Transpulmonary echo contrast agents improve the evaluation of left ventricular function by two-dimensional echocardiography due to a better endocardial border delineation. To compare the contrast effect in the right and left ventricular cavities, a new transpulmonary echocontrast agent, BY 963 and Albunex were intravenously administered to five non-anaesthetized dogs. The right and left ventricular echocardiographic image intensities were quantitatively measured at 60 cardiac cycles using a commercially available ultrasound system. BY 963 and Albunex were intravenously administered at three doses: 0.01 ml/Kg, 0.05 ml/Kg and 0.1 ml/Kg. The area under the curve (AUC, intensity units x heart cycles) and peak intensity (Peak I, intensity units) were estimated for the right (RV) and left ventricular (LV) cavities at the mid ventricular level using acoustic intensitometry. BY 963 injection produced the following values: At the dose of 0.01, 0.05 and 0.1 ml/Kg the AUC amounted to 702 +/- 449, 877 +/- 470 and 890 +/- 320 intensity units x heart cycles in RV and to 542 +/- 406, 806 +/- 557 and 721 +/- 392 in LV (LV/RV ratios: 77%, 92% and 81%). Peak I was at the doses 0.01, 0.05 and 0.1 ml/Kg 29 +/- 4.7, 33 +/- 5.2 and 35 +/- 3.2 intensity units in RV and 18 +/- 5.9, 21 +/- 6.2 and 20 +/- 3.3 in LV (LV/RV ratios: 62%, 64% and 57%). Albunex also produced right and left heart opacification values: at the doses 0.01, 0.05 and 0.1 ml/Kg the AUC amounted to 416 +/- 231, 493 +/- 231 and 674 +/- 390 in RV and to 71 +/- 71, 158 +/- 102 and 277 +/- 120 in LV (LV/RV ratios: 17%, 34% and 41%). Peak I was at the doses of 0.01, 0.05 and 0.1 ml/Kg 19 +/- 5.2, 23 +/- 5.4 and 29 +/- 4.1 in RV and 8 +/- 4.8, 13 +/- 4.7 and 17 +/- 3.2 in LV (LV/RV ratios: 42%, 57% and 59%). Intravenous injection of BY 963 leads to complete opacification of the left ventricular cavity and to high AUC values and peak intensity values at all three dosages. The loss of contrast effect from the right to the left ventricular cavity was very low: the LV/RV ratio of BY 963 was higher than that of Albunex. The new transpulmonary echo contrast agent BY 963 promises to be an excellent echo contrast agent for the noninvasive assessment of left ventricular function.

Albumins↗

PubMedDate not supplied

Assessment of successful valve reconstruction by intraoperative transesophageal echocardiography (TEE).

In 17 patients (10 patients with mitral insufficiency, 5 patients with tricuspid regurgitation, 2 patients with mitral stenosis) the result of valve reconstruction was evaluated by intraoperative two-dimensional transesophageal contrast-echocardiography (TEE). Therefore, 1-2cc of an agitated contrast-medium (Gelifundol) were injected into the left or right ventricle. The result of reconstruction was assessed by the extent of regurgitant microbubbles into the left or right atrium. A successful valve repair could be demonstrated in 15 patients without or with only minimal regurgitation of contrast-fluid. In one patient residual severe mitral insufficiency after valve reconstruction could only be detected when valve function was examined by contrast-TEE in the beating heart. An intraoperative decision for valve replacement was made. In another patient, mild to moderate residual mitral incompetence was shown; no further surgical intervention was done. By TEE the function of reconstructed valves can be examined under physiological conditions in the beating heart. Surgeons can obtain additional intra-operatively information and certainty about the result of reconstruction and an early decision for valve replacement can be made if necessary.

Adult↗

PubMedDate not supplied

Aortic dissection detected by transoesophageal echocardiography.

The diagnostic value of transoesophageal echocardiography was evaluated in 24 patients with aortic dissection and compared to transthoracic two-dimensional echocardiography, computer tomography, aortography, surgery and autopsy. Using transoesophageal echocardiography we found in 5 patients a type I dissection, in 5 patients a type II and in 14 patients a type III dissection. Transthoracic two-dimensional echocardiography was positive in 3/5 type I, 2/5 in type II and 2/14 in type III dissections. Computer tomography was unable to demonstrate an intimal flap in 1/2 patients with type I, 2/3 type II and 1/11 type III dissections. Aortography was negative in 1/4 type I, 3/5 type II and 3/12 patients with type III dissection. Additional information concerning thrombus formation, localisation of the entry tear, differentiation between true and false lumen, flow dynamics within the true and false lumen as well as accompanying aortic regurgitation may be obtained by transoesophageal echocardiography.

Adult↗

PubMedDate not supplied

[The determinants of intramyocardial pressure (author's transl)].

In 20 open-chest dogs intramyocardial pressure was measured simultaneously in two regions: a) in the normal myocardium (IMPsp) b) in a controlled perfused area of the myocardium, supplied by a cannulated coronary artery (IMPp). The preparation permitted the study of the influence of contractility, ventricular pressure and coronary blood flow on IMP. 1. A 47% change in coronary flow with a 26% change in coronary perfusion pressure results in changes of systolic and diastolic IMPp of 14% and 29% respectively. These effects can be explained by variations of intramural fluid content and, hence, of diastolic fiber length. 2. Changes of systolic ventricular pressure (mean 27%) by preload variations result in a mean change of systolic IMPsp of 19% and of systolic IMPp of 11%. 3. Changes of systolic ventricular pressure (mean 33%) by afterload variations augment IMPsp by 30% and IMPp by 13%. 4. The increases of IMPsp and IMPp induced by instantaneous changes of afterload are equal. The most important determinants of IMP are myocardial contractility, coronary perfusion and intraventricular pressure. The influence of coronary perfusion and ventricular pressure on IMP is of the same order of magnitude.

Animals↗

PubMedDate not supplied

Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism.

Transthoracic echocardiography generally provides only indirect signs of pulmonary embolism. In contrast, with transesophageal echocardiography the thromboembolus itself can be visualized in the central parts of the pulmonary artery. The aims of our study were to evaluate, first, the incidence of central pulmonary artery thromboemboli in patients with severe pulmonary embolism, and second, the accuracy of the echocardiographic diagnosis. Our study group comprised 60 patients with proved severe pulmonary embolism. All patients were examined by transthoracic and transesophageal echocardiography. The echocardiographic findings concerning the absence or presence of central pulmonary artery thromboemboli were compared with the results of different reference methods. Central pulmonary thromboemboli were found in 35 patients (58.3%) by echocardiography. Two types of thrombus were differentiated. Type A is a long, highly mobile thrombus, and type B is an immobile wall-adherent thrombus. In comparison with the reference methods, we determined a sensitivity of 96.7% and a specificity of 88% for the echocardiographic detection of central pulmonary artery thromboemboli in patients with severe pulmonary embolism. Transesophageal echocardiography seems to be a useful method for the diagnosis of severe pulmonary embolism. In our series, central pulmonary artery thromboemboli were present in more than half of the patients. In these cases, transesophageal echocardiography can clarify the diagnosis within a few minutes without further invasive diagnostic procedures.

Adult↗

PubMedDate not supplied

Three-dimensional imaging of cardiac mass lesions by transesophageal echocardiographic computed tomography.

Three-dimensional echocardiography is a new imaging technique that allows more realistic visualization of cardiac morphology. This study presents data about the diagnostic potentials of this technique concerning cardiac mass lesions, as well as its feasibility in clinical application. After the conventional investigation, multiple cross-sectional images were obtained during automatic forward advancement of a monoplane transducer mounted on a transesophageal probe. Three-dimensional reconstruction and volume determination were performed off line. Twenty-four patients were studied. In 14 cases results of echocardiographic computed tomography (echo-CT) were compared with those of monoplane/biplane transesophageal echocardiography. In 23 patients a conventional transesophageal investigation with the echo-CT probe and in 20 patients tomographic scanning were possible. Data acquisition required 12 +/- 4 minutes and three-dimensional reconstruction required 35 +/- 14 minutes. In 13 patients mass lesions were found; in 11 of 13 patients echo-CT provided diagnostic information about the precise spatial orientation and morphology of cardiac structures that could not be obtained by monoplane/biplane transesophageal echocardiography. The technique revealed accurate distance measurements and volume determination of mass lesions. Echo-CT is a further step toward the application of clinically useful three-dimensional echocardiography.

Echocardiography, Transesophageal↗

PubMedDate not supplied

Noncommunicating intramural hematoma: an indication of developing aortic dissection?

A 60-year-old patient was referred to the hospital for persisting chest pain. The first transesophageal echocardiogram showed localized hematomas without aortic dissection. Several days later the patient suffered complete paraplegia after a second episode of chest pain. The transesophageal echocardiogram now showed a complete aortic dissection. Thus whether intramural hematomas can be regarded as an early sign of impending aortic dissection needs to be investigated.

Aortic Dissection↗

PubMedDate not supplied

Value and limitations of transesophageal echocardiography in the evaluation of aortic prostheses.

Results of 34 transesophageal (TEE) studies in patients with suspected aortic prosthetic dysfunction were compared with transthoracic echocardiographic (TTE) results and to anatomic findings. Mass lesions noted at surgery (autopsy) were correctly described in 93% by TEE versus 43% by TTE. Abscesses were detected in 88% by TEE versus 18% by TTE. Bioprosthetic degeneration was visualized in 88% versus 38% and prosthetic obstruction correctly identified in 75% versus 50% by TEE and TTE, respectively. Anatomic aortic regurgitant lesions were identified in 96% by TEE versus 77% by TTE, whereas the correct origin was detected in 88% of cases by TEE versus 54% of cases by TTE. TEE provides valuable additional information on morphologic conditions and flow pathology in aortic valve prostheses.

Aortic Valve↗

PubMedDate not supplied

Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size.

The diagnostic value of transesophageal echocardiography in monitoring the clinical course has been evaluated in 83 patients with echocardiographic evidence of infective endocarditis. A total of 103 vegetations attached to the aortic or mitral valves were detected by use of the transesophageal approach. The patients were monitored for a mean of 74 weeks and underwent a minimum of two consecutive transesophageal echocardiographic examinations. Group A included patients with increasing or remaining constant size of vegetation (8.2 +/- 1.5 to 11.2 mm, p less than 0.05) during 4 to 8 weeks of antimicrobial therapy, whereas group B was formed by patients with decreasing vegetation size (8.3 +/- 0.8 to 4.9 +/- 0.8 mm, p less than 0.05). The incidences of complications after diagnosis and onset of therapy was higher in group A than in group B: valve replacement (45% versus 2%, p less than 0.05), embolic events (45% versus 17%, p less than 0.05), perivalvular abscess formation (13% versus 2%, p less than 0.05), and mortality (10% versus 0%, respectively, p less than 0.05). Staphylococcus aureus was the most frequent organism isolated in group A (44% versus 11% in B, p less than 0.05) and Streptococcus viridans in group B (33% versus 18% in A, p less than 0.05). Blood cultures were negative in nearly 50% of the patients in each group. There was no difference in the incidences of complications in patients with positive or negative blood cultures. We conclude that an increase in vegetation size during antibiotic therapy predicts a prolonged healing phase of infective endocarditis. This prolonged healing period is associated with a significantly increased risk of complications, independent of blood culture results. Monitoring vegetation size contributes important information concerning prognosis and stage of risk, and it aids in the choice of patient management in infective endocarditis. Because embolic events after diagnosis and onset of treatment are less frequent in rapid-healing endocarditis, surgery cannot be recommended to prevent further events taking into account the high risk of surgery.

Abscess↗

PubMedDate not supplied

Regurgitant flow in apparently normal valve prostheses: improved detection and semiquantitative analysis by transesophageal two-dimensional color-coded Doppler echocardiography.

In 128 patients with apparently normally functioning prosthetic valves (n = 136) in the aortic position (n = 79) and the mitral position (n = 57), the prevalence of transprosthetic regurgitant flow was studied by use of transthoracic and transesophageal two-dimensional color-coded Doppler echocardiography. With the transthoracic approach, regurgitant flow was detected in early systole or diastole for 28% of the mitral prostheses and for 29% of the aortic prostheses. With transesophageal color-coded Doppler echocardiography, regurgitant jets were visualized for 95% of the mitral prostheses and for 44% of the aortic prostheses. In 40% of the Björk-Shiley prostheses and 88% of the St. Jude Medical prostheses in the mitral position, more than one jet with an eccentric origin was detected, whereas in bioprostheses only one centrally localized regurgitant jet was noted. The regurgitant jet length was 22 +/- 2 mm in mitral prostheses and 12 +/- 2 mm in aortic prostheses. The jet area was 154 +/- 31 mm2 in mitral prostheses and 61 +/- 26 mm2 in aortic prostheses. Jets of this size and frequency have to be considered a normal finding and the equivalent of regurgitant flow known from in vitro studies. We conclude that only transesophageal color-coded Doppler echocardiography seems to be a reliable method for following up mitral valve prostheses to detect and differentiate regurgitant jets. For aortic valve prostheses the advantage of transesophageal color-coded Doppler echocardiography does not seem to be as obvious as the advantage for mitral prostheses.

Adolescent↗

PubMedDate not supplied

High-resolution two-dimensional echocardiography improves the quantification of left ventricular function.

It is not clear if newer echo technology prevents underestimation of ejection fraction in comparison with cineventriculography (CVG). Before undergoing CVG, 48 patients were studied with state-of-the-art, high-resolution two-dimensional echocardiography with a 3.5 MHz transducer, 96 crystals, and digital storing (slow motion and cine-loop). These data are compared with results published by us in 1983 (37 patients). Volumes were calculated using the biplane method of discs in a single area length. Exclusion criteria in 1990 were poor two-dimensional echocardiography quality (n = 6) and extra-systole during CVG (n = 4). The difference between the mean values of the angiography and echocardiography data in the new study (1990) were 4.7 ml/m2/body surface area (BSA) for the end-diastolic volume, 0.1 ml/m2 for the end-systolic volume, and 1.5% for the ejection fraction (all NS). The mean difference between both methods in the old study (1983) were -39.1 ml/m2/BSA (p less than 0.001) for end-diastolic volume, -17.4 ml/m2 (p less than 0.001) for end-systolic volume, and -7.2% for ejection fraction (p less than 0.001). The regression equation for determination of ejection fraction was y = 0.606x + 13, r = 0.803 for the old study, and y = 0.935x + 2.5; r = 0.935 for the new study. These results indicate that state-of-the-art, high-resolution two-dimensional echocardiography prevents the systematic underestimation of left ventricular volume and ejection fraction, most likely because of better delineation of endocardium in end-systole.

Adult↗

PubMedDate not supplied

Left ventricular volume determination using Albunex.

The aim of this study was to assess the ability of intravenous injection of Albunex to improve left ventricular volume determination in patients with various cardiac diseases. It is conceivable that the intravenous injection of microbubbles could improve echocardiographic left ventricular border delineation leading to improved interobserver variability. Echocardiograms were obtained during simultaneous intravenous injection of 0.08 and 0.12 ml/kg Albunex (four-chamber view). Within 6 hours after the recording of the contrast echocardiograms routine left heart angiography was performed. Volumes were measured using the slice method in native and contrast echocardiograms as well as in the angiograms by two independent investigators. The mean differences of angiographic-native echocardiographic and angiographic-contrast echocardiographic volumes (ml) as well as the calculated ejection fraction and their confidence intervals were tabulated and significance was anticipated if the confidence interval did not include zero. Significant changes to angiographic values could be observed concerning end-diastolic, echocardiographic, and contrast echocardiographic volumes at end diastole and end systole, while ejection fractions were similar. Differences between observers were significantly smaller in the contrast echocardiographic images than in the native echocardiographic images. Albunex led to a significantly decreased interobserver variability.

Adult↗

PubMedDate not supplied

Tomographic left ventricular volume determination in the presence of aneurysm by three-dimensional echocardiographic imaging. I: Asymmetric model hearts.

To improve the accuracy of measurements of left ventricular volume in the presence of an aneurysm, we used three-dimensional echocardiographic imaging to analyze the shape of left ventricles in 23 asymmetric model hearts with eccentric aneurysms of different sizes, shapes, and localizations. A standard 3.75 MHz ultrasound probe with a rotation motor device was used to obtain a three-dimensional data set. By rotating the probe stepwise 1 degree, 180 radial ultrasound pictures were digitized. On the basis of the three-dimensional data set, the following parameters were determined and compared with the dimensions of the model hearts obtained by direct measurement: total left ventricular volume (LVV), aneurysm volume, area of the aneurysm's base, the longest aneurysm long diameter, and the longest aneurysm cross diameter. In addition, quantification of LVV by three-dimensional echocardiography was compared with biplane two-dimensional echocardiographic measurement according to the disk method. Good agreements were found for LVV measured by both techniques, three-dimensional echocardiographic and direct measurement (mean of differences = 0.91 ml; SD of differences = +/- 6.23 ml; line of regression y = 1.07 x - 14.24 ml; r = 0.968; standard error of the estimate [SEE] = +/- 6.17 ml), aneurysm volume (mean of differences = 0.43 ml; SD of differences = +/- 2.14 ml; line of regression y = 1.05 x - 0.81 ml; r = 0.996; SEE = +/- 1.96 ml), area of the aneurysm's base (mean of differences = 0.24 cm2; SD of differences = +/- 1.72 cm2; line of regression y = 1.02 x - 0.02 cm2; r = 0.981; SEE = +/- 1.75 cm2), the longest aneurysm long diameter (mean of differences = -0.26 mm; SD of differences = +/- 1.60 mm; line of regression y = 0.97 x + 1.34 mm; r = 0.996; SEE = +/- 1.54 mm), and the longest aneurysm cross diameter (mean of differences = 1.35 mm; SD of differences = +/- 3.94 mm; line of regression y = 0.95 x + 3.17 mm; r = 0.941; SEE = +/- 3.99 mm). In contrast, in these extremely asymmetric-shaped model hearts, agreement between biplane two-dimensional echocardiographic and both direct LVV measurement (mean of differences = 7.8 ml; SD of differences = +/- 20.8 ml; line of regression y = 1.48 x - 92.45 ml; r = 0.874; SEE = +/- 18.36 ml) and three-dimensional echocardiographic measurements (mean of differences = -7.6 ml; SD of difference = +/- 18.1 ml; line of regression y = 0.59 x + 80.98 ml; r = 0.908; SEE = +/- 10.36 ml) was poor. Thus tomographic three-dimensional echocardiography allowed accurate volume determination of asymmetric model hearts in the shape of left ventricles with eccentric aneurysms.

Cardiac Volume↗

PubMedDate not supplied

Coronary microembolization.

Atherosclerotic plaque rupture is a key event in the pathogenesis of acute coronary syndromes and during coronary interventions. Atherosclerotic plaque rupture does not always result in complete thrombotic occlusion of the entire epicardial coronary artery with subsequent acute myocardial infarction; however, in milder forms it may result in the embolization of atherosclerotic and thrombotic debris into the coronary microcirculation. The present report summarizes the available morphologic evidence for coronary microembolization in patients who died of coronary artery disease, especially sudden death. The report then goes on to address the experimental pathophysiology of coronary microembolization in animal models of acute coronary syndromes and heart failure. Finally, the report presents the available clinical evidence for coronary microembolization, highlights its key features--arrhythmias, contractile dysfunction, infarctlets and reduced coronary reserve--and addresses prevention by mechanical protection devices and glycoprotein IIb/IIIa antagonism.

Animals↗