The pathogenesis of acute pulmonary edema associated with hypertension.

BACKGROUND: Patients with acute pulmonary edema often have marked hypertension but, after reduction of the blood pressure, have a normal left ventricular ejection fraction (> or =0.50). However, the pulmonary edema may not have resulted from isolated diastolic dysfunction but, instead, may be due to transient systolic dysfunction, acute mitral regurgitation, or both. METHODS: We studied 38 patients (14 men and 24 women; mean [+/-SD] age, 67+/-13 years) with acute pulmonary edema and systolic blood pressure greater than 160 mm Hg. We evaluated the ejection fraction and regional function by two-dimensional Doppler echocardiography, both during the acute episode and one to three days after treatment. RESULTS: The mean systolic blood pressure was 200+/-26 mm Hg during the initial echocardiographic examination and was reduced to 139+/-17 mm Hg (P< 0.01) at the time of the follow-up examination. Despite the marked difference in blood pressure, the ejection fraction was similar during the acute episode (0.50+/-0.15) and after treatment (0.50+/-0.13). The left ventricular regional wall-motion index (the mean value for 16 segments) was also the same during the acute episode (1.6+/-0.6) and after treatment (1.6+/-0.6). No patient had severe mitral regurgitation during the acute episode. Eighteen patients had a normal ejection fraction (at least 0.50) after treatment. In 16 of these 18 patients, the ejection fraction was at least 0.50 during the acute episode. CONCLUSIONS: In patients with hypertensive pulmonary edema, a normal ejection fraction after treatment suggests that the edema was due to the exacerbation of diastolic dysfunction by hypertension--not to transient systolic dysfunction or mitral regurgitation.

Three-dimensional surface area of the aortic valve orifice by three-dimensional echocardiography: clinical validation of a novel index for assessment of aortic stenosis.

BACKGROUND: A direct and accurate method of assessing aortic valve area (AVA) in patients with aortic stenosis (AS) is desirable because of the well-known theoretical and practical limitations of the currently available methods. We assessed the clinical feasibility and accuracy of a novel index, the 3-dimensional surface area (3-DSA) of the aortic valve orifice by 3-dimensional transesophageal echocardiography (3-DTEE) in patients with AS. METHODS: Intraoperative 3-DTEE was performed in 23 consecutive patients (mean age 58 +/- 15 years) with valvular AS using a Toshiba SSA-380A system with a multiplane TEE probe and a TomTec EchoScan system. The 3-DTEE acquisition, processing and reconstruction were conducted and the aortic valve orifice presented using a "surgeon's aortotomy view" (aortic valve orifice as if viewed through an open aortic root). The 3-D images were videotaped and calibrated and the 3-DSA measured by planimetry of the inner surface of the aortic valve leaflets at the maximal systolic opening using the dynamic 3-D images. For comparison, the 2-D cross sectional area (2-DCSA) of the aortic valve was also determined by 2-DTEE. The 3-DSA and 2-DCSA were compared with the AVA by the invasive Gorlin formula and the Doppler continuity equation method by transthoracic echocardiography. RESULTS: The 3-DSA and 2-DCSA measurements were feasible in all but one patient. Both 3-DSA and 2-DCSA correlated moderately well with the AVA by the Gorlin formula (n = 17, r = 0.66, standard error of the estimate [SEE] = 0.3 cm2, P <.05 for 3-DSA and r = 0.61, SEE = 0. 5 cm2 P <.05 for 2-DCSA, respectively). They also correlated well with the AVA by Doppler continuity equation method (n = 22, r = 0.90, SEE = 0.1 cm2, P <.05 for 3-DSA and r = 0.83, SEE = 0.3 cm2, P <.05 for 2-DCSA, respectively). There was no statistically significant difference between the 3-DSA and AVA by both the Gorlin formula (Delta = 0.1 +/- 0.3 cm2, P =.3) and the Doppler continuity equation (Delta = -0.0 +/- 0.3 cm2, P =.7). In contrast, the 2-DCSA significantly overestimated AVA by the Gorlin formula (Delta = 0.5 +/- 0.5 cm2, P <.005) and by the Doppler continuity equation (Delta = 0.5 +/- 0.6 cm2, P <.0001). CONCLUSIONS: Planimetry of 3-DSA of the aortic valve orifice by 3-DTEE is a clinically feasible and relatively accurate technique for assessment of AVA and is superior to 2-DCSA by 2-DTEE.

Morphology and dynamic change of discrete subaortic stenosis can be imaged and quantified with three-dimensional transesophageal echocardiography.

This report describes three-dimensional transesophageal echocardiographic findings in three consecutive patients with discrete subaortic stenosis. The discrete subaortic stenosis lesions included a circumferential, a remnant crescent, and a broken fibrotic subaortic membrane. The lesions were best imaged by using a three-dimensional transesophageal echocardiography-generated "aortotomy view" of the left ventricular outflow tract immediately below the plane of the aortic valve. The three-dimensional images correlated well with surgical and pathologic findings. The three-dimensional surface areas of the left ventricular outflow tract at the level of discrete subaortic stenosis during systole (0.8 +/- 0.5 cm2) and diastole (1.7 +/- 0.7 cm2) were measured by planimetry of the three-dimensional transesophageal echocardiographic images. The novel "aortotomy view" offered by three-dimensional transesophageal echocardiography provided direct visualization and quantification of discrete subaortic stenosis in a dynamic fashion. In summary, three-dimensional transesophageal echocardiography can accurately display and quantify discrete subaortic stenosis and could be a new clinically useful tool for assessing discrete subaortic stenosis and guiding surgical and transcatheter interventions.

Accuracy of transesophageal echocardiography in preoperative determination of aortic anulus size during valve replacement.

This prospective, blinded study evaluated the accuracy of transesophageal (TEE) and transthoracic echocardiography in predicting the size of the surgical aortic valve anulus in 20 consecutive patients undergoing aortic valve replacement. TEE was highly accurate in predicting surgical aortic valve anulus size (r = 0.98; p < 0.00001). The standard error of the TEE estimate of the size of the obturator anulus was only 0.04 mm, and in all cases the TEE estimate was within 1 mm of the direct surgical measurement. Both biplane and multiplane TEE probes were equally accurate and this accuracy was maintained over a wide range of sizes of surgical aortic anulus. Transthoracic echocardiography appeared less accurate in predicting anulus size (r = 0.64; p < 0.08). Therefore TEE can be used routinely for selection and preparation of aortic allografts before sternotomy, potentially reducing cardiopulmonary bypass pump time by 10 to 30 minutes and ensuring optimal size matching of the donor-recipient anulus.

Feasibility, accuracy, and incremental value of intraoperative three-dimensional transesophageal echocardiography in valve surgery.

In this prospective trial, intraoperative 2-dimensional (2-D) and 3-dimensional (3-D) transesophageal echocardiography (TEE) examinations were performed on 60 consecutive patients undergoing cardiac valve surgery. Both 2-D (including color flow and Doppler data) and 3-D images were reviewed by blinded observers, and major valvular morphologic findings recorded. In vivo morphologic findings were noted by the surgeon and all explanted valves underwent detailed pathologic examination. To test reproducibility, 6 patients also underwent 3-D TEE 1 day before surgery. A total of 132 of 145 attempted acquisitions (91%) were completed with a mean acquisition time of 2.8 +/- 0.2 minutes. Acquisition time was significantly shorter in patients with regular rhythms. Reconstructions were completed in 121 of 132 scans (92%) and there was at least 1 good reconstruction in 56 of 60 patients (93%). Mean reconstruction time was 8.6 +/- 0.7 minutes. Mean effective 3-D time, which was the time taken to complete an acquisition and a clinically interpretable reconstruction, was 12.2 +/- 0.8 minutes. Intraoperative 3-D echocardiography was clinically feasible in 52 patients (87%). Three-D echocardiography detected most of the major valvular morphologic abnormalities, particularly leaflet perforations, fenestrations, and masses, confirmed on pathologic examination. Three-D echocardiography predicted all salient pathologic findings in 47 patients (84%) with good quality images. In addition, in 15 patients (25%), 3-D echocardiography provided new additional information not provided by 2-D echocardiography, and in 1 case, 3-D echocardiographic findings resulted in a surgeon's decision to perform valve repair rather than replacement. In several instances, 3-D echocardiography provided complementary morphologic information that explained the mechanism of abnormalities seen on 2-D and color flow imaging. In the reproducibility subset, preoperative and intraoperative 3-D imaging detected a similar number of findings when compared with pathology. Thus, in routine clinical intraoperative settings, 3-dimensional TEE is feasible, accurately predicts valve morphology, and provides additional and complementary valvular morphologic information compared with conventional 2-D TEE, and is probably reproducible.

A prospective, randomized, blinded comparison of multiplane and biplane transesophageal echocardiographic techniques.

Although multiplane transesophageal echocardiography has become an accepted diagnostic technique, there is a paucity of literature directly comparing the diagnostic yield of multiplane and biplane transesophageal examinations. This study was designed to compare the ability of multiplane and biplane transesophageal echocardiographic techniques to visualize intracardiac structures. Complete multiplane and biplane transesophageal studies were performed on each of 50 patients (100 total studies) referred to the echocardiography laboratory for elective transesophageal echocardiography. The biplane examinations were performed with a multiplane probe with angles only at 0 and 90 degrees. Images of 29 prospectively selected cardiac structures and valvular function parameters were scored as follows: 0 = not visualized, 1 = visualized well enough to identify structure, 2 = diagnostic quality, and 3 = exceptional quality. The scores for the individual structures were combined to identify total structure visualization quality scores for each of the imaging techniques. A separate subjective score was also determined to assess the overall adequacy of each study for addressing the clinical indication. The total structure visualization quality score was significantly higher for multiplane transesophageal echocardiography than for biplane transesophageal echocardiography (49 +/- 7 versus 45 +/- 7; p = 0.0001). Several individual structures were visualized significantly better (p < 0.05) by the multiplane technique, including the left upper pulmonary vein, fossa ovalis, left main coronary artery, and proximal ascending aorta. The subjective score of overall adequacy of the study for addressing the clinical indication showed a strong trend (p < 0.06) in favor of the multiplane technique, with higher scores in 11 of 50 multiplane studies versus three of 50 biplane studies when the two techniques were compared in individual patients. Therefore multiplane transesophageal echocardiography provides superior overall visualization of intracardiac structures compared with biplane studies, particularly for the left upper pulmonary vein, fossa ovalis, left main coronary artery, and ascending aorta.

Double cardiomyopathy: coexistent cardiac amyloidosis and hypertrophic obstructive cardiomyopathy.

A combination of hypertrophic obstructive cardiomyopathy (HOCM) and cardiac amyloidosis in the same patient is very rare. Clinical diagnosis could be extremely difficult and may require myocardial biopsy. We are reporting a patient with this combination who was referred to our institution because of features of HOCM based on clinical, echocardiographic and Doppler criteria. Cardiac amyloidosis was only recognized after myocardial biopsy that failed to reveal evidence of HOCM. Only after the patient expired from severe, intractable heart failure did the autopsy findings confirm the association of HOCM. We believe that the combination of the two cardiomyopathic processes is very rare and makes treatment extremely difficult.

Magnetic resonance imaging evaluation of recipient for cryopreserved aortic allograft.

Aortic valve replacement with a cryopreserved aortic allograft is the procedure of choice for many patients with aortic valvular heart disease. We have used magnetic resonance imaging preoperatively to determine annular size and coronary artery orientation in the recipient, which not only has enabled us to select an allograft of appropriate size from a distant tissue bank, but also has helped us to identify preoperatively the recipient with a truly bicuspid valve in which the coronary arteries are oriented 180 degrees apart. Sixteen consecutive patients were evaluated preoperatively, the aortic annulus being measured with both magnetic resonance imaging and echocardiography. Cryopreserved aortic allografts were ordered on the basis of the magnetic resonance imaging measurement. Annular size was then measured intraoperatively with calibrated sizers. Magnetic resonance imaging annular measurements correlated highly with those found at operation (r = 0.92), whereas echocardiographic measurements correlated less well (r = 0.69). Coronary orientation was accurately predicted in every case (r = 1.0). Therefore, we have found magnetic resonance imaging to be useful in the preoperative evaluation of patients for aortic valve replacement with a cryopreserved aortic allograft.

Mechanism of physiologic and pathologic S3 gallop sounds.

Although the S3 gallop sound has long been used clinically as an indicator of left ventricular systolic dysfunction, the mechanism responsible for its production remains controversial. The same sound is often found in young healthy individuals, and whether a similar mechanism is responsible is also unknown. The relationship of the S3 gallop sound to the dynamics of left ventricular filling was compared in 18 healthy young triathletes and 15 older subjects with cardiac disease. Twenty healthy normal subjects without an S3 were included as controls. Phonocardiographic, two-dimensional echocardiographic, and Doppler echocardiographic analysis of left ventricular inflow were evaluated. The S3 in both groups always occurred close to peak early filling velocity (E), during early flow deceleration. Mean E deceleration rate was higher in the subjects with S3 (726 +/- 153 cm/sec2 in the triathletes and 819 +/- 274 cm/sec2 in those with cardiac disease) than in control subjects (563 +/- 131 cm/sec2, p less than 0.001 in both cases). Ten triathletes underwent examination both before and immediately after 30 degrees head-up tilt. E deceleration rate dropped significantly with head-up tilt (720 +/- 137 vs 590 +/- 174 cm/sec2, p less than 0.01), while concurrently the S3 disappeared or was diminished in amplitude. Similar changes were seen in subjects with cardiac disease. We conclude that both the "pathologic" and "physiologic" S3 are related to abnormally rapid deceleration of early diastolic left ventricular inflow. Although the presence of the S3 is not dependent on the state of left ventricular systolic function, diastolic filling is characterized by a predominance of early inflow with a rapid flow deceleration rate.

Perforation of the anterior mitral leaflet caused by aortic valve endocarditis: diagnosis by two-dimensional, transesophageal echocardiography and color flow Doppler.

Perforation of the mitral valve as a result of aortic valve endocarditis is rare. Recognition of such abnormality is very important before surgical intervention. Diagnosis is very difficult by either invasive or noninvasive techniques. This report stresses the role of echocardiography in evaluating this rare abnormality. Perforation of the anterior mitral valve leaflet developed in our patient as a complication of aortic valve endocarditis. The perforation was suggested by the surface echocardiogram (as an interruption of the leaflet continuity) and by the color flow Doppler (which suggested turbulent flow at the area of suspected interruption). The perforation was confirmed during surgery by transesophageal echocardiography and alerted the surgeon to repair, rather than replace, the valve.

Effect of alteration in loading conditions on both normal and abnormal patterns of left ventricular filling in healthy individuals.

Doppler analysis of mitral flow provides a means of analyzing left ventricular (LV) diastolic function. While experimental studies have suggested that changes in left atrial pressure may affect the normal pattern of early diastolic filling, the effect of such changes on abnormal patterns of filling is unknown. Accordingly, the Doppler pattern of LV filling was analyzed in 20 subjects with LV hypertrophy (mean age 59 +/- 13 years, +/- standard deviation), in 25 healthy normal subjects (29 +/- 6 years) and in 11 elderly subjects (68 +/- 5 years). All underwent Doppler examination of LV inflow at rest and immediately after postural changes. In all 3 groups, head-down positioning increased early diastolic flow velocity (E) (p less than 0.001), and raised the E to late diastolic flow velocity (A) ratio (p less than 0.01). However, an abnormal E/A ratio never approached a normal resting value. Likewise, although E and the E/A ratio decreased significantly in normal subjects with head-up positioning, it did not become abnormal. The magnitude of change in E, A and E/A ratio did not differ among the 3 groups in response to postural changes. Thus, alterations of LV loading conditions alter the pattern of LV filling, whether normal or abnormal at baseline. The magnitude of change appears to be independent of the resting flow pattern. Although loading conditions may affect the Doppler pattern of filling, simple changes in venous return do not "normalize" an abnormal pattern, nor do they "abnormalize" a normal pattern.

Mechanism of altered pattern of left ventricular filling with aging in subjects without cardiac disease.

The mechanism whereby aging, in the absence of cardiac disease, may alter the pattern of left ventricular (LV) diastolic filling is unknown. Accordingly, this study was designed to examine the factors that may be in part responsible for aging's effect on the pattern of LV diastolic filling. The LV end-diastolic pressure-volume relation was analyzed in 11 elderly subjects (68 +/- 5 years, mean +/- standard deviation) and 15 normal young adults (31 +/- 7 years) without coronary artery disease, systemic hypertension, LV hypertrophy or abnormality of LV systolic function. After catheterization, the subjects underwent pulsed Doppler analysis of mitral flow. All had normal 2-dimensional echocardiograms without LV or valvular dysfunction. Peak early filling velocity in the elderly subjects was decreased in comparison with that in young adults (61 +/- 14 vs 83 +/- 8 cm/s, p less than 0.001) and the ratio of early and late diastolic filling velocity was reduced (0.81 +/- 0.26 vs 1.88 +/- 0.40, p less than 0.001). The isovolumic relaxation time did not differ between the elderly and young subjects (158 +/- 20 vs 146 +/- 22 ms, difference not significant). In the elderly, LV end-diastolic pressure was increased (15 +/- 7 vs 11 +/- 4 mm Hg, p less than 0.05) despite a smaller end-diastolic volume index (60 +/- 16 vs 74 +/- 18 ml/m2, p less than 0.05), indicating a shift of the passive diastolic pressure-volume relation. It was concluded that early diastolic filling is reduced in normal aged subjects, even in the absence of coronary artery disease and systolic dysfunction. This altered pattern of diastolic filling may result from a shift of the passive LV diastolic pressure-volume relation.

Diastolic mitral regurgitation in acute but not chronic aortic regurgitation: implications regarding the mechanism of mitral closure.

In acute aortic regurgitation, left ventricular pressure rises rapidly during diastole, which produces presystolic mitral valve closure. This does not occur in chronic aortic regurgitation. Since normal, nonregurgitant mitral valve closure may depend on properly coordinated atrial and ventricular contractions, we hypothesized that abnormal mitral valve closure occurring before systole in acute aortic regurgitation may produce diastolic mitral regurgitation detectable by Doppler echocardiography. Accordingly, we performed ultrasonic Doppler examination of seven patients with acute aortic regurgitation and 12 patients with chronic aortic regurgitation. Regurgitant aortic flow was severe in all cases. Doppler sampling within the left atrium demonstrated regurgitant mitral flow in late diastole in all patients with acute aortic regurgitation. The onset of diastolic mitral regurgitation coincided with mitral valve preclosure in patients with acute aortic regurgitation and occurred regardless of the position of the mitral leaflets at the initiation of closure. In contrast, none of the 12 patients with chronic aortic regurgitation had mitral valve preclosure or diastolic mitral regurgitation (p less than 0.05 versus acute aortic regurgitation). We conclude that diastolic mitral regurgitation accompanies mitral valve preclosure, which occurs in acute but not chronic aortic regurgitation. Thus diastolic mitral regurgitation may be a Doppler sign of acute aortic regurgitation, in the absence of a markedly prolonged PR interval. Furthermore, this observation suggests that normal, nonregurgitant mitral closure requires more than an increase in left ventricular pressure above left atrial pressure, regardless of the position of the mitral leaflets before closure.

Intracardiac myxomas: twenty-year echocardiographic experience with review of the literature.

We reviewed the echocardiograms of 35 patients with intracardiac myxomas. Patient data were combined from two geographically distant laboratories. No significant variations in the patient profiles were encountered. Most patients were white (33 of 35) with a mean age of 45 years. The diagnosis was suspected on clinical grounds alone in only six of 35 patients before the echocardiogram was done. M-mode recordings were the primary echocardiographic modality available in the first 16 patients, whereas two-dimensional studies were also done in the others. Continuous and pulsed wave Doppler echocardiography were added in eight of the most recent studies. In one patient color flow imaging from both transthoracic and esophageal approaches was possible to better visualize a large left atrial tumor. Thirty-three patients had solitary tumors (29 left atrial, three right atrial, and one left ventricular), and two had multiple tumors. The most characteristic finding, as expected, was the demonstration of abnormal mass echoes produced by the myxoma tissue. Several interesting features not previously emphasized in the literature included abnormal notching of the interventricular septum and posterior left ventricular wall probably produced by displacement from the larger mobile left atrial tumors dropping into the mitral sleeve. This was best appreciated by the M-mode recordings. In one patient with an associated atrial septal defect, movement of the tumor into the defect appeared to alter the expected downward displacement into the mitral orifice. In the patients who were studied by two-dimensional, Doppler, or color flow imaging, tumor movement was evidenced by abnormal frequency shifts, and dispersion of flow around the tumor mass was readily appreciated. Surgical removal was performed in all patients. Follow-up echocardiograms were done postoperatively ranging up to 17 years. Recurrent tumors occurred in two patients, both of whom had congenital myxomas. Echocardiography is proving to be an unparalleled tool in the diagnosis of intracardiac tumors.

Intracardiac tumor: an unusual case of myocardial ischemia.

We have presented an unusual case of right ventricular tumor mimicking myocardial ischemia. Tumor invasion of deeper structures of the heart is rare, and we think the ECG and enzyme changes in our patient were due to invasion of the ventricular septum by the tumor.

Left atrial myxoma and atrial septal defect with recurrent pulmonary emboli.

We have reported a case of left atrial myxoma in association with an atrial septal defect in a patient followed up over a number of years for recurrent sterile pleural effusions and chronic obstructive lung disease of undetermined cause. During hospitalization for pneumonia, an intracardiac mass and atrial septal defect were found by echocardiography, and verified at operation to be a left atrial myxoma.

Myocardial infarction complicated by myocardial rupture and Bacteroides sepsis.

A patient in whom a myocardial rupture complicated recent myocardial infarction was found to have cardiac and systemic Bacteroides sepsis; he had just completed a course of steroids. Surgical repair of the cardiac rupture, mediastinal irrigation with povidone-iodine, and broad-spectrum antibiotics resulted in the patient's recovery.

Open mitral commissurotomy: long-term results with echocardiographic correlation.

Over 11 years, 91 patients with isolated mitral stenosis underwent open mitral commissurotomy. Twenty-nine were 50 or more years old; 15 had had prior commissurotomies. Four (4.4%) died perioperatively; 87 were followed for one to nine years (average: five years). Overall actuarial survival was 94% at 5 years. Sixty-nine patients (79%) were NYHA Functional Class (FC) I or II at latest follow-up. Arterial embolism occurred in five patients; 14 patients (16%) had a second valve operation. Patients who remain in FC I or II and who are free of embolism and reoperation are classified as complication-free. Actuarial analysis demonstrated 76% to be so classified at five years after operation. Actuarial curves show that age older than 40 years, sex, previous commissurotomy, and "radical" versus simple open mitral commissurotomy did not influence survival or the incidence of good results. Follow-up M-mode and 2D echocardiograms were obtained in 42 patients. The estimated mitral orifice accurately separated FC I patients (orifice equal to or larger than 2 cm2) from FC II and FC III patients (orifice smaller than 2 cm2), and showed that echocardiographic evidence of a 2 cm2 or larger mitral orifice correlates with a good result.