Detection of intrapericardial hematoma after open heart surgery: the roles of echocardiography and computed tomography.

Two patients who had right atrial compression caused by intrapericardial hematomas after coronary artery bypass grafting and aortic valve replacement are described. During the course of postoperative evaluation, each patient underwent an echocardiographic examination followed by computed tomography of the chest. Two-dimensional echocardiography visualized the hematomas in both cases. Computed tomography played a useful adjunctive role by further clarifying their nature, location and extent.

Surgical repair of uncomplicated atrial septal defect without "routine" preoperative cardiac catheterization.

Whether all patients with atrial septal defect should undergo cardiac catheterization before surgical correction is controversial. Of 152 patients of all ages with surgically documented isolated atrial septal defect (ostium secundum, ostium primum and sinus venosus types) who underwent preoperative two-dimensional echocardiography between January 1978 and December 1983, there were 55 (36%) (group 1) who did not have preoperative cardiac catheterization. These 55 patients are compared with the 97 patients (64%) who did have preoperative catheterization studies (group 2). Group 1 patients were younger (mean age 22 versus 36 years) and did not have clinical evidence of other associated cardiac disorders. Forty-four (80%) of the group 1 patients had typical findings for atrial septal defect on cardiac examination, chest radiograph and electrocardiogram compared with 16 (16%) of group 2 patients (p less than 0.001). The most frequent reasons for cardiac catheterization in group 2 patients were documentation of diagnosis, usually because of atypical clinical findings, and exclusion of associated cardiac abnormalities. Contrast echocardiography, radionuclide shunt studies and Doppler echocardiography were used as additional confirmatory tests in 36 patients (65%). In 19 patients (35%), two-dimensional echocardiography was the only confirmatory test. There were no false positive two-dimensional echocardiographic studies. There were no operative deaths or significant perioperative complications in any of the patients. At a mean follow-up of 28 months (range 6 to 64), there was one late death (3 1/2 years postoperatively) in a 61 year old man with chronic congestive heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of two-dimensional echocardiography in the prediction of in-hospital complications after acute myocardial infarction.

To evaluate prospectively the prognostic value of two-dimensional echocardiography after acute myocardial infarction, two-dimensional echocardiography was performed on 61 consecutive patients who were admitted to the hospital with this condition. A left ventricular wall motion score index was derived from analysis of regional wall motion; an index of 2.0 or more within 12 hours of admission identified patients at high risk for pump failure, malignant ventricular arrhythmia or death. These complications occurred in 24 of 27 patients with an initial wall motion score index of 2.0 or more, but in only 6 of 34 with an initial index of less than 2.0 (p less than 0.0005). Of the 47 patients who were in Killip class I on admission, complications developed in 11 (79%) of the 14 with an initial index of 2.0 or more, but in only 6 (18%) of the 33 with an initial index of less than 2.0. After acute myocardial infarction, early determination of the wall motion score index by two-dimensional echocardiography is useful for identifying patients at high risk for complications and is especially valuable in the subset of patients who initially seem to be in stable condition as judged from clinical variables.

Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients.

In the standard precordial echocardiographic imaging planes, there is frequent dropout of atrial septal echoes in the region of the fossa ovalis that can be minimized by use of the subcostal imaging approach. The diagnostic sensitivity of this approach was reviewed in 154 patients (mean age 31 years, range 2 months to 74 years) with documented atrial septal defect in whom a satisfactory image of the atrial septum could be obtained. Subcostal two-dimensional echocardiography successfully visualized 93 (89%) of the 105 ostium secundum atrial septal defects, all 32 (100%) ostium primum defects and 7 (44%) of the 16 sinus venosus defects. A defect was not visualized (false negative response) in 12 patients (11%) with an ostium secundum defect and in 9 patients (56%) with a sinus venosus defect. In three of the former and five of the latter, a two-dimensional echocardiographic contrast examination established the presence of the interatrial shunt. Twenty-four patients (16%) with clinical findings of uncomplicated atrial septal defect confirmed by two-dimensional echocardiography underwent surgical repair of the defect without preoperative cardiac catheterization. There were no perioperative complications. Two-dimensional echocardiographic examination of the atrial septum utilizing the subcostal approach is the preferred method for the confident, noninvasive diagnosis and categorization of atrial septal defects. Two-dimensional echocardiographic contrast and Doppler examinations complement the technique and enhance diagnostic accuracy.

Exercise echocardiography for the prognostic stratification of patients with low pretest probability of coronary artery disease.

PURPOSE: The aim of this study was to determine whether exercise echocardiography provides incremental data for risk stratification of patients with a low pretest probability of coronary artery disease. PATIENTS AND METHODS: The study included patients referred for exercise echocardiography whose probability of coronary artery disease was 25% or less. We calculated an exercise wall motion score index (on a 1-5 scale), an indicator of the extent and severity of exercise-induced abnormalities. The primary outcomes of the study were subsequent cardiac events (cardiac death and nonfatal myocardial infarction). RESULTS: We studied 571 men and 1047 women; their mean (+/- SD) age was 55 +/- 13 years. During a median follow-up of 3 years, there were 19 cardiac events (6 cardiac deaths and 13 nonfatal myocardial infarctions); an additional 37 patients underwent coronary revascularization. In a multivariate analysis of clinical, exercise electrocardiographic, and echocardiographic parameters, exercise wall motion score index (hazard ratio [HR] = 2.1 per 0.5 units; 95% confidence interval [CI]: 1.3 to 3.4), and age (HR = 2.0 per decade; 95% CI: 1.2-2.8) were independently associated with the risk of cardiac events. Although exercise echocardiographic variables contributed significantly (P = 0.01) to a model of the risk of adverse events, only 9 (47%) of the 19 patients with cardiac events were identified by an abnormal exercise echocardiogram. CONCLUSION: Among patients with low pretest probability of coronary artery disease by clinical criteria, exercise echocardiography identifies some, but not all, patients at risk of future events. Because of the low event rate, routine application of exercise echocardiography in a patient with a low pretest probability does not appear to be cost-effective and therefore cannot be recommended.

Risk of patients with severe aortic stenosis undergoing noncardiac surgery.

Aortic stenosis (AS) is a major risk factor for perioperative cardiac events in patients undergoing noncardiac surgery. We previously showed that selected patients with AS who were not candidates for, or refused, aortic valve replacement could undergo noncardiac surgery with acceptable risk. We extended our previous experience over a subsequent 5-year period by retrospectively analyzing the perioperative course of all patients with severe AS (aortic valve area index < 0.5 cm2/m2 or mean gradient > 50 mm Hg), determined with Doppler echocardiography or cardiac catheterization, who underwent noncardiac surgery. Nineteen patients underwent 28 surgical procedures: 22 elective and 6 emergency. The types of these procedures were 12 orthopedic, 6 intraabdominal, 4 vascular, 4 urologic, 1 otolaryngologic, and 1 thoracic. Mean age was 75 +/- 8 years. Of the 19 patients, 16 (84%) had > or = 1 symptom: dyspnea, angina, syncope, or presyncope. Mean left ventricular ejection fraction was 61 +/- 11%. The type of anesthesia was general in 26 procedures and continuous spinal in 2. Intraarterial monitoring of blood pressure was used in 20 of the 28 surgical procedures. Intraoperative hypotensive events were treated promptly, primarily with phenylephrine. In all cases the anesthesia team was aware of the severity of the AS and integrated this into the anesthetic plan. Two patients (elective operation in 1 and emergency in 1) had complicated postoperative courses and died. There were no other intraoperative or postoperative events in any of the other patients. Although aortic valve replacement remains the primary treatment for patients with severe AS, selected patients with severe AS, who are otherwise not candidates for aortic valve replacement, can undergo noncardiac surgery with acceptable risk when appropriate intraoperative and postoperative management is used.

Echocardiographic findings in pheochromocytoma.

M-mode and 2-dimensional echocardiography were used to study 26 consecutive, unselected patients with pheochromocytoma over a 3-year period. Only 1 patient had congestive heart failure; more than half had no cardiac symptoms or abnormalities. The most common (80% of patients) echocardiographic pattern was normal left ventricular (LV) mass with normal or even increased systolic performance. When LV mass was increased, LV systolic function was either normal or only borderline depressed in most of the patients. Patients with echocardiographic LV hypertrophy had symmetric thickening of ventricular walls; no case of asymmetric septal hypertrophy was found. There was no correlation between 24-hour urinary norepinephrine excretion and any of the echocardiographic variables studied. In some patients, increased LV wall thicknesses did not correlate with increased LV mass as calculated by the Woythaler echocardiographic method. Left atrial enlargement was not seen in any patient, including those with increased LV mass. The electrocardiogram and echocardiogram may be discordant: Electrocardiographic LV hypertrophy was seen in 6 patients, of whom 5 had normal echocardiographic LV mass. In patients with pheochromocytoma who have no cardiac symptoms or other clinical evidence of cardiac involvement, echocardiographic findings are usually normal.

Hypertensive response during dobutamine stress echocardiography.

Among 3,129 dobutamine stress echocardiographic studies, a hypertensive response, defined as systolic blood pressure (BP) > or = 220 mm Hg and/or diastolic BP > or = 110 mm Hg, occurred in 30 patients (1%). Patients with this response more often had a history of hypertension and had higher resting systolic and diastolic BP before dobutamine infusion.

Spectrum of cardiac involvement in Friedreich's ataxia: clinical, electrocardiographic and echocardiographic observations.

Combined 2-dimensional and M-mode echocardiography was used to assess the cardiac status of 22 patients with Friedreich's ataxia, and the findings were correlated with the clinical and electrocardiographic (ECG) data. Mean age at onset of Friedreich's ataxia was 8 years (range 3 to 18); mean age at echocardiography was 18 years (range 8 to 39). Echocardiographic findings were abnormal in 19 patients (86%). The 3 patients with normal echocardiographic findings did not have cardiac symptoms, but 1 had ECG repolarization abnormalities. Concentric left ventricular (LV) thickening, the most common echocardiographic finding, was found in 15 patients (68%) and in all 15 the papillary muscles were thickened. These 15 patients had ECG repolarization abnormalities and 5 had left-axis deviation; however, only 3 satisfied ECG criteria for LV or right ventricular hypertrophy. Two of the 15 patients (9%) had symptoms of heart failure. Two patients had asymmetric septal thickening without clinical evidence of LV outflow tract obstruction; neither had cardiac symptoms, but both had ECG repolarization abnormalities. Two patients showed a dilated cardiomyopathy pattern; both had heart failure and atrial flutter. One of these patients died, and necropsy revealed 4-chamber cardiac dilatation, biventricular hypertrophy and histologic findings of diffuse interstitial fibrosis, myocellular hypertrophy and necrosis. This study revealed a wide spectrum of cardiac abnormalities in patients with Friedreich's ataxia.

Accuracy of 2-dimensional echocardiographic diagnosis of congenitally bicuspid aortic valve: echocardiographic-anatomic correlation in 115 patients.

The preoperative 2-dimensional (2-D) echocardiograms of all patients less than 50 years of age in whom the aortic valve had been directly inspected by the surgeon or the pathologist or both were reviewed. From June 1977 to June 1981, 283 patients aged less than or equal to 50 years had aortic valve surgery at the Mayo Clinic: 115 (aged 1 to 50 years [mean 32]) had 2-D examinations preoperatively. The echocardiograms were reviewed blindly, and the aortic valve structure was categorized as bicuspid, tricuspid, or indeterminate. On the basis of combined surgical and pathologic inspection, 50 aortic valves were congenitally bicuspid, 60 were tricuspid, 4 were unicommissural, and 1 was quadricuspid. By 2-D echocardiography, the number of cusps was indeterminate in 29 patients (25%). When these patients were excluded, the sensitivity, specificity, and diagnostic accuracy of 2-D echocardiography for bicuspid aortic valve were 78,96, and 93%, respectively. Thus, with adequate 2-D images, echocardiography is a sensitive and highly specific technique for the diagnosis of bicuspid aortic valve.

Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients.

The records of 17 patients (10 men and 7 women) with the diagnosis of acute papillary muscle rupture secondary to acute myocardial infarction (AMI) were reviewed to determine the clinical course and pathologic features of this entity. Eight patients underwent operation after papillary muscle rupture had been diagnosed, and 9 had the diagnosis confirmed at autopsy without a prior surgical procedure. The ages were 44 to 80 years (mean 64). The site of AMI was inferolateral in 15 and anterior in 2. The recorded onset of mitral regurgitation ranged from less than 24 hours to 28 days after AMI (mean 6 days). Of the 11 patients presenting with pulmonary congestion alone, 6 remained stable and had subsequent mitral valve replacement and coronary artery bypass graft operation; however, 5 patients' condition initially stabilized with medical therapy and then suddenly deteriorated after a variable period (1 to 60 days), followed by death. Of the 6 patients who presented with systemic hypotension and pulmonary congestion, 4 were treated medically and died; 1 of the 2 who had surgical treatment survived. The extent of the AMI at autopsy was small and was limited to the subendocardium in half of the patients. Significant coronary artery disease was limited to a single vessel in 7 of 14 patients. The unpredictable and rapid clinical deterioration and the limited extent of coronary atherosclerotic disease and infarct size suggest that early surgical repair should be undertaken in patients with papillary muscle rupture after AMI.

Prognostic value of predischarge 2-dimensional echocardiogram after acute myocardial infarction.

The prognostic value of a 2-dimensional echocardiogram (2-D echo) was determined in 46 patients (32 men and 14 women) who survived an acute myocardial infarction (MI) from November 1979 to December 1980. The mean age of the patients was 61 years (range 36 to 92). The MI was anterior in 21, inferior in 22 and indeterminate in 3; it was transmural in 31 and nontransmural in 15. A 2-D echo was obtained 10 to 15 days after the MI--that is, 1 to 3 days before hospital discharge. A wall motion score index (WMSI) was derived with the use of a 14-segment model of the left ventricle. Each segment was assigned a number corresponding to its wall motion (0 = hyperkinetic, 1 = normal, 2 = hypokinetic, 3 = akinetic, 4 = dyskinetic and 5 = aneurysm) and the WMSI was calculated by dividing the sum of these numbers by the number of segments visualized (1.0 = normal wall motion). During a mean follow-up of 21 months (range 15 to 28), 17 patients had a complication: death, recurrence of MI, congestive heart failure of New York Heart Association class III or IV, or angina graded New York Heart Association class III or IV. Patients with compared to those without complications had a significantly higher WMSI (2.2 +/- 0.4 and 1.7 +/- 0.5, p less than 0.005). The difference in WMSI between those who died and those who survived was not significant because of the small number of deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients.

Pericardiocentesis guided by 2-dimensional echocardiography has been used at the Mayo Clinic since April 1980. The 2-dimensional examination localizes the pericardial fluid. Particular note is made of the place on the body wall closest to the fluid. An entry track that permits puncture of the pericardial sac without damage to any vital structure is then selected for the pericardiocentesis needle. Between April 1980 and March 1984, 132 consecutive pericardiocenteses in 117 patients were done by this technique. The volume of fluid obtained ranged from 75 to 1,700 ml (mean 650). Seventy percent of the taps were done for therapy, 21% for diagnosis, and 9% for both therapy and diagnosis. A Teflon-sheathed "intracath" needle was used to complete 80% of the pericardiocenteses. In the other 20%, a large catheter was secondarily introduced and connected to a closed drainage system. There were no deaths related to the procedure. One symptomatic pneumothorax occurred. There were 3 minor complications. Two-dimensional echocardiographic imaging of the heart and pericardial fluid permits a safe and effective means of performing pericardiocentesis.

Stable angina pectoris: 1. Clinical patterns.

The symptoms of angina pectoris reflect transient inadequacy of myocardial oxygen supply as a consequence of decreased myocardial blood flow, increased myocardial oxygen demand, or both. The prognosis for patients with angina depends on the extent and severity of coronary artery disease, on left ventricular systolic function, and on the presence and severity of ischemia on exercise testing. The characteristics of angina may be variable, but certain clinical patterns are consistent and are helpful for diagnosis. Angina must be distinguished from various noncardiovascular and cardiovascular conditions; in most cases, the differences can be established by careful clinical assessment.

Stable angina pectoris: 2. Cardiac evaluation and diagnostic testing.

The examination of a patient with angina pectoris begins with clinical assessment. Certain clinical findings that are present only during angina, such as mitral regurgitation due to ischemia-induced papillary muscle dysfunction, may clarify an otherwise uncertain diagnosis. Electrocardiography is a useful and relatively inexpensive test for detecting evidence of ischemia in patients with suspected angina. The presence of cardiomegaly on the chest roentgenogram has adverse prognostic implications. Exercise stress testing is important in the diagnosis of coronary artery disease and also provides prognostic information. Patients should be classified into high-, intermediate-, or low-risk subsets by noninvasive techniques. Although relatively easy and inexpensive, treadmill exercise stress testing cannot be performed in all patients, and sometimes it will yield equivocal results. In these cases, radionuclide testing (with thallium scintigraphy or radionuclide angiography) can be helpful and also can identify high-risk patients. Some patients will require coronary angiography.

Stable angina pectoris: 3. Medical treatment.

The therapeutic goals for the patient with angina pectoris are to minimize the frequency and severity of angina and to improve functional capacity at a reasonable cost and with as few side effects as possible. An integrated approach necessitates attention to conditions that might be aggravating angina, such as anemia or hypertension. Alterations in life-style and personal habits, such as cessation of cigarette smoking, are often necessary and should be continually reinforced by the physician. Certain concomitant diseases, such as chronic obstructive pulmonary disease, may influence the selection of drug therapy. Nitrates, beta-adrenergic blockers, and calcium entry blockers are the major classes of drugs that can be used alone or in combination in a program that is designed for the individual patient.

An unusual mediastinal lipoma simulating cardiomegaly.

A patient with vague, nonspecific symptoms was initially thought to have an enlarged cardiac silhouette on chest roentgenogram, and a primary intracardiac disorder was suspected. At surgery, a mediastinal lipoma was diagnosed and excised. The roentgenographic appearance represents an unusual presentation of a mediastinal tumor.

Preoperative assessment of cardiac patients undergoing noncardiac surgical procedures.

A careful clinical history and physical examination are the most important components of the preoperative assessment of the cardiac patient who is to undergo a noncardiac surgical procedure. From these factors and the nature of the surgical procedure planned, a reasonable estimate of potential cardiac risk can be formulated to guide judicious preoperative testing for further definition of potentially high-risk patients. The potential risks associated with an invasive cardiac procedure or surgical intervention must always be considered along with the potential benefits of such a procedure in an attempt to reduce the cardiac risk of noncardiac operations. Aggressive and conscientious preoperative assessment and perioperative care of the high-risk patient by the concerted efforts of the medical consultant, anesthesiologist, and surgeon may substantially diminish cardiac-related morbidity and mortality during noncardiac surgical procedures.

Hypertension and left ventricular diastolic function.

In recent years, there has been increased recognition of the relative importance of abnormalities of diastolic function in patients with essential hypertension. Indeed, diastolic dysfunction may be the earliest indicator of hypertensive heart disease. In this article, the mechanisms governing normal ventricular relaxation and the factors that may cause diastolic dysfunction are reviewed. Noninvasive clinical methods, particularly Doppler echocardiography and radionuclide angiography, for determination of diastolic function are outlined, and the limited experience in the management of hypertensive patients with abnormalities of diastolic function is discussed. When congestive heart failure develops in a patient with hypertension, it is especially important to determine whether it is due primarily to systolic or to diastolic left ventricular dysfunction.

Selection of optimal drug therapy for the patient with angina pectoris.

The development of new drugs, especially beta-blocking and calcium entry-blocking agents, has greatly facilitated the medical treatment of angina pectoris. The specific needs of each patient should dictate the appropriate treatment of angina pectoris. Angina may occur in patients who have various concomitant disorders such as hypertension, diabetes mellitus, peripheral vascular disease, chronic obstructive pulmonary disease, or arrhythmias, and the physician must take these factors into account when a drug regimen is prescribed. Individual drugs should be chosen on the basis of specifically desired pharmacologic effects, and the dosages should be gradually adjusted according to the patient's response. Although a therapeutic regimen should be selected primarily on the basis of efficacy, the physician must also attempt to recommend a simple and cost-effective program.