Effusive constrictive pericarditis: 2D, 3D echocardiography and MRI imaging.

The entity of effusive constrictive pericarditis (ECP) combines clinical and echocardiographic features of pericardial effusion and constrictive pericarditis. We describe a case of ECP, of probable tuberculous etiology, with typical hemodynamic findings of pericardial constriction, which persisted after the pericardial effusion was drained. Thickening of parietal and visceral pericardium was seen on 2D and 3D echo, and on MRI. Two important variations of ECP-due to tuberculous and to staphylococcal etiology, respectively-show some important differences that are relevant to management of therapy.

The right subclavian vein can be used as a surrogate of the inferior vena cava, as an echocardiographic indicator of systemic venous congestion.

Respiratory variations in the caliber of the inferior vena cava, imaged in the subcostal view with the patient supine, correlated well with respiratory variation in the caliber of the right subclavian vein with the patient reclining at a 45 degrees angle. The subclavian vein was imaged by a right supraclavicular approach. We suggest that the right subclavian vein caliber be used as a surrogate of the inferior vena cava caliber when the latter cannot be used because of obesity, epigastric tenderness, or other reasons.

Echocardiographic aspects of hiatal hernia: A review.

It was realized 20 years ago that the sonographic appearance of a diaphragmatic hernia could simulate a left atrial mass. Many papers have appeared on this topic since then, but they mainly consist of single case reports. Clinical symptoms due to cardiac compression by the hernia are uncommon but may occur if the hernia is very large; such patients have presented with episodes of syncope or dyspnea, typically after a large meal. Sonographers, cardiologists, gastroenterologists, and internists are generally not yet aware that sonographic presentations can be varied and are often perplexing. These include the combination of hiatal hernia with gastroesophageal reflux demonstrable in the subcostal view, and hiatal hernia in patients with ascites.

Three-dimensional echocardiographic appearances of pericardial effusion with tamponade.

A patient with pericardial effusion and tamponade was studied by routine two-dimensional as well as three-dimensional echocardiogram. Chamber "collapses" of the right atrium, left atrium, right ventricle, and inferior vena cava were visualized by both modalities, but were better appreciated on three-dimensional echo imaging, perhaps because three-dimensional echo imaging is more suited to depicting three-dimensional changes in chamber shape.

Unusual superior vena cava thrombus (partly obstructive) extending through right atrium to eustachian valve.

A 50-year-old patient with end-stage renal disease who was being dialyzed with an internal jugular catheter presented with fever. Transthoracic and transesophageal echo demonstrated a thrombus in the inferior vena cava, protruding into the right atrium and extending to the eustachian valve to which it was adherent. Multiple organisms grew from the blood as well as the catheter tip. Antibiotic therapy was started with Vancomycin and Gentamicin but later changed to other combinations according to sensitivity studies. Coumadin was also given.

Incompetence of the internal jugular venous valve: spectrum of echo-Doppler appearances.

The echocardiographic literature contains very scant reference to incompetence of the valve in the internal jugular vein. However, we found frequent Doppler evidence of such incompetence, especially in patients with congestive failure. This incompetence manifests as a variety of color Doppler and pulsed Doppler patterns, illustrated here in 3 patients.

Local intense mosaic pattern at site of flail mitral leaflet: report of a new color Doppler sign.

Color flow Doppler has been useful in diagnosing the presence and severity of mitral regurgitation (MR). We noted a hitherto unreported sign of MR due to flail mitral leaflet: intense local mosaic pattern at the site of the flail leaflet. This sign was seen well in 11 of 14 patients (79%) with the two-dimensional echocardiographic features of flail mitral leaflet, all with moderate or severe MR. In 3 other patients, the sign was absent; two of those had flail mitral leaflet with severe MR. No local mosaic pattern was seen on color Doppler in 20 other patients with MR but no flail mitral leaflet. We speculate that the focal intense mosaic color Doppler morphology may have been caused by intrusion of the flail leaflet into the MR stream, or to a Coanda-like effect of the MR jet "adhering" to the flail leaflet.

Echocardiography of the superior vena cava.

The anatomy and applied echocardiographic anatomy of the superior vena cava (SVC) are briefly described. Right supraclavicular interrogation of the SVC has been in use for many years, but supraclavicular two-dimensional (2-D) imaging of the SVC has been virtually ignored. We have recently shown that supraclavicular 2-D imaging can provide excellent views of the SVC and its main tributaries. Transthoracic echocardiography (TEE) is suitable for imaging of the lower (juxtaatrial) SVC. Persistence of a left SVC is an uncommon variant, diagnosed echocardiographically by coronary sinus dilatation and passage of contrast into it from a left arm vein. Extensive SVC compression by mediastinal masses is well known, but recently intravascular SVC obstruction has been increasingly reported as a complication of radiofrequency ablation for ectopic atrial tachycardia, for thrombosis of the SVC or its main tributaries following indwelling catheters, or following insertion of pacemaker leads. Doppler interrogation or TEE imaging of the SVC have been used in recent years to elucidate such pathology.