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.

Frequency and implications of resetting and entrainment with right atrial stimulation in atrial flutter.

Thirty-three patients (24 with typical and 9 with atypical flutter-wave morphology) were studied to evaluate the incidence and implications of resetting and entrainment of atrial flutter with right atrial stimulation. Resetting with single extrastimulus was present in 23 cases (group A) and absent in 10 (group B). Most cases of reset flutter were typical (20 of 23). Fixed fusion indicative of entrainment was observed in all 29 cases with pacing trains. Groups A and B did not differ significantly in flutter cycle length (230 +/- 20 vs 223 +/- 19 ms), atrial functional refractory period (165 +/- 18 vs 167 +/- 22 ms) or longest paced cycle length producing entrainment (213 +/- 19 vs 210 +/- 19 ms). In contrast, the return cycle after the longest paced cycle length producing entrainment was significantly shorter in group A (228 +/- 27 vs 284 +/- 56 ms; p = 0.001). The return cycle in group A was virtually identical to the flutter cycle length, whereas in group B it was greater (p = 0.002 compared with group A). Resetting was more frequent in typical than atypical flutter (20 of 24 vs 3 of 9; p = 0.01). Both typical and atypical flutter can be transiently entrained by right atrial pacing. Lack of resetting and longer return cycle, suggesting a longer conduction time between the reentrant circuit and the stimulation site, were mostly observed in atypical flutter. The data suggest a different location for both types of flutter, and may have implications for ablation techniques. A more cautious approach, with more extensive mapping, appears appropriate for ablation attempts of atypical flutter.

[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)

[Refibrinolysis with r-tPA for thrombosis of the mitral prosthesis after an acute myocardial infarct]. / Refibrinólisis con r-tPA por trombosis de prótesis mitral tras un infarto agudo de miocardio.

We report the case of a 62-year-old patient with a mitral prosthesis hospitalized with an anterior acute myocardial infarction who was treated with r-tPA. Some days later, the patient had mitral thrombosis with heart failure. Because of the high risk of surgical intervention, he was successfully treated with a new dose of r-tPA.

[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 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.

[Left atrial mass after heart transplantation. A clinical case and transesophageal echocardiographic diagnosis]. / Massa auricular esquerda pós-transplante cardíaco. Caso clínico e diagnóstico ecocardiográfico transesofágico.

We report a clinical case of a 60 year old male patient with a orthotopic cardiac transplant, submitted to a transesophageal echocardiographic study. This semi-invasive study showed a mobile multi-lobulated mass of the left atria, related with the hyperplastic process of the surgical suture area and directly associated with the cardiac transplant procedure. We discuss the rarity of this benign case, the different forms of two-dimensional echocardiographic presentation of this type of lesions, the problems of non invasive diagnostic techniques, the risk and the prognostic value of these structures. We conclude that a longitudinal study in a larger number of cardiac transplant patients will be needed, in order to define better the clinical implications of these echocardiographic findings.

[Changes in the physiologic pattern of mitral prosthesis regurgitation in the presence of a prosthetic dysfunction]. / Alteração do padrão fisiológico de regurgitação protésica mitral em presença de disfunção.

AIM OF STUDY: Evaluation by transesophageal echocardiography of the effect on the characteristics of physiological regurgitant jets (JF) resulting from prosthetic disfunction due to pathologic regurgitation (JF). PATIENTS AND METHODS: We studied 69 consecutive patients with the diagnosis of prosthesis in mitral position using transesophageal echocardiography and color doppler codification. The patients were divided in two groups (N and D groups) according to the presence of prosthesis disfunction by pathologic regurgitation. In each patient we determined planimetric areas and atrial peak depth of each JF and also the sum of JF planimetric areas of each mitral prosthesis. When pathological regurgitation was present we calculated the highest planimetric area, severity degree and atrial peak depth in each JP. RESULTS: The planimetric area in each JF of group N was 330 +/- 167 mm2 and in group D 117 +/- 116 mm2 (p less than 0.001). The sum of the areas of JF in group N was 474 +/- 204 mm2 and in group D 254 +/- 176 mm2 (p less than 0.01). The atrial depth of JF in group was 32 +/- 15 mm and in group D 26 +/- 18 mm (p less than 0.01). In group D 29% of the patients had mild pathological regurgitation, 10% moderate and 61% severe. The maximum planimetric area of JP in group D was 1078 +/- 1007 mm2 with atrial depth of 37 +/- 28 mm. CONCLUSION: The pathological regurgitation in disfunction prosthesis in mitral position has a significant reduction effect in the dimension of prosthesis physiologic regurgitation jets. This transesophageal echocardiographic observation makes it possible to characterize and clarify more precisely the different types of mitral prosthesis jets.

[Transesophageal echocardiography study of mitral valve prosthesis]. / Estudo ecocardiográfico transesofágico de próteses valvulares em posição mitral.

OBJECTIVE: Transesophageal (TEE) and Transthoracic (TTE) comparative echocardiographic analysis of patients with mitral valve prosthesis. DESIGN: Prospective study. SETTING: In hospital and out patients with mitral prosthesis in a follow-up study by the Cardiology Department and referred to the echocardiographic laboratory of Gregorio Marañon General Hospital, Madrid. PATIENTS: We studied 90 consecutive patients with mitral prosthesis diagnosis. INTERVENTIONS: Comparative and prospective echocardiographic study of transthoracic and transesophageal techniques in mitral prosthesis pathology. RESULTS: TTE diagnosed 18% of dysfunctioning mitral prosthesis patients compared to 56% of cases identified by TEE. TTE observed 1% of mitral prosthesis vegetation compared to 8.8% by TEE. TEE diagnosed left atrial thrombosis in 2.2% and TEE in 10%. Left atrial spontaneous dynamic contrast was identified exclusively by TEE in 55% of all cases. Paravalvular mitral prosthesis leak was correctly identified exclusively by TEE in 20% of cases. CONCLUSIONS: TEE has a greater diagnostic capacity compared to TTE in mitral prosthesis patients. This technique can give a greater security in evaluating mitral prosthesis thrombi, vegetations and leak, establishing a more precise diagnosis of mitral prosthesis dysfunction. The authors concluded that TEE is the technique of choice in noninvasive evaluation of patients admitted with the suspicion of mitral prosthesis dysfunction.

[Multiplanar transesophageal echocardiography: technique, methodology, and applications]. / Ecocardiografia transesofágica multiplano: técnica, metodologia e aplicações.

OBJECTIVE: To present the experience of transesophageal echocardiography with a multiplane probe, its methodology, the advantages, disadvantages and diagnostic improvements of this type of probe. SETTING: Laboratory of Echocardiography of the General Hospital Gregorio Marañon. MATERIAL AND METHODS: Analysis of the first 1000 examinations performed on hospitalized patients and outpatients, in most cases to study either native valvular heart disease and valvular prosthesis or to search for embolic sources. We evaluate the advantages, disadvantages, initial difficulties and complications of this type of probe. RESULTS: Multiplane probe provides continuous imaging from 0 degree to 180 degrees without need of intraesophagic movements. This type of probe increases the diagnostic capability of transesophagic echocardiography because it performs as a scanning of anatomy and pathological features of cardiac chambers and great vessels. Pulmonary artery and its branches, right heart chambers and tricuspid valve, inferior and superior vena cava, outflow tract of both ventricles, aortic root, pulmonary veins and segmental views of both ventricles are well analyzed. Also in native and prosthetic regurgitants jets, cardiac tumors and other masses, diagnosis and complications of endocarditis, aortic dissection and in anomalous return of pulmonary veins, multiplane probe proves to be more informative. There was no difficulties in the intubation despite the bigger size of the transducer. No severe complications occurred. The higher price and the initial more difficult understanding of the images are the only disadvantages we have found. CONCLUSIONS: Multiplane probe contributes to increase diagnostic capability of transesophageal echocardiography without significant risk and it is an important and promising refinement of the transesophageal technique.

[Value of transesophageal echocardiography in the assessment of blunt chest trauma: correlation with electrocardiogram, heart enzymes, and transthoracic echocardiogram]. / Valor da ecocardiografia transesofágica na avaliação de doentes com traumatismo torácico fechado: correlação com o electrocardiograma, enzimas cardíacas e ecocardiograma transtorácico.

OBJECTIVE: To asses the feasibility, usefulness and clinical rentability of the transesophageal echocardiography (TEE) in the evaluation of patients suffering a severe blunt chest trauma as well as to correlate the TEE findings with those provided by the conventional electrocardiogram (ECG), cardiac isoenzymes assay and transthoracic echocardiography (TTE). DESIGN: Prospective study using ECG, blood cardiac enzymes assay, TTE and TEE. SETTING: Intensive care unit of a general hospital. PATIENTS: We studied 34 patients admitted with blunt chest trauma and suspected cardiac contusion in spite of the existence of other traumatic injuries in some of them. There were 23 (67.6%) males and 11 females, with a mean age of 37.1 +/- 19.4 years (range: 16-69 years). MATERIAL AND METHODS: Patients with a previous history of cardiovascular or chronic pulmonary disease, cardiac arrest upon admission or positive cocaine or amphetamine levels in the urine were excluded from the study. Suspected cardiac contusion was established by clinical data, electrocardiographic findings, enzymes blood values (CPK-total and MB-fraction) and TTE findings. Additionally, a TEE was performed in each patient. Patients were stratified into two groups according to the TEE findings: Group A patients had signs compatible with cardiac contusion and in Group B patients there was a lack of evidence to substantiate this diagnosis. Those tests were evaluated in respect to their accuracy in the diagnosis of cardiac contusion when compared to transesophageal echocardiography and TEE findings were compared, whenever possible, to surgical or necropsic findings. RESULTS: We found TEE signs of cardiac injury in 22 (64.7%) patients and a wide spectrum of traumatic cardiac abnormalities were identified. TEE signs of ventricular injury were found in 15 pts of Group A (68.2%) being the right ventricle the most frequent affected. There were also two cases of mitral leaflet rupture, one case of tricuspid valve prolapse (with severe tricuspid regurgitation and associated with right ventricle wall motion abnormalities) and seven cases of pericardial effusion as well as one case of thoracic aortic dissection. In every patient submitted to cardiothoracic surgery or necropsy the TEE findings were confirmed. TEE provided significant information, sometimes crucial, to the patient evaluation and management, it was performed without any difficulty and it doesn't carried out any related complication. TTE was technically suboptimal in 53% and fail to demonstrate many cases of cardiac contusion and the thoracic aorta lesion, being the number of cardiovascular injuries demonstrated by TEE significantly higher (p = 0.029). No statistically significant difference was found between the number of patients with either an abnormal ECG or high values of CPK-MB in each group. Neither clinical findings, cardiac enzymes values, serial ECG's nor TTE predicted all the patients who had traumatic cardiac injury and those would subsequently developed complications related to cardiac contusion. CONCLUSIONS: A severe blunt chest trauma frequently results in cardiac injury. The ECG and the CPK-MB measurements appears both to be fairly sensitive and specific tests in the cardiac contusion diagnosis. TTE has shown to have important limitations in these patients, thus not allowing neither a complete echo evaluation nor a reliable one. TEE plays an important role in the evaluation and management of this type of patients providing rapid diagnostic information and being of high value in the rule out cardiac contusion as well as in the establishment of a specific diagnosis of cardiac and/or thoracic aorta injuries with a consequent better assessment and treatment strategy in these patients.

[The contribution and usefulness of routine intraoperative transesophageal echocardiography in cardiac surgery. An analysis of 130 consecutive cases]. / Contributo e rentabilidade da ecocardiografia transesofágica intraoperatória de rotina em cirurgia cardíaca. Análise de 130 casos consecutivos.

PURPOSE: To assess the value of routine intraoperative transesophageal echocardiography (TEE) in unselected patients (P) undergoing cardiac surgery. DESIGN: Routine intraoperative TEE in unselected patients undergoing cardiac surgery and evaluation of its usefulness and contribute to a successful surgery. PATIENTS: In-hospital patients from cardiology, cardiac surgery and intensive care departments of a general hospital classified as a reference medical centre in cardiovascular pathology. MATERIAL AND METHODS: From February 1994 to May 1994 an intraoperative TEE was routinely performed in patients undergoing cardiac surgery. A total of 130 TEE studies were made corresponding to 128 patients, 69 males and 61 females, with a mean age of 49.4 +/- 12.1 years. Indications for surgery were as following: a) Coronary artery bypass grafting (C.A.B.G.)-39; b) Valvular surgery-76; c) C.A.B.G. and valvular surgery-5; d) Thoracic aorta pathology associated or not to aortic valve surgery and/or coronary arteries re-implantation-6; e) Other-4. TEE performed using either a monoplane, biplane or multiplane probe and the images acquisition was made before thoracotomy and cardiopulmonary bypass (CPB) and after CPB with hemodynamic stabilization. RESULTS: Pre CPB imaging yielded unsuspected findings in 11 P (8.5%) that changed the planned surgery in 7 cases (5.4%). Post CPB echo study, which was performed after hemodynamic stabilization, modified the surgical strategy in 13 cases (10.9%) avoiding 1 predetermined surgical procedure (tricuspid ring annuloplasty) and a new surgery in another case, leading to a 3 non-predetermined surgical procedures (by showing significative tricuspid regurgitation), to a further surgery in the same valve in 6 patients (mitral paravalvular leak with significative regurgitation in 1P, another mitral prosthesis dysfunction in 1P, residual mitral valve insufficiency after mitral valve repair in 3 P and aortic prosthesis dysfunction in 1 P), to a intraaortic counterpulsation balloon device in 1 P and to new CPB due to an insufficient extraction of calcified pericardium in one case of constrictive pericarditis. In 23 cases (17.7%) TEE has modified the anesthetic procedure by demonstrating signs of hemodynamic changes before Swan-Ganz catheter, thus prompting changes in the administrations of fluids and either in inotropic or vasodilator agents. In total, intraoperative TEE has changed the surgical and/or anesthetic plan in 43 cases (33.0%). There was no difficulties or complications related to the procedure. CONCLUSION: These data indicate that intraoperative TEE is useful in formulating the surgical plan and assessing immediate operative results as well as a guide to anesthetic procedures. Its high rentabillity in modifying the surgical and/or anesthetic plans lead us to believe that it must be used as a routine procedure in patients undergoing cardiac surgery.