Flow characteristics in the dilated left ventricle with thrombus: qualitative and quantitative Doppler analysis.

In an attempt to determine whether mural thrombus in a dilated left ventricle is associated with specific flow patterns, a study was undertaken to assess qualitatively and quantitatively the flow characteristics by conventional pulsed and two-dimensional Doppler color flow examination. Forty patients with cardiomyopathy formed the study group (20 with an apical thrombus and 20 without). The groups did not differ with respect to age, gender, origin of ventricular dysfunction, ventricular size and ejection fraction. Guided by the Doppler color flow pattern, a quantitative analysis of flow velocity profile in the ventricular inflow and outflow "compartments" was performed by serial pulsed wave Doppler sampling. Inflow velocity at the ventricular apex was significantly lower in the thrombus group than in the no thrombus group (11.7 +/- 15.3 versus 28.3 +/- 10.5 cm/s, p less than 0.0001). Flow velocities were generally lower in the thrombus group at the other levels in the inflow compartment (that is, mitral anulus, leaflet tips and papillary muscle level). The systolic flow velocity at the apex was similarly significantly lower in the thrombus group than in the no thrombus group (7.1 +/- 8.1 versus 15.3 +/- 7.0 cm/s, p less than 0.001). Additionally, a higher prevalence of mitral regurgitation was noted in the no thrombus group (14 patients) than in the thrombus group (3 patients). Thus, specific abnormal flow profiles are associated with a left ventricular thrombus. Whether the abnormal flow is a primary event in the genesis of left ventricular thrombus or occurs secondary to development of the thrombus cannot be determined from this study.

Survival of patients with aortic valve endocarditis. The prognostic implications of the echocardiogram.

The clinical and prognostic implications of the echocardiogram were assessed in 32 patients with clinical aortic valve endocarditis. Seventeen patients had an echocardiographic diagnosis of a vegetation, a flail cusp, or a root abscess (group 1). Ten group 1 patients had embolic episodes. Eight group 1 patients were treated surgically and all survived, while nine group 1 patients were treated medically and two survived. Eleven patients had echocardiographic aortic valve sclerosis (group 2). One group 2 patient had an embolic episode. Six group 2 patients were treated surgically and four survived, while five group 2 patients were treated medically and three survived. Four patients had normal aortic valve echograms (group 3). One group 3 patient had an embolic episode. All group 3 patients were treated medically and survived.

Dissecting aortic aneurysm associated with a midsystolic click.

A midsystolic click occurred in a patient with a type 1 dissecting aneurysm. The mechanism of production of the systolic click may be related to rapid deceleration of blood against the intimal flap. Combined phonocardiography and echocardiography (using a new second right intercostal space approach) proved to be helpful in differentiating this sound from an aortic and pulmonary ejection click. In addition, other causes of midsystolic clicks, such as mitral and tricuspid valve prolapse, were excluded.

Rapidly progressing, massive mitral annular calcification. Occurrence in a patient with chronic renal failure.

Calcification of the mitral annulus developed in a patient while undergoing dialysis. The rapid onset of events corresponded to the onset of end-stage renal failure and uncontrolled secondary hyperparathyroidism. Sequential echocardiograms verified the progression of calcification of the annulus as well as the valve. A new systolic and diastolic murmur and reduced valve orifice on two-dimensional echocardiography suggested acquired nonrheumatic mitral stenosis and insufficiency. We propose that metastatic calcium deposition rather than long-term hypertensive and degenerative effects was the predominant mechanism for massive calcification of the annulus and valve. It is suggested that M-mode echocardiography be used sequentially to follow both the occurrence and progression of calcification of the mitral annulus or valve in patients with chronic renal failure, secondary hyperparathyroidism, or both.

Mitral annular calcification. Clinical and echocardiographic correlations.

Clinical, echocardiographic, and radiographic findings in 41 patients with mital annular calcification are presented. Clinical diagnosis included rheumatic heart disease (32%), noninflammatory calcific disease (34%), and chronic renal failure (32%). Mitral annular calcification is recognized echocardiographically as a dense echo band beneath the posterior mitral leaflet with motion paralleling that of the free left ventricular wall. Only two patients of 41 (5%) with mitral annular calcification had calcification on routine x-ray films, and six of 16 (38%) on cinefluoroscopy. The left atrial size is enlarged, and the mitral leaflets are thickened, with reduced motion (D-E) in rheumatic heart disease, but the leaflet motion is well preserved in the nonrheumatic patients. The association of mitral annular calcification with idiopathic hypertrophic subaortic stenosis, chronic renal failure, and bacterial endocarditis is discussed. Echocardiography appears to be a sensitive method of detecting mitral annular calcification and may be helpful in differentiating rheumatic and nonrheumatic etiologies.

Wide splitting of the first heart sound secondary to tricuspid valve endocarditis. A phonocardiographic-echocardiographic study.

A patient is described with tricuspid valve endocarditis in whom the vegetation interfered with valve closure resulting in marked wide splitting of the first heart sound. M-mode and two-dimensional echocardiographic studies detected the presence of a vegetation. Simultaneous phonocardiographic and echocardiographic studies documented the marked delay in tricuspid valve closure and differentiated wide splitting of the first heart sound from other causes of early and mid-systolic sounds. Following pulmonary embolization, the first heart sound returned to normal. Echocardiographic disappearance of the vegetation of the tricuspid valve was also noted. Regrowth of the vegetation again produced the abnormal phonocardiographic and echocardiographic findings.

Pseudoaneurysm of the left ventricle complicated by Salmonella typhimurium infection. Recognition by two-dimensional echocardiography.

A patient is described with a large posterior left ventricular pseudoaneurysm complicated by Salmonella typhimurium infection. M-mode echocardiography displayed a massive echo-free space behind the posterior left ventricular wall, and two-dimensional echocardiography specifically defined the orifice and saccular contour of the false aneurysm. These findings were confirmed by cardiac catheterization and surgery. The unusual features of Salmonella endovascular infection and the noninvasive methods to detect left ventricular pseudoaneurysms are reviewed.

Magnetic resonance imaging and two-dimensional echocardiography. Alternative approach to aortography in diagnosis of aortic dissecting aneurysm.

Unrecognized acute dissection of the aorta requires rapid and accurate diagnosis for appropriate management. The "gold standard" for diagnosis has been invasive angiography, but this diagnosis can be achieved noninvasively via two-dimensional echocardiography, computed tomographic scanning, and magnetic resonance imaging. Two patients are described in whom echocardiography and magnetic resonance imaging were complementary diagnostic aids. The advantages and disadvantages of echocardiography, computed tomographic scanning, magnetic resonance imaging, and aortography in aortic dissection are discussed. It is anticipated that a combination of noninvasive diagnostic aids will eliminate the need for invasive angiography in many instances in the future.

Comparison of two-dimensional and M-mode echocardiography in the evaluation of patients with infective endocarditis.

M-mode and two-dimensional echocardiographic evaluation of infectious endocarditis and its complications was reviewed. In 21 consecutive patients with clinical endocarditis, 22 valves were involved (12 aortic, 5 mitral and 5 tricuspid). M-mode echocardiography detected vegetations in 10 patients (four aortic, two mitral and four tricuspid) and detected complications of endocarditis in 2 patients (one aortic root abscess and one flail aortic cusp). Two-dimensional echocardiography detected vegetations in 9 patients (four aortic, one mitral and four tricuspid) and detected complications in ten patients (five flail aortic cusps, one aortic root abscess, one sinus on Valsalva aneurysm, two flail mitral leaflets and one flail tricuspid valve). Thus, although M-mode and two-dimensional echocardiography had a similar ability to detect actual vegetations, two-dimensional echocardiography was superior to M-mode echocardiography in diagnosing complications of the destructive process.

Two dimensional echocardiographic recognition of the descending thoracic aorta.

Two dimensional echocardiography was used to identify the descending thoracic aorta in 106 subjects. In 12 of these subjects, contrast injection techniques were used to identify this structure as it descended posteriorly adjacent to the atrioventricular groove. The course of the descending thoracic aorta was mapped using both the long axis and transverse axis views. The normal descending thoracic aorta (26 subjects) measured 10 +/- 1.4 mm/m2 during diastole. Unusual M mode echocardiographic patterns of the descending aorta may be confused with other disease states; they are clarified with the two dimensional study. The size and appearance of the descending aorta in different types of cardiovascular disease, including aortic aneurysm, in 80 patients are described. It is anticipated that two dimensional echocardiography will prove to be a useful method of studying patients with aortic disease.

M mode and two dimensional echocardiography in mitral and aortic regurgitation: pre- and postoperative evaluation of volume overload of the left ventricle.

Both M mode and two dimensional echocardiography are useful in determining the origin of mitral regurgitation. Two dimensional echocardiography appears to be superior to M mode echocardiography in the diagnosis of a flail leaflet, papillary muscle dysfunction and cleft mitral valve. It is possible to differentiate valvular causes from myocardial causes of regurgitation. Unfortunately, the severity of mitral regurgitation is difficult to quantify with either the M mode or the two dimensional technique. Echocardiography does allow differentiation of acute forms of mitral and aortic regurgitation from chronic volume overload of the left ventricle. Rupture of chordae tendineae is the most common cause of acute mitral regurgitation, and two dimensional echocardiography is 96 percent sensitive in its detection. Bacterial endocarditis, flail aortic valve and dissecting aneurysm as causes of acute aortic regurgitation can be detected with two dimensional echocardiography. Systolic left ventricular cavity dimension, percent fractional shortening and ejection fraction are important variables in predicting optimal time for surgery in patients with chronic aortic and mitral regurgitation. The noninvasive technique of echocardiography may be especially useful in decision making in the asymptomatic patient.

Two dimensional echocardiography in congenital heart disease.

Two dimensional echocardiography has enhanced the ability of the clinician to define accurately intracardiac anatomy and great vessel relations. By visualizing relations of the great arteries and determining ventricular situs in the parasternal short axis planes and by assessing the relation of the great arteries to ventricles atrioventricular (A-V) valves and the interventricular septum in the parasternal and apical long axis view, complex congenital heart disorders can readily be differentiated. The subcostal approach allows accurate identification and localization of interatrial and interventricular septal defects. Utilizing the apical parasternal four chambered or subcostal four chambered view, complex malformations of the A-V valves such as complete endocardial cushion defect and Ebstein's anomaly can readily be appreciated. The suprasternal approach has allowed direct visualization of a coarcted aortic segment. The differentiation of left and right ventricular outflow obstruction is also possible. In some patients, it is possible to achieve an accurate diagnosis with two dimensional echocardiography alone. In others, two dimensional echocardiography provides accurate and detailed information with regard to spatial anatomy and valve morphology so that invasive studies can be performed more expeditiously, with less contrast agent and hence with greater safety. With regard to future developments, better resolution capability with newer instrumentation and combined two dimensional echocardiography with Doppler blood flowmeter studies may provide even greater diagnostic accuracy in the evaluation of patients with congenital heart disorders.

Statistical comparison of M mode and two dimensional echocardiographic diagnosis of flail mitral leaflets.

Forty-five patients who had surgical therapy for pure mitral insufficiency were evaluated prospectively with both M mode and two dimensional echocardiography; 26 patients (Group I) had a flail mitral valve leaflet, and 19 patients (Group II) had intact chordae tendineae. The M mode echocardiographic criteria of a flail valve (systolic left atrial echoes, systolic mitral valve flutter, diastolic mitral flutter and chaotic paradoxic diastolic posterior leaflet motion) were compared statistically with the two dimensional echocardiographic criterion (loss of systolic leaflet coaptation). The presence of one M mode echocardiographic finding had a sensitivity of 60 percent, a specificity of 53 percent, a predictive accuracy of 63 percent and a predictive value of 50 percent. The sensitivity (96 percent), specificity (84 percent), predictive accuracy (89 percent) and predictive value (94 percent) of the two dimensional echocardiogram were statistically superior to those of the M mode study (p less than 0.05 or better for each criterion). Thus, two dimensional echocardiography is distinctly superior to M mode echocardiography in the diagnosis of flail mitral valve leaflets.

Doppler evaluation of changing cardiac dynamics during Cheyne-Stokes respiration.

For the purpose of elucidating the mechanisms and/or effects of the cardiovascular changes occurring during Cheyne-Stokes respiration, we utilized Doppler echocardiography to determine intracardiac flow velocity profiles during the changing phases. Left ventricular inflow (LVI) and outflow (LVO) were examined in ten patients, nine with heart failure and one with a cerebrovascular accident. The mean LVI, peak early (E) and late diastolic (A) and LVO velocities were measured at the end of both the hyperpneic and apneic phases. The phasic hemodynamic changes observed during Cheyne-Stokes respiration by Doppler profile could be explained by the development of LV diastolic dysfunction and a decrease in LV stroke volume during the apneic phase of Cheyne-Stokes respiration. Alternatively, an increase in PCO2 during the apneic phase may increase pulmonary vascular resistance lowering preload and stroke volume, whereas during the hyperpneic phase, pulmonary vascular resistance is reduced with resultant increase in left ventricular preload and increase in stroke volume. Both theories are speculative and the precise hemodynamic changes associated with Cheyne-Stokes respiration requires further investigation.

Flow patterns in dilated cardiomyopathy: a pulsed-wave and color flow Doppler study.

In 48 patients with dilated cardiomyopathy, pulsed-wave and color Doppler examination were performed. In addition, 14 normal patients served as control subjects. Peak inflow velocity at the level of the mitral valve, middle left ventricle, and apex and outflow velocity at the level of the apex, middle left ventricle, and subaortic area were measured. In normal patients there was brisk propagation of inflow velocity to the apex. Patients with dilated cardiomyopathy demonstrated delayed propagation and prolongation of the duration of inflow compared with control subjects (p less than 0.04). Continuous apical flow was visualized in 25% of dilated cardiomyopathies and in no normal patients. Apical velocities were significantly increased in cardiomyopathies with significant mitral regurgitation. Outflow velocities were decreased in dilated cardiomyopathy. In patients with dilated cardiomyopathy and apical dyskinesis, flow directed toward the base was measured in the middle left ventricle during isovolumic relaxation secondary to dyskinetic rebound. Patterns of abnormal flow in dilated cardiomyopathies are readily apparent by color M-mode and two-dimensional color Doppler.

Geriatric cardiology: managing the most common nonischemic disorders.

Two-dimensional echocardiography is the method of choice for calculation of left ventricular mass, especially in patients with abnormal left ventricular geometry and segmental disease. Predominating diastolic abnormalities may be responsible for signs and symptoms of heart failure in some patients. These patients should not be treated in the conventional manner, but require special treatment with beta blockers or calcium-channel blocking agents.