RESUMEN
The clinical and echocardiographic variables related to left atrial spontaneous echo contrast were prospectively evaluated in a consecutive series of 400 patients undergoing transesophageal echocardiography with a 5-MHz single plane transducer. Left atrial spontaneous echo contrast was found in 75 patients (19%) and was significantly associated with atrial fibrillation, mitral stenosis, absence of mitral regurgitation, increased left atrial dimension and a history of suspected embolism. Seventy-one (95%) of the patients with spontaneous echo contrast had atrial fibrillation or mitral stenosis. Anticoagulant therapy had no significant association with spontaneous echo contrast. Multivariate analysis in 89 patients with mitral stenosis or mitral valve replacement showed that spontaneous echo contrast was the only independent predictor (p = 0.03) of left atrial thrombus or suspected embolism, or both. In 60 patients with atrial fibrillation of nonvalvular origin, spontaneous echo contrast (p = 0.01) and age (p = 0.03) were the only independent predictors of left atrial thrombus or suspected embolism, or both. It is concluded that left atrial spontaneous echo contrast is 1) a common finding in patients undergoing transesophageal echocardiography, 2) associated with conditions favoring stasis of left atrial blood, and 3) a marker of previous thromboembolism in patients with nonvalvular atrial fibrillation and those with mitral stenosis or mitral valve replacement.
Asunto(s)
Fibrilación Atrial/diagnóstico por imagen , Ecocardiografía , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/diagnóstico por imagen , Estenosis de la Válvula Mitral/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Fibrilación Atrial/epidemiología , Femenino , Cardiopatías/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estenosis de la Válvula Mitral/epidemiología , Análisis Multivariante , Prevalencia , Estudios Prospectivos , Trombosis/epidemiologíaRESUMEN
OBJECTIVES: This study examined the influence of left atrial spontaneous echo contrast on the subsequent stroke or embolic event rate and on survival in patients with nonvalvular atrial fibrillation. BACKGROUND: Left atrial spontaneous echo contrast is associated with atrial fibrillation and a history of previous stroke or other embolic events. However, the prognostic implications of spontaneous contrast in patients with nonvalvular atrial fibrillation are unknown. METHOD: The study group comprised 272 consecutive patients with nonvalvular atrial fibrillation undergoing transesophageal echocardiography. Clinical and echocardiographic data were collected at baseline, and patients were prospectively followed up, and all strokes, other embolic events and deaths were documented. The relation between spontaneous contrast at baseline and subsequent stroke, other embolic events and survival was analyzed. RESULTS: Left atrial spontaneous echo contrast was detected at baseline in 161 patients (59%). The mean follow-up was 17.5 months. The stroke or other embolic event rate was 12%/year (15 strokes, 3 transient ischemic attacks, 2 peripheral embolisms) in patients with, compared with 3%/year (5 strokes) in patients without, baseline spontaneous contrast (p = 0.002). In 149 patients without previous thromboembolism, the event rate was 9.5%/year in patients with and 2.2%/year in patients without spontaneous contrast (p = 0.003). There were 25 deaths in patients with and 11 deaths in patients without spontaneous contrast. Patients with spontaneous contrast had significantly reduced survival (p = 0.025). On multivariate analysis, spontaneous contrast was the only positive predictor (odds ratio 3.5, p = 0.03) and warfarin therapy on follow-up the only negative predictor (odds ratio 0.23, p = 0.02) of subsequent stroke or other embolic events. CONCLUSIONS: Transesophageal echocardiography can risk stratify patients with nonvalvular atrial fibrillation by identifying left atrial spontaneous echo contrast. These patients have both a significantly higher risk of developing stroke or other embolic events and a reduced survival, and they may represent a subgroup in whom the risk/benefit ratio of anticoagulation may be most favorable.
Asunto(s)
Fibrilación Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Atrios Cardíacos/diagnóstico por imagen , Análisis Actuarial , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Fibrilación Atrial/mortalidad , Trastornos Cerebrovasculares/complicaciones , Embolia/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
The management of anticoagulant therapy in patients with atrial fibrillation undergoing electrical cardioversion remains controversial, largely because of inadequate studies demonstrating risk or benefit, a relatively inconvenient anticoagulation management strategy and the increasing use of transesophageal echocardiography. Recent investigations into the potential mechanisms involved in the development of thrombus and systemic embolism in patients undergoing electrical cardioversion of atrial fibrillation may provide insight into underlying predisposing factors, with subsequent modification of management strategies. Conventional wisdom suggests that preexisting thrombus is responsible for thromboembolic events after cardioversion. However, development of a thrombogenic milieu after cardioversion, particularly in the left atrial appendage, may also be an important predisposing factor. To protect against both potential mechanisms of embolization, these data support therapeutic anticoagulation for all patients with atrial fibrillation of > 2 days in duration from the time of, as well as after cardioversion for a total of 4 weeks, undergoing cardioversion, even in the absence of thrombus on echocardiography. Therefore, the role of transesophageal echocardiography in this setting should be to enable early cardioversion if atrial thrombus is excluded and to identify high risk patients with atrial thrombi so as to postpone cardioversion and avoid the risk of embolization. Ultimately, however, a controlled, randomized and prospective clinical trial will be required to compare conventional management with a transesophageal echocardiography-guided strategy.
Asunto(s)
Fibrilación Atrial/terapia , Ecocardiografía Transesofágica , Cardioversión Eléctrica , Cardiopatías/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Embolia/prevención & control , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/complicaciones , Humanos , Trombosis/complicacionesRESUMEN
OBJECTIVES: This study examined the relation between left atrial spontaneous echo contrast, hematologic variables and thrombo-embolism in patients with nonvalvular atrial fibrillation. BACKGROUND: Left atrial spontaneous echo contrast is associated with left atrial stasis and thromboembolism in patients with nonvalvular atrial fibrillation. However, its hematologic determinants in patients with nonvalvular atrial fibrillation are unknown. METHODS: Clinical, hematologic and echocardiographic variables were prospectively measured in 135 consecutive patients with nonvalvular atrial fibrillation undergoing transesophageal echocardiography. RESULTS: Patients with left atrial spontaneous echo contrast (n = 74, 55%) had an increased fibrinogen concentration (p = 0.029), platelet count (p = 0.045), hematocrit (p = NS) and left atrial dimension (p = 0.005). Multivariate analysis showed that left atrial spontaneous echo contrast was independently related to hematocrit (odds ratio = 2.24, p = 0.002), fibrinogen concentration (odds ratio = 2.08, p = 0.008) and left atrial dimension (odds ratio = 1.90, p = 0.004) but not platelet count. It was also associated with left atrial thrombus (n = 15, p = 0.001) and with recent embolism (n = 40, p < 0.001). In 40 clinically stable outpatients without previous embolism, left atrial spontaneous echo contrast was significantly related to hematocrit (p = 0.005), fibrinogen concentration (p = 0.035) and left atrial dimension (p = 0.029) but not to coagulation factor VII, D-dimer, erythrocyte sedimentation rate, platelet count, plasma beta-thromboglobulin, plasma glycocalicin or glycocalicin index. CONCLUSIONS: Left atrial spontaneous echo contrast in patients with nonvalvular atrial fibrillation is independently related to hematocrit, fibrinogen concentration and left atrial dimension, indicating a relatively hypercoagulable state in addition to stasis. These findings support the hypothesis that left atrial spontaneous echo contrast is due to erythrocyte aggregation. Hematologic factors may contribute to its association with thromboembolism.
Asunto(s)
Fibrilación Atrial/diagnóstico por imagen , Atrios Cardíacos/diagnóstico por imagen , Tromboembolia/etiología , Anciano , Fibrilación Atrial/sangre , Fibrilación Atrial/complicaciones , Función del Atrio Izquierdo/fisiología , Ecocardiografía/métodos , Agregación Eritrocitaria/fisiología , Femenino , Fibrinógeno/análisis , Hematócrito , Humanos , Masculino , Análisis Multivariante , Factores de Riesgo , Tromboembolia/sangre , Tromboembolia/epidemiologíaRESUMEN
OBJECTIVES: This study was designed to develop a quantitative method of spontaneous echo contrast (SEC) assessment using integrated backscatter and to compare integrated backscatter SEC measurement with independent qualitative grades of SEC and clinical and echocardiographic predictors of thromboembolism. BACKGROUND: Left atrial SEC refers to dynamic swirling smokelike echoes that are associated with low flow states and embolic events and have been graded qualitatively as mild or severe. METHODS: We performed transesophageal echocardiography in 43 patients and acquired digital integrated backscatter image sequences of the interatrial septum to internally calibrate the left ventricular cavity and left atrial cavity under different gain settings. Patients were independently assessed as having no, mild or severe SEC. We compared intensity of integrated backscatter in the left atrial cavity relative to that in the left ventricular as well as to the independently assessed qualitative grades of SEC. Fourier analysis characterized the temporal variability of SEC. The integrated backscatter was compared with clinical and echocardiographic predictors of thromboembolism. RESULTS: The left atrial cavity integrated backscatter intensity of the mild SEC subgroup was 4.7 dB higher than that from the left ventricular cavity, and the left atrial intensity of the severe SEC subgroup was 12.5 dB higher than that from the left ventricular cavity. The left atrial cavity integrated backscatter intensity correlated well with the qualitative grade. Fourier transforms of SEC integrated backscatter sequences revealed a characteristic dominant low frequency/high amplitude spectrum, distinctive from no SEC. There was a close relationship between integrated backscatter values and atrial fibrillation, left atrial size, left atrial appendage flow velocities and thrombus. CONCLUSIONS: Integrated backscatter provides an objective quantitative measure of SEC that correlates well with qualitative grade and is closely associated with clinical and echocardiographic predictors of thromboembolism. The relationship between integrated backscatter measures and cardioembolic risk will be defined in future multicenter studies.
Asunto(s)
Ecocardiografía Transesofágica/métodos , Cardiopatías/diagnóstico por imagen , Anciano , Estudios de Casos y Controles , Femenino , Análisis de Fourier , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Procesamiento de Señales Asistido por Computador , Tromboembolia/epidemiología , Tromboembolia/etiologíaRESUMEN
Confirming the diagnosis of acute transection of the descending aorta can be problematic. Unnecessary patient movement and time delay are often associated with conventional investigations. We describe a patient in whom such an injury was clearly and quickly defined at the bedside by transesophageal echocardiography.
Asunto(s)
Rotura de la Aorta/diagnóstico por imagen , Ecocardiografía/métodos , Adulto , Aorta Torácica/lesiones , Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Humanos , MasculinoRESUMEN
We report a case of systemic embolization of a left atrial ball thrombus during transesophageal echocardiography (TEE). A 49-year-old man with rheumatic mitral stenosis and atrial fibrillation underwent TEE to evaluate a transient cerebral ischemic attack. TEE demonstrated a free-floating left atrial thrombus. Disappearance of the thrombus during the study occurred after tachycardia and was associated with acute hemiplegic stroke and an absent radial pulse. The possible mechanism of embolization and the implications for the selection and management of patients undergoing TEE are discussed.
Asunto(s)
Ecocardiografía/efectos adversos , Embolia/etiología , Cardiopatías/terapia , Trombosis/terapia , Ecocardiografía/métodos , Atrios Cardíacos , Cardiopatías/diagnóstico por imagen , Humanos , Ataque Isquémico Transitorio/etiología , Masculino , Persona de Mediana Edad , Trombosis/diagnóstico por imagenRESUMEN
Right and left upper pulmonary venous flow is usually assessed with monoplane transesophageal echocardiography (TEE) in the transverse imaging plane. Pulmonary venous flow in the transverse imaging plane may be relatively difficult to record because of the larger angle between the pulmonary vein and the transducer beam. To compare the quality of echocardiographically derived Doppler flows of the right and left upper pulmonary veins between the longitudinal and transverse imaging planes with TEE, we performed pulsed-wave Doppler TEE of both upper pulmonary veins in transverse and longitudinal imaging planes in 36 patients with various diseases. We also recorded a quality index for each flow profile and the angle between the transducer beam and the pulmonary vein. The quality index of the left pulmonary venous flow assessed with the longitudinal and transverse imaging planes was similar in 35 (95%) of 36 patients, whereas the longitudinal imaging plane was superior to the transverse plane in one patient (3%). In contrast, the quality index of the right pulmonary venous flow assessed with the longitudinal and transverse imaging planes was similar in only 19 (53%) of 36 patients, whereas in 17 patients (47%) the longitudinal imaging plane was superior to the transverse imaging plane. The quality index had a significant effect on the Doppler flow recordings; suboptimal-quality flow recordings significantly underestimated the pulmonary venous diastolic flow integrals. The left atrium was larger in those patients with unobtainable flows than in those patients with exclusively obtainable flows (p < 0.001). The angle between the sample volume and the right pulmonary vein was larger in the transverse imaging plane than in the longitudinal plane (p < 0.001). In conclusion, the longitudinal imaging plane is generally superior to the transverse imaging plane for assessing right pulmonary venous flow and is recommended for performing a comprehensive assessment of pulmonary venous flow. The ability to obtain quality images and accurate assessment of flow may be related to the size of the left atrium and angle of the pulmonary vein.
Asunto(s)
Ecocardiografía Transesofágica/métodos , Venas Pulmonares/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Velocidad del Flujo Sanguíneo , Ecocardiografía Doppler de Pulso/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Venas Pulmonares/diagnóstico por imagen , Flujo Sanguíneo RegionalRESUMEN
Left atrial (LA) spontaneous echo contrast (SEC), or "smoke," is a frequent finding on transesophageal echocardiography (TEE), but it is rarely detected with transthoracic echocardiography. LA SEC is characterized by dynamic smoke-like echoes within the LA cavity or appendage. Most patients with LA SEC have atrial arrhythmias, mitral stenosis, or a mitral valve prosthesis, and they have an enlarged LA, conditions that are associated with LA stasis. Conversely, mitral regurgitation is protective against LA SEC. LA SEC is present in almost all patients with LA thrombus and is associated with previous embolic events in many patient populations. In patients with nonvalvular atrial fibrillation, LA SEC predicts future embolism and death. LA SEC may therefore assist in selecting patients with atrial fibrillation or with mitral stenosis and sinus rhythm who benefit the most from anticoagulation. Hematological studies have shown that LA SEC is a marker of an hypercoagulable state. LA SEC is a manifestation of red cell aggregation, arising from an interaction between red cells and plasma proteins such as fibrinogen, at low shear rates. LA SEC does not require platelets. The detection of LA SEC on ultrasound arises from the increased amplitude of backscatter from red cell aggregates rather than single cells. Patients with LA SEC should be considered for anticoagulant therapy and may require correction of underlying cardiovascular abnormalities. Future directions in LA SEC include further assessment of integrated backscatter for quantification, assessment of its prognostic role in clinically low-risk patients with nonvalvular AF, and novel pharmacological treatment.
Asunto(s)
Ecocardiografía Transesofágica , Atrios Cardíacos/diagnóstico por imagen , Fibrilación Atrial/sangre , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Agregación Eritrocitaria , Prótesis Valvulares Cardíacas , Humanos , Estenosis de la Válvula Mitral/diagnóstico por imagen , Pronóstico , Tromboembolia/diagnóstico por imagen , Tromboembolia/etiologíaRESUMEN
Left atrial (LA) spontaneous echo contrast, also known as "smoke," is a frequent transesophageal echocardiographic finding characterized by swirling, smokelike echoes in the LA cavity or appendage. LA smoke is associated with conditions favoring stasis of LA blood, including atrial fibrillation, mitral stenosis, the absence of mitral regurgitation, and LA enlargement. LA spontaneous echo contrast is a marker of previous embolic events in patients with atrial fibrillation, mitral stenosis, or mitral valve replacement. Most LA thrombi are accompanied by smoke. Recent studies show that LA spontaneous echo contrast is also associated with increased fibrinogen, hematocrit, and blood viscosity, indicating a relatively hypercoagulable state in addition to stasis. These findings suggest that LA spontaneous echo contrast is a manifestation of erythrocyte aggregation, and that hematologic factors may contribute to the association between spontaneous echo contrast and thromboembolism.
Asunto(s)
Ecocardiografía Transesofágica/métodos , Cardiopatías/diagnóstico por imagen , Embolia/diagnóstico por imagen , Embolia/etiología , Atrios Cardíacos/patología , Humanos , Trombosis/diagnóstico por imagen , Trombosis/etiologíaRESUMEN
Serum concentrations of apolipoprotein(a) [apo(a)], the unique glycoprotein of lipoprotein(a), are increased in patients with end-stage renal failure. We prospectively studied serum apo(a) and other lipoproteins in 20 consecutive patients, ages 46 +/- 11 years, before and for six months after successful renal transplantation. All patients received cyclosporine, and no patient was treated for hyperlipidemia. The mean creatinine clearance increased from 7.5 mL/min before transplant surgery to 40.9 mL/min six months afterwards (P less than 0.001). Apo(a) decreased from a median of 403 units/L before transplantation to 184 units/L at one week (P less than 0.001) and was 170 units/L (P less than 0.001) at six months. For the assay used, 1 unit of apo(a) is equivalent to 1 mg of lipoprotein(a). In contrast, from baseline to six months, increases were found for low-density lipoprotein (LDL) cholesterol (P = 0.03), high-density lipoprotein cholesterol (P = 0.06), apo B (P = 0.07), and apo A-I (P = 0.01). The decrease in apo(a) in individual patients was significantly correlated with the increase in creatinine clearance (r = -0.48, P less than 0.001). The single patient who developed nephrotic syndrome after renal transplantation had marked increases in apo(a) (693-1595 units/L), apo B, and LDL cholesterol, which paralleled the degree of proteinuria. These findings suggest that abnormal renal function affects the regulation of lipoprotein(a) metabolism.
Asunto(s)
Apolipoproteínas A/metabolismo , Fallo Renal Crónico/sangre , Trasplante de Riñón , Adulto , Apolipoproteína A-I/metabolismo , Apolipoproteínas B/sangre , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome Nefrótico/sangre , Estudios Prospectivos , Triglicéridos/sangreRESUMEN
Multiple fistulae between all 3 major coronary arteries and the left ventricle were found at cardiac catheterization in a 69-year-old woman presenting with typical angina. Subsequent necropsy showed abnormal intramyocardial vessels communicating with the left ventricular lumen. This is the first report to document clinical, angiographic, and pathologic findings in this anomaly.
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Anomalías de los Vasos Coronarios/patología , Fístula/congénito , Ventrículos Cardíacos/anomalías , Anciano , Cateterismo Cardíaco , Angiografía Coronaria , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Femenino , Fístula/diagnóstico por imagen , Fístula/patología , Ventrículos Cardíacos/patología , HumanosRESUMEN
Technology for pacemakers and automatic implantable defibrillators continues to evolve. Emphasis is placed not only on preventing cardiac death, but also on improving symptoms and quality of life. The basic antibradycardia function of pacemakers is complemented by highly sophisticated rate-responsive capabilities. The search for the perfect physiologic sensor has not ended; potential limitations of the systems currently available are considered in this review. Reports on outcome with pacing in different populations are also discussed. There have been two important advances in automatic implantable defibrillators. One is the introduction of the third generation defibrillator in clinical investigation. A tiered therapy (including antitachycardia pacing, cardioversion, and defibrillation) can now be programmed in the same device, with the protection of back-up antibradycardia pacing. The other remarkable innovation is the expanding use of nonthoracotomy techniques for implantable cardioverter-defibrillator placement. This approach permits the avoidance of a subcutaneous patch electrode in some cases, the system being entirely transvenous. Finally, recent insights on external cardioversion for atrial arrhythmias are briefly reviewed.
Asunto(s)
Arritmias Cardíacas , Estimulación Cardíaca Artificial , Desfibriladores Implantables , Cardioversión Eléctrica/métodos , Marcapaso Artificial , Adulto , Arritmias Cardíacas/prevención & control , Arritmias Cardíacas/terapia , Niño , Cardioversión Eléctrica/efectos adversos , Electrodos , Humanos , Calidad de VidaRESUMEN
This study prospectively evaluated the role of transesophageal echocardiography (TEE) in screening for atrial thrombi before electrical cardioversion in 40 nonanticoagulated patients with nonvalvular atrial fibrillation (n = 33) or atrial flutter (n = 7). Transthoracic echocardiography did not detect atrial thrombus in any patient. TEE detected left atrial appendage thrombi in five patients (12%, p = 0.03), significantly associated with left ventricular systolic dysfunction (p = 0.02) and left atrial spontaneous echo contrast (p = 0.04). Cardioversion was cancelled in the five patients with thrombi and in two patients with spontaneous reversion before planned cardioversion. Cardioversion was successful in 25 (76%) of the 33 remaining patients. Cerebral embolism occurred 24 hours after successful cardioversion in one patient with atrial fibrillation and left ventricular dysfunction, who had left atrial spontaneous echo contrast, but no thrombus was detected by TEE before cardioversion. Repeat TEE after embolism showed a fresh left atrial appendage thrombus and increased left atrial spontaneous echo contrast. These results indicate that TEE improves the detection of left atrial appendage thrombi in candidates for cardioversion, in whom the procedure may be deferred. However, the exclusion by TEE of preexisting atrial thrombi before cardioversion does not eliminate the risk of embolism after cardioversion because of persistent atrial stasis and de novo thrombosis.
Asunto(s)
Fibrilación Atrial/diagnóstico por imagen , Aleteo Atrial/diagnóstico por imagen , Ecocardiografía/métodos , Cardioversión Eléctrica , Cardiopatías/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Anticoagulantes , Fibrilación Atrial/terapia , Aleteo Atrial/terapia , Embolia/prevención & control , Femenino , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Trombosis/epidemiologíaRESUMEN
The role of transoesophageal echocardiography (TEE) was evaluated in a consecutive series of 100 procedures performed in 86 patients (age 17-81, mean 56 years). All patients had prior transthoracic echocardiography (TTE). TEE was performed with a 5 MHz phased array transoesophageal transducer with pulsed wave Doppler and colour flow mapping capability. Forty-four per cent of patients received intravenous sedation and 36% received antibiotic prophylaxis. There were no complications of TEE. The TTE and TEE findings were compared. In patients referred for possible cardiac source of embolism, left atrial thrombi were detected in 8/27 TEE studies but in none of 27 TTE studies. In 12 patients with prosthetic valve dysfunction TEE distinguished prosthetic from periprosthetic regurgitation in 9/12 studies compared to 3/12 with TTE. In 11 patients with suspected aortic dissection TEE correctly detected dissection in all seven cases in which the diagnosis was subsequently confirmed, whereas TTE showed only equivocal findings in two cases. Vegetations were detected by TEE in 4/5 studies in patients with proven native valve endocarditis and by TTE in 2/5. No vegetations were detected by TTE or TEE in five studies in patients with proven prosthetic valve endocarditis. Compared with other investigations there were no false positive TEE studies and one possible false negative study. We conclude that TEE is a safe procedure which often provides additional clinical information to transthoracic echocardiography.
Asunto(s)
Ecocardiografía Doppler/efectos adversos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Ecocardiografía Doppler/métodos , Esófago , Femenino , Humanos , Masculino , Persona de Mediana Edad , TóraxRESUMEN
Cardiac ultrasound and upper gastrointestinal endoscopy are relatively old technologies. With the introduction of new ultrasound probes and by incorporating ultrasound technology into conventional endoscopes, 'new tricks' in cardiac imaging were discovered. Posterior structures of the heart are now able to be imaged clearly by the ultrasound probe from the oesophagus. Consequently, better resolution of cardiac anatomy allows more accurate diagnosis of cardiac pathologies which is not possible using conventional transthoracic (TT) approach. Over a period of two years, 1200 cases of transoesophageal echocardiography (TOE) were undertaken in our institution. The major indications were diseases of the aorta (10%), source of cardioembolism (28%), assessment of native and prosthetic valve function (20%), suspected endocarditis and its complication (17%), pre and post percutaneous transluminal mitral valvotomy (PTMV [13%], congenital heart disease (2%) and others (10%). The greatest impact with TOE is in the diagnosis of aortic dissection and transection. TOE is superior to conventional TT approach in detecting potential source of embolism, valvular vegetations and its complication, native and prosthetic valve dysfunction and LA thrombus prior to PTMV. Observations by TOE such as spontaneous echo contrast (SEC) in the left atrium open new challenges for further research in its role in the pathogenesis of LA thrombus and its association with cardioembolic event. Other areas of interest include; reclassification of distal aortic dissection and the use of TOE in intra-operative work.
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Ecocardiografía/métodos , Cardiopatías/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Embolia/diagnóstico por imagen , Esófago , Cardiopatías Congénitas/diagnóstico por imagen , HumanosRESUMEN
BACKGROUND: Percutaneous transseptal mitral valvotomy (PTMV) has been established as an alternative to surgery in the treatment of mitral stenosis. AIM: To review our experience in the first 200 attempted PTMV procedures in patients with mitral stenosis, and the short and medium term follow-up. METHODS: PTMV was attempted on 200 occasions in 189 patients with significant mitral stenosis between May 1988 and May 1994. There were 156 females and 33 males, mean age 53.5 years (range 14 to 83 years). Six patients were pregnant at the time of the procedure. RESULTS: Valve split was achieved at the initial attempt in 183/189 procedures (97%). Clinical improvement of at least one New York Heart Association (NYHA) functional class was achieved in 172/189 patients (91%). The mean mitral valve gradient (mean +/- SD) decreased from 11.5 +/- 5.1 mmHg to 4.9 +/- 4.1 mmHg, mean cardiac output rose from 3.9 +/- 1.1 L/minute to 4.4 +/- 1.4 L/minute and mean calculated mitral valve area increased from 1.0 +/- 0.3 cm2 to 2.1 +/- 0.9 cm2. Ten patients developed clinically significant mitral incompetence requiring surgical mitral valve replacement. There were two transient cerebral embolic events. Small atrial septal defects were detected echocardiographically in 42 patients, but none has been a clinical problem. There were no early deaths; there were 11 late deaths, four of which were non-cardiac. Twenty patients have had repeat PTMV for re-stenosis, four to 67 months after the first. CONCLUSIONS: PTMV provides significant haemodynamic and clinical improvement with low risk and should be considered the treatment of choice in patients with mitral stenosis.
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Cateterismo/métodos , Estenosis de la Válvula Mitral/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo/efectos adversos , Ecocardiografía , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Estenosis de la Válvula Mitral/diagnóstico por imagen , Embarazo , Complicaciones Cardiovasculares del Embarazo/terapia , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine the value of transoesophageal echocardiography in the assessment of selected patients at risk of cardiogenic embolism or after it. DESIGN: Prospective comparison of the results of transoesophageal and transthoracic echocardiography. Transoesophageal echocardiography was performed with a 5 MHz single plane phased array transducer. SETTING: University teaching hospital. PATIENTS: 100 patients referred for transoesophageal echocardiography after a cerebral ischaemic event or peripheral arterial embolism (n = 63), before percutaneous balloon dilatation of the mitral valve (n = 23), or before electrical cardioversion of atrial fibrillation (n = 14). RESULTS: Transthoracic echocardiography showed potential sources of embolism in four patients including left ventricular thrombus in two patients (with one false positive), left atrial appendage thrombus (n = 1), and patent foramen ovale (n = 1). Transoesophageal echocardiography showed 59 potential embolic sources in 45 patients including left atrial spontaneous echo contrast (n = 33), left atrial appendage thrombus (n = 13), left ventricular thrombus (n = 5), patent foramen ovale (n = 3), left ventricular spontaneous echo contrast (n = 2), mitral valve prosthesis thrombus (n = 1), mitral valve prolapse (n = 1), and pronounced aortic atheroma (n = 1). Transoesophagal echocardiography showed potential embolic sources in 36/53 (68%) patients with atrial fibrillation compared with 9/47 (19%) patients in sinus rhythm. Percutaneous balloon dilatation of the mitral valve was performed without embolic complications in 18 patients without left atrial thrombi and in three patients with small fixed thrombi in the left atrial appendage. It was cancelled in two patients with large thrombi in the left atrial appendage. Cardioversion was performed without embolic complications in 14 patients without left atrial thrombi. CONCLUSIONS: Transoesophageal echocardiography detects potential sources of embolism better than transthoracic echocardiography in selected patients at risk of cardiogenic embolism or after it.
Asunto(s)
Embolia/diagnóstico por imagen , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Trombosis Coronaria/diagnóstico por imagen , Ecocardiografía Doppler , Embolia/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de RiesgoRESUMEN
Left atrial spontaneous echocardiographic contrast (SEC) is an important marker of increased thromboembolic risk in patients with mitral stenosis. To evaluate the effect of percutaneous transseptal mitral valvuloplasty (PTMV) on SEC, we performed transesophageal echocardiography 1 day before and 3 months after PTMV on 88 consecutive patients. SEC was present in 65 (74%) patients before PTMV and was associated with absence of moderate or severe mitral regurgitation (p = 0.01), a smaller valve area (p = 0.02), an older age (p = 0.04), and atrial fibrillation (p = 0.05). At 3 months, PTMV resulted in a mean absolute and relative increase in valve area of 0.54 +/- 0.36 cm2 and 53% +/- 43%, respectively. SEC resolved in 37 patients but persisted in 28 (32%) patients at the 3-month study. The absolute and relative increase of valve area and worsened mitral regurgitation after PTMV were predictors of resolution of SEC, with the relative increase in valve area being the only significant predictor on multivariate analysis. PTMV frequently results in resolution of SEC, which may have important implications in reducing the thromboembolic risk in these patients.
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Cateterismo , Ecocardiografía Transesofágica , Ecocardiografía , Válvula Mitral/diagnóstico por imagen , Tromboembolia/epidemiología , Adulto , Anciano , Cateterismo/métodos , Cateterismo/estadística & datos numéricos , Ecocardiografía/instrumentación , Ecocardiografía/métodos , Ecocardiografía/estadística & datos numéricos , Ecocardiografía Transesofágica/instrumentación , Ecocardiografía Transesofágica/métodos , Ecocardiografía Transesofágica/estadística & datos numéricos , Femenino , Atrios Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Estenosis de la Válvula Mitral/complicaciones , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/terapia , Pronóstico , Estudios Prospectivos , Cardiopatía Reumática/complicaciones , Cardiopatía Reumática/diagnóstico por imagen , Cardiopatía Reumática/terapia , Factores de RiesgoRESUMEN
BACKGROUND AND PURPOSE: This study examined whether patients suffering from stroke and other systemic embolic events may be selected for transesophageal echocardiography on the basis of clinical and transthoracic echocardiographic findings. METHODS: We performed transthoracic and transesophageal echocardiography on 824 patients after stroke and other suspected embolic events. Patients were classified into group A if they were in sinus rhythm and had a normal transthoracic echocardiogram. Group B consisted of all other patients. Transesophageal echocardiographic findings of left atrial spontaneous contrast, left atrial thrombus, complex aortic atheroma, and interatrial septal anomalies were correlated with clinical and transthoracic echocardiographic results. RESULTS: Transesophageal echocardiography detected at least one potential source of embolism in 399 patients (49%): spontaneous contrast in 214 patients (26%), left atrial thrombus in 54 (7%), complex atheroma in 111 (13%), and interatrial septal anomalies in 126 (15%). In group A (n = 236), only 3 (1%) had spontaneous contrast, 11 (4.6%) had complex atheroma, and none had left atrial thrombus. In group B (n = 588), 211 patients (36%, P < .001) had spontaneous contrast, 54 (9.2%, P < .001) had atrial thrombus, and 100 (17%, P < .001) had complex atheroma. Interatrial septal anomalies were detected in similar proportions of patients (18% in group A versus 14% in group B). Left atrial spontaneous echo contrast, thrombus, and complex atheroma were significantly more prevalent in older patients, but interatrial septal anomalies were more prevalent in younger patients irrespective of transthoracic echocardiographic findings. Multivariate analysis identified both an abnormal transthoracic echocardiogram and patient age to be independent predictors of transesophageal echocardiographic findings of left atrial spontaneous echo contrast, left atrial thrombus, or complex atheroma. CONCLUSIONS: Transesophageal echocardiography has a low yield for left atrial spontaneous contrast, left atrial thrombus, or complex aortic atheroma in patients with normal transthoracic echocardiogram and sinus rhythm and in younger patients. Interatrial septal anomalies are more prevalent in younger patients. Transthoracic echocardiogram should be performed in patients after stroke or systemic embolic events as a noninvasive screening tool. We recommend transesophageal echocardiogram for patients with abnormal transthoracic echocardiogram and in younger patients when the finding of a patent foramen ovale may contribute to patient management.