

Comparison of multiple views for the evaluation of pulmonary arterial blood flow by Doppler echocardiography.

Forty adult patients underwent Doppler and two-dimensional echocardiographic examination of the pulmonary artery from multiple views to determine the variability in the magnitude of Doppler-determined flow velocity and pulmonary arterial diameter from various echocardiographic windows. Flows were recorded from two or more views in 32 patients (80%). Twelve of these patients (38%) had flow velocities recorded from two or more views that were within 6% of each other. Twenty of these patients (62%) had view-dependent differences in measured flow velocity ranging from 7% to 48%. The commonly used parasternal short-axis view yielded the highest pulmonary arterial flow velocity in only 35% of the patients studied. Determinations of pulmonary arterial blood flow can vary markedly when measured from different sites, and this is presumably due to varying ability to approximate a zero-degree Doppler angle from different views. Measurement of pulmonary arterial flow velocity should be attempted from multiple views, and the highest flow velocity should be selected as that obtained with the best zero-degree Doppler angle approximation.

Use of a mouth gag instrument to facilitate bite block insertion and prevent finger and probe bites during transesophageal echocardiography.

Transesophageal echocardiography greatly enhances the examination of patients difficult to image transthoracically. While of low patient risk, a potential for harm from human bites to the echocardiography staff and to the transesophageal probe remains, particularly when dealing with uncooperative patients. This risk potential prompted implementation of additional anti-bite protection in our universal precautions policy beyond use of a standard mouth guard. A mouth gag instrument was modified by placing latex rubber tubing over the instrument blades. This instrument was inserted into the mouth and set in an open position giving the operator safe access for probe and mouth bite guard insertion. This technique improved access to the patient's mouth and visualization of probe insertion without the mouth bite guard. The mouth gag instrument provided an insertion of the transesophageal probe in impaired or otherwise uncooperative patients, which was safer for the patient, laboratory staff, and the probe itself.

Detection of left ventricular thrombus by two-dimensional echocardiography: sensitivity, specificity, and causes of uncertainty.

To define the sensitivity, specificity and predictive accuracy of two-dimensional echocardiographic detection of left ventricular thrombus, the echocardiograms of 78 patients who had independent proof of the presence or absence of a left ventricular thrombus were interpreted without knowledge of any clinical data. The presence of thrombus was established by autopsy in four patients, by aneurysmectomy in three, and by indium-111 platelet imaging in 15; the absence of thrombus was proved by autopsy in 55 patients and by aneurysmectomy in one patient. The characteristics of true-positive and false-positive echocardiograms, interobserver variability, and clinical features associated with proved thrombus were also defined. The echocardiogram was positive for thrombus in 22 patients, equivocal in seven and negative in 49. For detection of thrombus, a positive or equivocal echocardiogram had a sensitivity of 95% (21 of 22), a specificity of 86% (48 of 56), and a predictive value of 72% (21 of 29); the predictive value of a negative study was 98% (48 of 49). Considering positive and equivocal studies separately, the predictive value of a positive study was 86% (19 of 22), while that of an equivocal study was only 29% (two of seven). Compared with patients who had no thrombus, patients with proved thrombus had a higher prevalence of electrocardiographic transmural anterior infarction (86% vs 13%), left ventricular aneurysm (73% vs 5%), and clinical systemic emboli (36% vs 7%) (all p less than 0.05). These clinical features help to identify a subset of patients most likely to have left ventricular thrombi who may benefit from echocardiography. Two-dimensional echocardiography is highly sensitive in detecting left ventricular thrombus, but false-positive studies are relatively common. Several echocardiographic criteria derived from analysis of the true and false positives in this study may help minimize diagnostic errors.

Relation between diastolic left ventricular function and myocardial blood volume during adenosine-induced coronary hyperemia.

Adenosine infusion is accompanied by increases in coronary blood flow and myocardial blood volume. Myocardial blood volume may produce changes in diastolic left ventricular (LV) performance by increasing myocardial turgor. Diastolic dysfunction may also be the result of myocardial ischemia. The relation between changes in LV mass and diastolic function has not been previously investigated. This study examined the relation between changes in LV mass during adenosine-induced coronary hyperemia and LV diastolic function. Serial two-dimensional and Doppler echocardiographic measurements were made before, during, and after adenosine infusion (140 micrograms/min for 6 min) in 21 patients with (group 1) and 10 patients without (group 2) coronary artery disease (CAD). The LV mass and transmitral diastolic filling indexes were determined from digitized images from apical four-chamber view. Adenosine infusion produced a greater increase in LV mass in group 2 than in group 1 (29% +/- 11% vs 9% +/- 6%, p < 0.0002). The ratio of transmitral early (E) to atrial (A) filling velocity (E/A) increased 10% +/- 16% in group 2 and decreased 8% +/- 20% in group 1 (p < 0.02), and the velocity time integral of early filling increased 11% +/- 52% in group 2 and decreased 20% +/- 31% in group 1 (p < 0.04). There was a correlation between the change in E/A ratio and the LV mass (r = 0.53, p < 0.003). Thus adenosine infusion caused a greater increase in LV mass in normal subjects than in patients with CAD. There were also changes in Doppler-derived indexes of diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

Doppler echocardiographic evaluation of the spectrum of left ventricular diastolic dysfunction in essential hypertension.

Left ventricular topography and diastolic and systolic functions were studied in 41 patients with essential hypertension (group 1) and 33 age-matched normal adults (group 2) by Doppler echocardiography. In group 1 54% had LV concentric hypertrophy, 19% had combined concentric hypertrophy and eccentric remodeling, and 27% had concentric remodeling. LV systolic function was within the normal range. In concentric LV remodeling, the EDV was significantly decreased (compared with group 2) (84 +/- 15 vs 130 +/- 38 ml, p < 0.05), whereas the NPFR was normal (2.89 +/- 0.65 vs 3.22 +/- 0.83 sec-1, p = NS). In concentric hypertrophy, LV end-diastolic and end-systolic volumes were normal, but the NPFR was decreased (2.04 +/- 0.59 sec-1). Patients with concentric hypertrophy and eccentric remodeling had the largest end-diastolic (140 +/- 48 ml) and end-systolic (62 +/- 32 ml) volumes and the lowest NPFR (1.67 +/- 0.69 sec-1). The LVMI inversely correlated with the NPFR (r = -0.89, p < 0.0001). Thus LV concentric hypertrophy with or without concentric or eccentric remodeling is seen in patients with systemic hypertension. A decrease in peak filling occurs early in the evolution of hypertensive heart disease and is observed even when systolic performance is still normal.

Long-term follow-up after mitral valve reconstruction: incidence of postoperative left ventricular outflow obstruction.

Reconstructive surgery of the mitral valve has been an alternative to mitral valve replacement in patients with mitral regurgitation. Previously, we reported on postoperative left ventricular outflow tract obstruction associated with systolic anterior motion of the anterior mitral leaflet. The current study was designed to evaluate the incidence of this complication and the long-term results of mitral valve reconstructive surgery. Sixty-five patients, aged 19 to 78 years, had mitral valve reconstructive surgery. Two patients died perioperatively, and three died late after surgery. The 60 surviving patients were studied by M mode, two-dimensional, and Doppler echocardiography 1 to 55 months postoperatively (mean 21). Fifty patients had no evidence of postoperative mitral regurgitation, two patients had moderate mitral regurgitation, three patients had mild mitral regurgitation, and five patients had trace mitral regurgitation. No significant mitral stenosis was detected in any patient postoperatively. After surgery, the diameter of the left ventricular outflow tract was significantly smaller than that before surgery. The echocardiograms of six patients showed abnormal systolic anterior motion of the anterior mitral leaflet that was not observed preoperatively. Doppler echocardiography demonstrated pressure gradients across the left ventricular outflow tract between 10 and 64 mm Hg. Inhalation of amyl nitrite increased these gradients. An additional patient who had systolic anterior motion but no gradient developed a 36 mm Hg gradient after inhalation of amyl nitrite. The remaining patients had no gradient induced by amyl nitrite. Abnormal systolic anterior motion of the anterior mitral leaflet may be surgically induced by changes in left ventricular geometry and the size of the left ventricular outflow tract during systole.(ABSTRACT TRUNCATED AT 250 WORDS)

Swine models for cardiovascular research: a low stress transport and restraint system for large swine.

A restraint and transport system was developed for handling large swine during cardiovascular research studies. The major design criteria provided for comfortable, low stress restraint of the swine, safety for laboratory personnel and ability to perform a wide variety of hemodynamic and echocardiographic measurements in the standing, supported standing and sedated, or in Panepinto sling positions. A head gate is provided for venipuncture procedures, and an auxiliary feeding and watering front panel can replace the head gate for use of the system as a post-operative "recovery room". Using this system animals weighing 22 to 150 kg can be easily managed.

Mitral valve repair is superior to valve replacement for the early preservation of cardiac function: relation of ventricular geometry to function.

The immediate effect or mitral valve repair (MVP) or replacement (MVR) on cardiac function was compared in patients with mitral regurgitation in relation to the changes in left ventricular (LV) function and geometry by using intraoperative transesophageal echocardiography in 29 patients with MVP and 21 patients with MVR, before and immediately after cardiopulmonary bypass. The LV volumes, ejection fraction, and long-axis and short-axis lengths and eccentricity index (ratio of long axis to short axis) at end-systole and end-diastole were measured. After both MVP and MVR, there were significant decreases in LV end-diastolic volume (p < 0.0001). However, the ejection fraction did not change after MVP, whereas it decreased after MVR (p < 0.0001). After MVP, there was an increase in eccentricity index at end-systole (p < 0.0001). After MVR, there was no decrease in end-systolic volume, and the eccentricity index was lower than that after MVP (p < 0.0001). The change in LV ejection fraction correlated with the changes in eccentricity index at end-systole (r = 0.55; p < 0.0001) and end-diastole (r = 0.42; p < 0.0003). Immediate intraoperative LV function is preserved after MVP but is depressed after MVR for mitral regurgitation. The changes in ejection fraction correlate with changes in ventricular geometry.