Changes in speckle tracking echocardiography measures of ventricular function after percutaneous implantation of the Edwards SAPIEN transcatheter heart valve in the pulmonary position.

BACKGROUND: Patients with free pulmonary regurgitation or mixed pulmonary stenosis and regurgitation and severely dilated right ventricles (RV) show little improvement in ventricular function after pulmonary valve replacement when assessed by traditional echocardiographic markers. We evaluated changes in right and left ventricular (LV) function using speckle tracking echocardiography in patients after SAPIEN transcatheter pulmonary valve (TPV) placement. METHODS: Echocardiograms were evaluated at baseline, discharge, 1 and 6 months after TPV placement in 24 patients from 4 centers. Speckle tracking measures of function included peak longitudinal strain, strain rate, and early diastolic strain rate. RV fractional area change, tricuspid annular plane systolic excursion, and left ventricular LV ejection fraction were assessed. Routine Doppler and tissue Doppler velocities were measured. RESULTS: At baseline, all patients demonstrated moderate to severe pulmonary regurgitation; this improved following TPV placement. No significant changes were detected in conventional measures of RV or LV function at 6 months. RV longitudinal strain (-16.9% vs. -19.6%, P < 0.01), strain rate (-0.87 s(-1) vs. -1.16 s(-1) , P = 0.01), and LV longitudinal strain (-16.2% vs. -18.2%, P = 0.01) improved between baseline and 6 month follow-up. RV early diastolic strain rate, LV longitudinal strain rate and early diastolic strain rate showed no change. CONCLUSION: Improvements in RV longitudinal strain, strain rate, and LV longitudinal strain are seen at 6 months post-TPV. Diastolic function does not appear to change at 6 months. Speckle tracking echocardiography may be more sensitive than traditional measures in detecting changes in systolic function after TPV implantation.

The use of intracardiac echocardiography during percutaneous pulmonary valve replacement.

High-quality live imaging assessment of cardiac valves and cardiac anatomy is crucial for the success of catheter-based procedures. We present our experience using Intracardiac echocardiography (ICE) during transcatheter Percutaneous Pulmonary Valve replacement (tPVR).This is a retrospective study that included 35 patients who underwent tPVR between April 2008 and June 2012. Thirty-one of these patients had the procedure performed under continuous ICE guidance. Pre-procedure transthoracic echocardiography (TTE) was obtained in all patients. ICE was performed at baseline, during the procedure, and at the conclusion of the procedure. Comparisons between the pre-procedure TTE and baseline ICE data and between post-procedure ICE data and the following day TTE were performed. Total of 35 patients had tPVR during the above-mentioned time period. Twenty-one patients received the Edwards Sapien valve and 14 patients had the Melody valve. Thirty-one patients had the procedure performed under continuous ICE guidance. The mean Pre-TTE peak gradient (PG) and Pre-ICE-PG were 45.5 ± 20 vs 33 ± 13 mmHg (p < 0.001) and the mean Pre-TTE mean gradient (MG) and Pre-ICE-MG were 27.7 ± 13 vs 21 ± 18 mmHg (p < 0.001). The mean Post-TTE- PG and Post-ICE-PG were 24.3 ± 11 vs 15.3 ± 7 mmHg (p < 0.001) and the mean of the Post-TTE-MG and Post-ICE-MG were 14.2 ± 7 vs 8.4 ± 4 mmHg (p < 0.001). There was a good correlation between peak ICE and TTE gradient at baseline and after valve placement. For the degree of pulmonary regurgitation, there was no significant difference between TTE and ICE. ICE is an important modality to guide tPVR in patients with dysfunctional homograft valve between the right ventricle and pulmonary artery and should be used to assess valve function before, during and immediately after the procedure.

Early clinical experience with a novel self-expanding percutaneous stent-valve in the native right ventricular outflow tract.

INTRODUCTION: Balloon expandable transcatheter pulmonary valve systems are not applicable to the large majority of patients with chronic severe pulmonary regurgitation (PR) following surgical right ventricular outflow tract (RVOT) rehabilitation. This report describes the clinical use and short-term follow-up of a novel transcatheter self-expanding pulmonary valve system (Venus P Valve) for rehabilitation of the RVOT in patients with chronic severe PR. METHODS: Patients with native RVOT and severe PR were selected on a case-by-case basis as part of early clinical experience with this valve. Patient demographics and pre-procedural, intra-procedural, and follow-up data were reviewed. RESULTS: Five patients (four females) with a mean weight of 54.8 ± 11.4 kg were selected for attempted valve deployment. Patients were either NYHA class II (n = 3) or class III (n = 2) at baseline. PR was grade 4 in all cases with mean right ventricular end-diastolic volumes of 155.0 ± 16.6 ml/m(2) on cardiac MRI. Mean minimum "annular" diameter on transthoracic echocardiogram was 22.8 ± 2.5 mm and mean RVOT diameter was 31.8 ± 5.1 mm. Uncomplicated successful valve delivery was achieved in all five cases with a mean fluoroscopy time of 22.8 ± 8.8 min. Valve sizes used were 26 (n = 3), 30 (n = 1), and 32 (n = 1). Mean pulmonary artery diastolic pressure increased from 3 ± 3.7 mm Hg to 9.9 ± 6.9 mm Hg (P = 0.06). On mean follow-up of 3.4 ± 2.5 months PR grade is 0 (n = 3) or 1 (n = 2) in all cases. NYHA class has improved at least one class in all cases and right ventricular volumes assessed by echocardiography have normalized in all three patients with follow-up to 3 months. CONCLUSIONS: The Venus P Valve provides excellent short-term pulmonary valvar function in the native RVOT of patients with surgically induced chronic severe PR.

Early echocardiographic changes after percutaneous implantation of the Edwards SAPIEN transcatheter heart valve in the pulmonary position.

OBJECTIVES: To evaluate echocardiographic changes after SAPIEN valve implantation in the pulmonary position. BACKGROUND: The feasibility of the SAPIEN transcatheter pulmonary valve (TPV) has recently been demonstrated. We evaluated changes in pulmonary valve function and the right ventricle after SAPIEN TPV placement. METHODS: We evaluated echocardiograms at baseline, discharge, 1 and 6 months after TPV placement in 33 patients from 4 centers. Pulmonary insufficiency severity was graded 0-4. TPV peak and mean gradients were measured. Right ventricular (RV) size and function were quantified using routine measures derived from color, spectral, and tissue Doppler indices and two-dimensional echocardiography. RESULTS: At baseline, 94% patients demonstrated pulmonary insufficiency grade 2-4. This decreased to 12% patients at 6 months (P < 0.01). TPV peak (P < 0.01) and mean gradient (P < 0.01) decreased. RV end-diastolic area indexed to body surface area (BSA) (P < 0.01), Tricuspid regurgitation (TR) gradient (P < 0.01), and the ratio of TR jet area to BSA (P < 0.01) decreased. Tricuspid inflow peak E:A, tissue Doppler imaging (TDI): septal E' and A', TDI: tricuspid A' improved between baseline and discharge, but trended back to baseline by 6-month follow-up. Tricuspid valve annulus z-score, RV area change, tricuspid annular plane systolic excursion (TAPSE), RV dP/dt, tricuspid E:E', and TDI: tricuspid annulus E' showed no change. CONCLUSION: Improvements in pulmonary insufficiency and stenosis, RV size, and TR gradient and severity are seen after SAPIEN TPV placement. Selected indices of RV diastolic function improve immediately after TPV implantation, but return to baseline by 6 months. RV systolic function is unchanged.

Fenestration of a Gore Helex Septal Occluder device in a patient with diastolic dysfunction of the left ventricle.

We report successful deployment of a fenestrated Helex Septal Occluder in a 46-year-old lady with a moderate-sized secundum atrial septal defect and elevated left-ventricular end diastolic pressure secondary to renovascular hypertension. Initial balloon occlusion of the defect lead to significant rise in left atrial pressure. Creation of a 4-mm fenestration offered controlled decompression of the left atrium while reducing the atrial shunt considerably.

Innovative resource utilization to fashion individualized covered stents in the setting of aortic coarctation.

OBJECTIVES: We describe our experience with self-fabricated covered stents in the setting of coarctation of the aorta (CoA). BACKGROUND: Balloon-expandable covered stents are increasingly being utilized to treat CoA in older children and adults. These stents however, are not available in the United States limiting the interventionalist's ability to treat this condition safely and effectively. METHODS: Retrospective analysis and follow-up data review of our complete experience with self-fabricated covered stents for CoA. Stents were fashioned by suturing an appropriate length of tubular polytetraflouroethylene to a bare metal stent and deploying this stent across the coarctation in a standardized fashion. RESULTS: Over a 9-year period we implanted 53 balloon-expandable stents in 49 patients with CoA. Of these 13 were self-fabricated covered stents deployed in 13 patients (7 male). Median age at implantation was 25.4 years (range, 8.7-49.5 years) with median weight of 65.5 kg (range, 28-168 kg). Indications for stent placement were native coarctation/aortic atresia (n = 9), aneurysm formation (n = 3), and re-coarctation (n = 1). The median systolic pressure gradient across the coarctation of 33 mm Hg (range, 12-69 mm Hg) was reduced to 3 mm Hg (range, 0-19 mm Hg) post procedure (P < 0.001). There were no deaths on median follow-up of 44 months (range, 1-83 months). One patient developed acute contained extravasation at implantation, treated with a self-expanding stent graft. Another patient required thrombectomy for femoral arterial thrombosis. CONCLUSIONS: Innovative application of available materials adds to the armamentarium of the interventionalist. Our self-fabricated covered stent provides effective gradient reduction with no compromise in stent delivery or durability on follow-up.

Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients.

OBJECTIVES: We report our 10-year experience with percutaneous closure of adult congenital and acquired (non-post-infarct) ventricular septal defects (VSDs) using different types of Amplatzer occluder devices. BACKGROUND: Adult congenital and acquired VSDs may produce significant morbidity and mortality. Furthermore, such VSDs pose a significant surgical challenge. METHODS: Between February 2000 and August 2009, data were retrospectively reviewed from 28 patients who underwent 29 procedures for percutaneous device closure of hemodynamically significant VSDs. Seventeen had unrepaired congenital VSDs, 10 had post-operative VSDs (5 with residual patch-margin defects, 4 post-aortic valve replacement, 1 post-myomectomy), and one had an acquired traumatic VSD. INDICATIONS FOR CLOSURE INCLUDED: symptoms related to significant shunt (dyspnea on exertion); unexplained deterioration of LV function, and/or LV dilation; recurrent endocarditis, and pulmonary hypertension. Outcome parameters were procedural success, procedure-related complications, evidence of residual shunt by echocardiography, and improvement in the signs/symptoms for which the procedure was performed. The mean follow-up interval was 68 months. RESULTS: Of the 28 patients studied, a single VSD was present in 26 patients, while one patient had two defects, and one patient had one defect on the LV side with three openings at the RV side. The median size of the defects by echocardiography was 6 mm. A device was successfully implanted in 28 of 29 (97%) procedures and 28 of 28 (100%) patients. PROCEDURE-RELATED COMPLICATIONS OCCURRED IN TWO CASES: one involving an access site hematoma not requiring transfusion as well as nonsustained ventricular tachycardia that resolved spontaneously and the other involving acute mitral regurgitation due to inadvertent trapping of the anterior mitral valve leaflet between the left ventricular disk and the septum that was resolved by recapturing of the disk. There was immediate complete closure in 20 patients (71%). In six cases there was trivial residual shunt and in two patients the residual shunt was mild. At the latest follow-up, four of the eight with a residual shunt had no shunt and in the remaining four the residual shunt was trivial. Among symptomatic patients 18 (64%), there was marked improvement in symptoms and for those patients 17 (61%) for whom the procedure was performed to address left ventricular enlargement, there was reduction or stabilization in LV size on serial echoes. CONCLUSIONS: Percutaneous closure of VSDs in the adult patient appears to be safe and effective.

Transcatheter pulmonary valve implantation using the Edwards SAPIEN transcatheter heart valve.

BACKGROUND: Conduits placed in the right ventricular outflow tract (RVOT) have limited longevity which often requires increasingly complex reoperations. Transcatheter pulmonary valve implantation improves conduit hemodynamics through a minimally invasive approach. We present data for 7 patients treated with the Edwards SAPIEN transcatheter heart valve (THV). PATIENTS: Patients' ranged in age from 16 to 52 years, one was female, and all had NYHA class II-III symptoms. Patients had pulmonary homografts that had been placed 2-25 years earlier during the Ross procedure (n = 4), repaired double outlet right ventricle with situs inversus (n = 1), or Rastelli repair for D-TGA, pulmonary atresia, and ventricular septal defect (n = 2). Patients had either severe pulmonary stenosis and/or moderate to severe pulmonary regurgitation. RESULTS: All patients had successful percutaneous implantation of the 23 mm SAPIEN THV under general anesthesia. Fluoroscopy times ranged from 16 to 49 mins and procedure times ranged from 110 to 237 mins. The RV:systemic pressure ratio decreased from 78 +/- 18 to 39 +/- 8%, the RVOT gradient improved from 60.7 +/- 24.3 to 14.9 +/- 6.9 mm Hg, no patients had pulmonary insufficiency, and all patients had symptom improvement. At a maximum follow-up of 3.5 years (median 22.5 months), Doppler peak gradients ranged from 7-36 mm Hg, and there is no evidence of late stent fracture or structural valve failure. CONCLUSION: The SAPIEN THV can be used successfully in the treatment of patients with right ventricle to pulmonary artery homograft failure. The valve is durable to at least 3.5 years without stent fracture or regurgitation. Clinical trials are underway to assess the long-term safety and efficacy of this valve.

Feasibility of real-time three-dimensional transoesophageal echocardiography for guidance of percutaneous atrial septal defect closure.

AIMS: Intracardiac echocardiography (ICE) and two-dimensional transoesophageal echocardiography (2D TEE) are used in most centres for guiding transcatheter atrial septal defect (ASD) closure. ASDs have complex shapes that are not well characterized with 2D imaging. Real-time 3D TEE (RT3D TEE) provides en-face visualization of the ASD, allowing precise assessment of ASD dimensions. Accordingly, our aims were (i) to determine the feasibility of RT3D TEE to guide ASD closure and (ii) to compare ASD and balloon dimensions (BDs) using RT3D TEE vs. ICE and 2D TEE. METHODS AND RESULTS: Thirteen patients with ostium secundum ASD underwent transcatheter ASD closure. 2D TEE, RT3D TEE, and ICE images were acquired sequentially. RT3D TEE was feasible in all patients. Comparing RT3D TEE and 2D imaging, the mean difference in long-axis dimension was +0.5 mm (P= NS for both), and -1.4 mm in short-axis (2D TEE, P < 0.05; ICE, P = 0.06). BD was greater with 3D TEE vs. ICE (+0.9 mm). CONCLUSION: RT3D TEE can be used to guide transcatheter ASD closure with the advantages of lower cost than ICE, and ability to visualize en-face views of the ASD. ASD and BD as measured by RT3D TEE differ when compared with 2D imaging.

Intracardiac echocardiography for the guidance of percutaneous procedures.

Interventional cardiology has seen great advances in the past decade. A wide range of interventional procedures has been established as standard therapeutic modalities and more are yet to come. Multiple imaging modalities have been used to guide these procedures. Intracardiac echocardiography (ICE) provides an accurate imaging tool to guide the appropriate performance of many of these procedures. Early studies compared ICE as a new imaging modality to guide interventional closure of atrial communications with other more established imaging techniques, such as transesophageal echocardiography, with excellent accuracy. In this article, we discuss the value of using ICE in guiding some percutaneous interventional procedures. We also discuss the imaging protocol for using ICE to guide atrial level shunt device closure. Our experience in using ICE for guiding percutaneous valve placement is also discussed.

Device closure of muscular ventricular septal defects using the Amplatzer muscular ventricular septal defect occluder: immediate and mid-term results of a U.S. registry.

OBJECTIVES: We sought to report the results of a U.S. registry of device closure of congenital muscular ventricular septal defects (VSDs) using the new Amplatzer mVSD occluder (AGA Medical Corp., Golden Valley, Minnesota). BACKGROUND: Muscular VSDs pose a significant surgical challenge with increased morbidity and mortality. METHODS: Data were prospectively collected from 83 procedures involving 75 patients who underwent an attempt of percutaneous (70 [93.3%] of 75) and/or perventricular (surgical) (6 [8.0%] of 75) device closure of hemodynamically significant muscular VSDs. The patients' median age was 1.4 years (range 0.1 to 54.1 years). Outcome parameters were procedural success, evidence of residual shunts on echocardiography, and occurrence of procedure-related complications. The median follow-up was 211 days (range 1 to 859 days). RESULTS: The median size of the primary VSD was 7 mm (range 3 to 16 mm) and in 34 of 78 (43.6%) procedures, patients had multiple VSDs (range 2 to 7). The device was implanted successfully in 72 of 83 (86.7%) procedures. In 17 of 83 (20.5%) procedures, multiple devices were implanted (range 2 to 3). Procedure-related major complications occurred in 8 of 75 (10.7%) patients. Device embolization occurred in two patients and cardiac perforation in one patient. There were two (2.7%) procedure-related deaths. The 24-h postprocedural complete closure rate was 47.2% (34 of 72 patients), increasing to 69.6% (32 of 46 patients) at 6 months and 92.3% (24 of 26 patients) at 12 months. Six patients underwent successful closure using the perventricular surgical (beating heart) approach, with complete closure at day 1 in three patients and trivial/small residual shunts in the remainder of the patients. CONCLUSIONS: The Amplatzer mVSD device (AGA Medical Corp.) offers excellent closure rates and low mortality when used to close congenital muscular VSDs. The device appears to be safe and effective.

Speckle-Tracking Echocardiographic Measures of Right Ventricular Function Correlate With Improvement in Exercise Function After Percutaneous Pulmonary Valve Implantation.

BACKGROUND: Speckle-tracking echocardiographic (STE) measures of right ventricular (RV) function appear to improve after transcatheter pulmonary valve implantation (TPVI). Measures of exercise function, such as ventilatory efficiency (the minute ventilation [VE]/carbon dioxide production [VCO2] slope), have been shown to be prognostic of mortality in patients who may require TPVI. The aim of this study was to evaluate the correlation between STE measures of RV function and changes in VE/VCO2 after TPVI. METHODS: Speckle-tracking echocardiography and cardiopulmonary exercise testing were performed at baseline and 6 months after TPVI in 24 patients from four centers. Conventional echocardiographic measures of RV function were also assessed. Echocardiographic and exercise stress test results were interpreted by single blinded observers at separate core laboratories. RESULTS: All patients demonstrated relief of pulmonary regurgitation and stenosis after TPVI. Improvements in RV longitudinal strain (-16.9 ± 3.5% vs -19.7 ± 4.3%, P < .01) and strain rate (-0.9 ± 0.4 vs. -1.2 ± 0.4 s(-1), P < .01) were noted. The VE/VCO2 slope improved (32.4 ± 5.7 vs 31.5 ± 8.8, P = .03). No other significant echocardiographic or exercise changes were found. On multivariate regression, the change in VE/VCO2 was independently associated with change in RV longitudinal early diastolic strain rate (P < .001) and tricuspid A velocity (P < .001). Preintervention RV longitudinal strain was found to be a predictor of change in VE/VCO2 after TPVI (r = -0.60, P < .001). CONCLUSIONS: STE measures of RV function appear to hold the potential for use as predictors of improved outcomes in patients requiring TPVI. Future studies should directly assess the prognostic significance of STE measures of RV function in this population.

Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results.

OBJECTIVE: Both surgical management and percutaneous device closure of muscular ventricular septal defects have drawbacks and limitations. This report describes our initial experience with intraoperative device closure of muscular ventricular septal defects without cardiopulmonary bypass in 6 consecutive patients. METHODS: A median sternotomy or a subxiphoid minimally invasive incision was performed. Under continuous transesophageal echocardiographic guidance, the right ventricle free wall was punctured, and a wire was introduced across the largest defect. The Amplatzer (AGA Medical Corporation, Golden Valley, Minn) muscular ventricular septal defect occluding device (a self-expandable double-disk device) was used. An introducer sheath was fed over the wire, with the sheath tip positioned in the left ventricle cavity. The device was then advanced inside the sheath and deployed by retracting the sheath. Associated cardiac lesions, if any, can then be repaired during cardiopulmonary bypass. A similar technique can also be applied for periatrial closure of complex atrial septal defects. RESULTS: The initial 6 patients are presented. Cardiopulmonary bypass was not needed in any patient for placement of the device and needed in 4 patients for repair of concomitant malformations only (double-outlet right ventricle, aortic arch hypoplasia, pulmonary artery band removal). No complications from using this technique occurred. Discharge echocardiograms showed no significant shunting across the ventricular septum. CONCLUSIONS: Perventricular closure of multiple muscular ventricular septal defects is safe and effective. We believe that this could become the treatment of choice for any infant with muscular ventricular septal defects or any child with muscular ventricular septal defect and associated cardiac defects.

State of the art catheter interventions in adults with congenital heart disease.

Catheter interventions in adults with congenital heart disease have rapidly advanced. Transcatheter valve repair and replacement techniques have been added to the existing spectrum of well-established procedures. This review summarizes current transcatheter management strategies for congenital cardiac anomalies seen in the adult population.

Transcatheter closure of congenital and acquired muscular ventricular septal defects using the Amplatzer device.

Surgical closure of congenital or post-myocardial infarction (MI) muscular ventricular septal defect (MVSD) is associated with significant mortality and morbidity; therefore, both surgeons and cardiologists would welcome a safe non-surgical approach. The aim of this study is to report the combined experience of 2 cardiac centers in the transcatheter occlusion of both congenital and acquired MVSDs using the Amplatzer MVSD occluder device (AGA Medical Corporation, Golden Valley, Minnesota). Thirty-two patients underwent attempted transcatheter closure of an MVSD. Nineteen of these patients had congenital unoperated MVSD, twelve had post-MI MVSD and 1 patient had an acquired VSD post-surgical repair of hypertrophic cardiomyopathy. The median age of patients was 11.5 years (range, 0.1 86.0 years) and median weight was 34.5 kg (3.4 123.0 kg). All patients had significant shunt documented by echocardiography with a median Qp/Qs ratio of 1.7 (range, 1.0 5.3). The VSD location was mid-muscular in 14 patients, posterior in 10, apical in 5 and anterior in 3. The systolic pulmonary artery pressure ranged from 10 85 mmHg (median, 34.5 mmHg). The device was implanted successfully in 30 patients. The device size ranged from 6 26 mm (2 of these were ASD devices). There was immediate complete closure of the defect in 15 patients and 14 patients had residual shunt (foaming through the device). The median fluoroscopy time was 56.7 minutes (range, 11.7 146.0 minutes). Complications included: tamponade in 1 patient resulting in death; device malposition in 1 patient requiring surgical removal; severe hemolysis in 2 patients; and transient junctional rhythm in 1 patient. Among the 30 patients with successful implantation, three died in the hospital and 2 died later. On follow-up evaluation, there were no episodes of endocarditis, thromboembolism, hemolysis or wire disruption. We conclude that the Amplatzer MVSD occluder is a safe and effective device for closure of MVSDs up to 14 mm in diameter. Further clinical trials with this device are underway.

Three-Dimensional Echocardiographic Reconstruction of the Left Ventricle by a Transesophageal Tomographic Technique: In Vitro and In Vivo Validation of its Volume Measurement.

Accurate determination of left ventricular (LV) volume has important therapeutic and prognostic implications in patients with cardiac disease. Volume estimations by two-dimensional techniques are not very accurate due to geometric assumptions. OBJECTIVES: To validate LV volume determinations by a new transesophageal three-dimensional echocardiographic technique. We performed three-dimensional reconstruction of the LV using an echo-computed tomographic (CT) technique based on serial pullback parallel slice imaging technique in both in vitro and in vivo settings. Fourteen latex balloons with various sizes (30-235 mL) and shapes (conical, pear shaped, round, elliptical, and aneurysms in various locations) filled with known volumes of water were imaged in a water bath. From the static three-dimensional image, the LV long axis was defined and the LV was sectioned perpendicular to this axis into 2-mm slices. The volume of each slice was calculated with the observer blinded to the actual volume as the product of the slice thickness and the manually traced perimeter of the slice and the LV volume as the sum of the volumes of the slices (Simpson's method). The calculated LV volume closely correlated with the actual volume (r = 0.99, P < 0.0001, calculated volume = 1.06x - 11.3, Deltavolume = -5.7 +/- 10.0 cc). Using the same system, transesophageal echocardiographic (TEE) images of the LV were obtained in 15 patients gated to respiration and ECG. Satisfactory dynamic three-dimensional reconstruction of the LV was possible in ten patients. The three-dimensional LV volumes (systolic and diastolic) using Simpson's method correlated well with those obtained from biplane or multiplane TEE images using the area length method (r = 0.89, p < 0.0001, y = 12.7 + 0.84x, Deltavolume = 1.3 +/- 18.1 cc). The LV major-axis diameters by the two methods showed very close correlations as well (r = 0.86, P < 0.0001, y = 19 + 0.74x, Deltadiameter = 1.0 +/- 7.2 mm). We conclude that three-dimensional LV volume calculation by the echo-CT technique is intrinsically sound, is independent of LV geometry, and with some limitations, is applicable in vivo. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Multiplane Transthoracic Echocardiography: Image Orientation, Anatomic Correlation, and Clinical Experience with a Prototype Phased Array Multiplane Surface Probe.

Multiplane transthoracic echocardiography provides numerous sequential images by rotation of the transducer imaging array through 180 degrees with the surface probe at a fixed site. We explored the potential of this new technique with a 3.7/5-MHz prototype multiplane transthoracic probe. Echoanatomic correlations were first examined in ten explanted hearts. The transducer was then applied in 30 normal humans at transthoracic acoustic windows to determine the imaging planes available. Use of this probe in 76 patients with various cardiac disorders indicated that this probe eases the procedure of transthoracic echocardiographic examination, provides incremental information for improved delineation and understanding of cardiac pathology, and yields many novel insights to echocardiographic interpretation. Multiplane transthoracic echocardiography appears to expand the versatility of transthoracic two-dimensional echocardiography.

Volumetric Holography of Cardiac Defects in Humans: Initial Clinical Experience Using Tomographic Echocardiographic Data.

We have previously described a method to develop holograms that does not entail the presence of laser light source in the clinical environment. Although we have demonstrated the feasibility of holography from cardiac ultrasound data to depict normal and abnormal cardiac anatomy in experimental studies, the ability of holography from ultrasound data to image structural cardiac anomalies in patients is not known. In this exploratory study, we addressed the question of whether it was possible to image cardiac pathology by holography in patients with mitral valve disease, atrial septal defects, and ventricular aneurysms. Parallel, tomographic echocardiographic data obtained during transesophageal echocardiography were used to generate holograms of cardiac disorders. Holographic three-dimensional (3-D) reproduction contains up to 1024 by 1024 pixels and full gray scale in each of the individual slices. Holograms of cardiac defects depicted their true spatial location, which not only enhanced the anatomic appreciation of the defect itself, but also revealed the depth and the relationship of the structures in proximity of the defect. Thus, 3-D imaging of cardiac anomalies by volumetric multiplexed holography is feasible.

New Therapeutic Avenues with Hybrid Pediatric Cardiac Surgery.

Abstract Background: Minimally invasive strategies can be expanded by combining standard surgical and interventional techniques. Methods: A longitudinal prospective study was conducted of all pediatric patients who have undergone hybrid cardiac surgery at the University of Chicago Children's Hospital. Hybrid cardiac surgery was defined as combined catheter-based and surgical interventions in either one surgical setting or planned sequential surgical settings within a 24-hour period. Results: Between June 2000 and June 2003, 24 patients were treated with hybrid approaches. Sixteen patients with muscular ventricular septal defects (VSDs)with a mean age of 4 months (range, 2 weeks to 4 years) underwent either sequential Amplatzer device closure in the catheterization laboratory followed by surgical completion (group 1A [n = 9]: right ventricular (RV)outflow tract enlargement, 6 patients; closure of other VSDs, 5 patients; tricuspid valvuloplasty, 3 patients; bidirectional Glenn shunt, 1 patient; Maze procedure, 1 patient; and retrieval of embolized device, 1 patient) or, more recently, a 1-stage intraoperative off-pump device closure (group 1B;n =7)with the subsequent repair of concomitant heart lesions in 5 patients (double-outlet RV, 2 patients; arch hypoplasia/coarctation of the aorta, 2 patients; and pulmonary artery (PA) debanding, 1 patient). Cardioplegic arrest was either avoided or shortened in the muscular VSD patients. Eight patients with branch PA stenoses (group 2)underwent intraoperative PA stenting or stent balloon dilation along with RV outflow procedure (5 patients)or Fontan completion (3 patients with Maze procedure, mitral valvuloplasty, or Damus-Kaye-Stansel procedure in 1 patient each). All patients survived hospitalization. Complications from the hybrid approach in group 1A patients included tricuspid regurgitation in 2 patients, RV disk malposition in 1 patient, embolization of a VSD device into the aorta in 1 patient, and a residual VSD in 1 patient. No complications from the hybrid approach occurred in group 1B patients, and PA rupture from stent overinflation and ventricular dysfunction occurred in 1 patient each in group 2. During a mean follow-up period of 18 months (range, 2-36 months), 2 group 1A patients died suddenly several months after discharge. All of the other patients are doing well. Conclusions: Hybrid pediatric cardiac surgery performed in tandem by surgeons and cardiologists is a safe and effective means of reducing or eliminating cardiopulmonary bypass. Patients with muscular VSDs who are small, have poor vascular access, or have concomitant cardiac lesions are currently treated in one setting with the perventricular approach.