Pericardial effusions after bone-marrow transplantation.
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Adult↗
Biomedical subjects
J B Seward
Publications and source records attributed to J B Seward.
Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion.
OBJECTIVE: This study was designed to delineate the utility and results of intraoperative transesophageal echocardiography in the evaluation of patients undergoing mitral valve repair for mitral regurgitation. BACKGROUND: Mitral valve reconstruction offers many advantages over prosthetic valve replacement. Intraoperative assessment of valve competence after repair is vital to the effectiveness of this procedure. METHODS: Intraoperative transesophageal echocardiography was performed in 143 patients undergoing mitral valve repair over a period of 23 months. Before and after repair, the functional morphology of the mitral apparatus was defined by two-dimensional echocardiography; Doppler color flow imaging was used to clarify the mechanism of mitral regurgitation and to semiquantitate its severity. RESULTS: There was significant improvement in the mean mitral regurgitation grade by composite intraoperative transesophageal echocardiography after valve repair (3.6 +/- 0.8 to 0.7 +/- 0.7; p less than 0.00001). Excellent results from initial repair with grade less than or equal to 1 residual mitral regurgitation were observed in 88.1% of patients. Significant residual mitral regurgitation (grade greater than or equal to 3) was identified in 11 patients (7.7%); 5 underwent prosthetic valve replacement, 5 had revision of the initial repair and 1 patient had observation only. Of the 100 patients with a myxomatous mitral valve, the risk of grade greater than or equal to 3 mitral regurgitation after initial repair was 1.7% in patients with isolated posterior leaflet disease compared with 22.5% in patients with anterior or bileaflet disease. Severe systolic anterior motion of the mitral apparatus causing grade 2 to 4 mitral regurgitation was present in 13 patients (9.1%) after cardiopulmonary bypass. In 8 patients (5.6%), systolic anterior motion resolved immediately with correction of hyperdynamic hemodynamic status, resulting in grade less than or equal to 1 residual mitral regurgitation without further operative intervention. Transthoracic echocardiography before hospital discharge demonstrated grade less than or equal to 1 residual mitral regurgitation in 86.4% of 132 patients studied. A significant discrepancy (greater than 1 grade) in residual mitral regurgitation by predischarge transthoracic versus intraoperative transesophageal echocardiography was noted in 17 patients (12.9%). CONCLUSIONS: Transesophageal echocardiography is a valuable adjunct in the intraoperative assessment of mitral valve repair.
Adolescent↗
Fixed subaortic stenosis in atrioventricular canal defect: a Doppler echocardiographic study.
OBJECTIVES: The objectives of this retrospective study were to describe the Doppler and echocardiographic features of fixed subaortic stenosis in the setting of atrioventricular (AV) canal defect and to document the de novo occurrence of subaortic stenosis and progression of this lesion over time on the basis of sequential echocardiographic studies. BACKGROUND: The coexistence of fixed subaortic and AV canal defect has been sporadically noted, but no single or multicenter experience with this constellation of abnormalities has been previously described. METHODS: All patients with a diagnosis of subaortic stenosis and complete or partial AV canal defect who had one or more Doppler echocardiographic examinations were identified from a computer data bank. Retrospective analysis was performed, including review of patients' charts, operative notes, recorded videotapes and hard copy recordings when available. RESULTS: Twenty-one patients with both subaortic stenosis and AV canal defect were identified over a 13-year period. Fifteen were female and the mean age at diagnosis of subaortic stenosis was 16 years. Fifteen patients had partial AV canal defect with prior repair in 10; 6 patients had complete AV canal defect with prior repair in 4. The mean interval from prior repair to recognition of subaortic stenosis was 6.8 years. In six patients, serial examinations demonstrated the de novo occurrence of subaortic obstruction over a period of 10 to 87 months. In five patients, progression of known subaortic stenosis was documented over a 10- to 59-month period. Surgical resection of subaortic stenosis was performed in 16 patients; the echocardiographic diagnosis was confirmed in 15 of the 16. CONCLUSIONS: In the largest reported echocardiographic series of this lesion complex, it is concluded that subaortic stenosis can occur de novo, is often recognized only after repair of the canal defect and is progressive. Doppler echocardiography is the method of choice for diagnosis and serial follow-up of these patients.
Adolescent↗
Fistulous pseudoaneurysm complicating surgical accessory pathway interruption for Wolff-Parkinson-White syndrome.
Pseudoaneurysms of the left ventricle are unusual operative complications that have commonly been associated with replacement of the mitral valve. In this report, we describe a 31-year-old man who was referred to our institution because of atypical chest pain. He had previously undergone three operations for ablation of an accessory pathway because of Wolff-Parkinson-White syndrome. A pseudoaneurysm of the left ventricle was noted on transesophageal echocardiography, biplanar left ventriculography, and ultrafast cine computed tomography of the heart. Elective surgical repair was successful. Although rare, this case demonstrates an unusual but potentially serious complication of surgical treatment of Wolff-Parkinson-White syndrome.
Adult↗
Echocardiographic documentation of splenic anatomy in complex congenital heart disease.
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Abnormalities, Multiple↗
Transesophageal echocardiography and cardiac masses.
Although transthoracic two-dimensional echocardiography has been a procedure of choice for diagnosing cardiac mass lesions, the advent of transesophageal echocardiography (TEE) provided better visualization of cardiac structures, especially those at a considerable depth from the chest wall, and lesions that involve the left atrial appendage. In this study, we examined the experience at our institution with TEE imaging of cardiac mass lesions (excluding valvular vegetations) from April 1988 to July 1990. TEE studies detected 83 lesions (in 80 patients), which we characterized by type and site: 46 left atrial, 16 right atrial, 7 left ventricular, 2 right ventricular, and 12 extracardiac mass lesions. Of the 46 left atrial lesions, 9 were tumors and 37 were thrombi that involved the body of the left atrium, the left atrial appendage, or both. Associated mitral valve disease, chronic atrial fibrillation, or spontaneous microcavitations were common. Of the 16 right atrial mass lesions, 4 were tumors and 12 were thrombi, including "string" thrombi characteristic of venous thromboembolism. Of the seven left ventricular mass lesions, six were thrombi and one was a papilloma. Of the 12 extracardiac mass lesions, 2 were pericardial cysts and the rest were solid lesions. TEE added new or important clinical information beyond that derived from transthoracic echocardiography in left atrial thrombi, right atrial masses, and extracardiac lesions and was assessed to have influenced the management of patients most in these areas also. TEE is a useful addition to transthoracic echocardiography for diagnosis and clarification of cardiac mass lesions in selected patients.
Academic Medical Centers↗
A patient with pulseless extremities: an unusual manifestation of cardiac tamponade.
We describe a 51-year-old man who came to our institution with cold cyanotic extremities. He was receiving radiation therapy for adenocarcinoma of the lung and superior vena cava syndrome. Findings on initial physical examination were notable for absent peripheral pulses and increased jugular venous pulsations. Shortly after admission, the patient experienced severe dyspnea and tachypnea. Arterial blood gas studies revealed mild metabolic acidosis. A chest roentgenogram showed an enlarged cardiac silhouette and the known mass in the right upper lobe of the lung. An electrocardiogram demonstrated no evidence of ischemia but low-voltage QRS complexes. An emergency echocardiogram disclosed a large pericardial effusion and evidence of hemodynamic compromise. With use of echocardiographic-guided pericardiocentesis, 600 ml of bloody fluid was removed; the pulses were immediately palpable in the patient's extremities. Although symptoms associated with the extremities are unusual as the initial complaint of patients with cardiac tamponade, we illustrate several key physical findings and abnormal results of laboratory test characteristic of this disorder. In addition, we underscore the importance of considering this diagnosis, especially in patients with a malignant tumor, and we describe the prompt response to therapy.
Adenocarcinoma↗
Prognostic significance of Doppler measures of diastolic function in cardiac amyloidosis. A Doppler echocardiography study.
BACKGROUND: We have previously characterized the left ventricular diastolic filling abnormalities in cardiac amyloidosis by Doppler methods. The various filling patterns were shown to be related to the degree of cardiac amyloid infiltration. The purpose of this study was to determine the value of Doppler diastolic filling variables for assessing prognosis in cardiac amyloidosis. METHODS AND RESULTS: We performed pulsed-wave Doppler studies of the left ventricular inflow and obtained clinical follow-up data in 63 consecutive patients with biopsy-proven systemic amyloidosis. All patients had typical echocardiographic features of cardiac involvement. The patients were subdivided into two groups according to deceleration time: Group 1 (33 patients) had a deceleration time of 150 msec or less, indicative of restrictive physiology, and group 2 (30 patients) had a deceleration time of more than 150 msec. Of the 63 patients, 32 (51%) died during a mean follow-up period of 18 +/- 12 months. Of these deaths, 25 (78%) were cardiac deaths, and 19 of the 25 patients (76%) were from group 1. The 1-year probability of survival in group 1 was significantly less than that in group 2 (49% versus 92%, p less than 0.001). Bivariate analysis revealed that the combination of the Doppler variables of shortened deceleration time and increased early diastolic filling velocity to atrial filling velocity ratio were stronger predictors of cardiac death than were the two-dimensional echocardiographic variables of mean left ventricular wall thickness and fractional shortening. CONCLUSIONS: Doppler-derived left ventricular diastolic filling variables are important predictors of survival in cardiac amyloidosis.
Amyloidosis↗
Value and limitations of transesophageal echocardiography in assessment of mitral valve prostheses.
BACKGROUND: Transthoracic Doppler echocardiography examination has become an integral part of the investigations performed in patients with mitral valve prostheses. The limitations of the transthoracic approach are well documented. Transesophageal echocardiography provides a unique window for achieving a clear view of the mitral prosthesis. METHODS AND RESULTS: This study shows the usefulness of transesophageal echocardiography in clinical practice for assessment of patients with a mitral valve prosthesis. This technique demonstrated an abnormality in 48% of patients who had normal results on transthoracic examination. The overall sensitivity of transesophageal echocardiography was 96%. CONCLUSIONS: Transesophageal echocardiography constitutes an essential part of a comprehensive two-dimensional/Doppler echocardiographic examination in patients with suspected malfunction of mitral prostheses.
Adolescent↗
Prospective evaluation of the risk of bacteremia associated with transesophageal echocardiography.
BACKGROUND: Transient bacteremia may lead to endocarditis in patients with significant valvular lesions. METHODS AND RESULTS: Because transesophageal echocardiography selects a patient population with a high prevalence of valvular lesions, we prospectively evaluated the risk of transient bacteremia associated with transesophageal echocardiography in 49 patients. Blood cultures were obtained immediately before transesophageal echocardiography and at 5, 10, and 20 minutes after the start of the procedure. For each culture, 30 ml venous blood was obtained and 10 ml was inoculated into each of an Isolator tube, Septi-chek bottle, and a nonvented Trypticase soy broth bottle. Broth cultures were incubated for 14 days. Blood from the Isolator tube was plated onto appropriate media for recovery of bacteria and fungi. Two patients were excluded from analysis because the final two sets of blood cultures could not be obtained. Among the remaining 47 study patients, two preprocedure control blood cultures were positive, and two of 141 subsequent cultures were positive. All isolates were considered contaminants. Thus, we found no significant bacteremia due to pathogenic oral flora during transesophageal echocardiography (0%; 95% CI, 0.0-7.5%). CONCLUSIONS: Although recommendations for antimicrobial prophylaxis for transesophageal echocardiography should be individualized for each patient, many patients may not require antimicrobial prophylaxis.
Adult↗
Transesophageal echocardiography in critically ill patients.
The feasibility, safety and clinical impact of transesophageal echocardiography were evaluated in 51 critically ill intensive care unit patients (28 men and 23 women; mean age 63 years) in whom transthoracic echocardiography was inadequate. At the time of transesophageal echocardiography, 30 patients (59%) were being mechanically ventilated. Transesophageal echocardiography was performed without significant complications in 49 patients (96%), and 2 patients with heart failure had worsening of hemodynamic and respiratory difficulties after insertion of the transesophageal probe. The most frequent indication, in 25 patients (49%), was unexplained hemodynamic instability. Other indications included evaluation of mitral regurgitation severity, prosthetic valvular dysfunction, endocarditis, aortic dissection and potential donor heart. In 30 patients (59%), transesophageal echocardiography identified cardiovascular problems that could not be clearly diagnosed by transthoracic echocardiography. In the remaining patients, transesophageal echocardiography permitted confident exclusion of suspected abnormalities because of its superior imaging qualities. Cardiac surgery was prompted by transesophageal echocardiographic findings in 12 patients (24%) and these findings were confirmed at operation in all. Therefore, transesophageal echocardiography can be safely performed and has a definite role in the diagnosis and expeditious management of critically ill cardiovascular patients.
Echocardiography↗
Incidence, description and functional assessment of isolated quadricuspid aortic valves.
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Adult↗
Comprehensive Doppler assessment of right ventricular diastolic function in cardiac amyloidosis.
To assess right ventricular diastolic function in cardiac amyloidosis, pulsed wave Doppler ultrasound measurements of right ventricular inflow velocities and superior vena cava and hepatic vein flow velocities with respiratory monitoring were performed in 41 patients with primary systemic amyloidosis and two-dimensional echocardiographic features of cardiac involvement. Right ventricular diastolic function was abnormal in 31 (76%) of these patients, the major abnormality being a short deceleration time (less than 150 ms) in 21 (68%), suggesting restriction. In contrast, 7 (23%) of the 31 patients had a decreased ratio of early (E) and late (A) diastolic peak flow velocities and a prolonged deceleration time (greater than 240 ms), suggesting abnormal relaxation. The patients were classified into two groups on the basis of right ventricular free wall thickness: group 1, less than 7 mm and group 2, greater than or equal to 7 mm. Compared with normal values, group 1 showed an increased peak late flow velocity (44 +/- 19 versus 39 +/- 6 cm/s; p less than 0.01) and a decreased E/A velocity ratio (1.1 +/- 0.4 versus 1.5 +/- 0.3; p less than 0.01). Group 2 showed a markedly shortened deceleration time (151 +/- 37 versus 225 +/- 28 ms; p less than 0.01), characteristic of restriction. In the overall group, superior vena cava peak flow velocity was decreased in systole and increased in diastole and flow reversals during inspiration were increased compared with normal values. Hepatic venous flow velocities were similar to those in the superior vena cava except for larger flow reversals in the hepatic vein. Thus, in cardiac amyloidosis, right ventricular diastolic function is abnormal. There is a spectrum of right ventricular filling abnormalities and the restrictive filling pattern is seen only in the advanced stages of the disease.
Amyloidosis↗
Serial Doppler echocardiographic follow-up of left ventricular diastolic function in cardiac amyloidosis.
A spectrum of left ventricular diastolic filling abnormalities noted on Doppler echocardiography has been demonstrated in patients with cardiac amyloidosis. To determine how these filling abnormalities evolve over time and the significance of any change, serial pulsed wave Doppler studies of left ventricular inflow were performed over 12.6 +/- 4.9 months in 41 consecutive patients (36 men and 15 women, mean age 59 +/- 11 years) with typical two-dimensional echocardiographic features of cardiac involvement. The measurements were peak left ventricular inflow in early diastole (E) and atrial contraction (A) velocities, E/A ratio, deceleration time and isovolumetric relaxation time. Patients were classified by mean left ventricular wall thickness into an early group (less than 15 mm) of 24 patients and an advanced group (greater than or equal to 15 mm) of 17 patients. The total group showed an increased E/A ratio (1.7 +/- 0.9 versus 1.4 +/- 0.9, p = 0.009) and decreased deceleration time (164 +/- 57 versus 174 +/- 51 ms, p = 0.11) at follow-up compared with baseline study. The early group showed significant changes in the E/A ratio (1.6 +/- 1.0 versus 1.2 +/- 0.7, p = 0.001) between the two studies. Seven patients (29%) in the early group showed a change from an abnormal relaxation or "normal" pattern to one of restriction, coincident with increased symptoms in six of these patients. Fifteen (88%) of the 17 patients in the advanced group did not show significant changes in the measures during the follow-up study, but these patients already showed a restrictive pattern.(ABSTRACT TRUNCATED AT 250 WORDS)
Amyloidosis↗
Progression of aortic stenosis in adults: new appraisal using Doppler echocardiography.
This study examined progression of aortic stenosis (AS) as assessed by Doppler echocardiography. One hundred twelve consecutive adult patients had calcific AS and underwent three examinations during a mean 25-month period (range 7 to 54 months). At the time of entry into the study, mean values for initial peak aortic velocity and ejection fraction (EF) were 2.9 +/- 0.7 m/sec and 63 +/- 10%, respectively; 52% of the patients were symptomatic. At the third examination the percentage of symptomatic patients increased to 65% (p = 0.0039 compared to baseline values), and the aortic peak velocity increased to 3.3 +/- 0.8 m/sec (p less than 0.001). Age, sex, and EF were not predictors of progression. Documented coronary artery disease (in 57 patients) did not affect progression, and neither did the aortic peak velocity at the time of entry into the study. Thirty-eight patients reported an increase in symptoms from the first to third examination, and their rate of progression was significantly different from that of the rest of the population: 0.33 +/- 0.50 m/sec/yr compared to 0.18 +/- 0.26 m/sec/yr (p less than 0.03).
Aged↗
Wide-field transesophageal echocardiographic tomography: feasibility study.
In this report, we describe our initial investigation of wide-field ultrasonic cardiothoracic tomography utilizing a transesophageal transducer. Examination included manual rotation of an esophageal transducer 180 to 360 degrees in order to visualize contiguous related structures. Consecutive sector views were photographed and then incorporated into a digital graphics computer for smoothing. This feasibility study introduces the concept of wide-field transesophageal cardiothoracic ultrasound tomography, which holds promise for tomographic depiction of cardiothoracic and mediastinal anatomy.
Aged↗
The mechanism of blood flow during closed chest cardiac massage in humans: transesophageal echocardiographic observations.
Despite years of research, the mechanism of forward blood flow during closed chest cardiac massage remains controversial. Two theories have been suggested: the cardiac pump theory and the thoracic pump theory. Transesophageal echocardiography offers a new approach for study of the flows and cardiac morphologic features during chest compressions in humans. Case reports are presented to illustrate the use of transesophageal echocardiography during cardiopulmonary resuscitation. The findings included right and left ventricular compression, closure of the mitral valve during compression, opening of the mitral valve during the release phase, and atrioventricular valvular regurgitation during compression, indicating a positive ventricular-to-atrial pressure gradient. These findings suggest that direct cardiac compression was the predominant mechanism of forward blood flow during cardiopulmonary resuscitation in these patients. An understanding of the actual mechanisms involved is necessary if improved cardiopulmonary resuscitative techniques or adjuncts are to be rationally developed for enhancing the outcome of resuscitation.
Aged↗
Biplanar transesophageal echocardiography: anatomic correlations, image orientation, and clinical applications.
Clinical transesophageal echocardiography is a rapidly expanding diagnostic procedure. Conventional transesophageal endoscopes allow imaging from a single array mounted in the horizontal plane. This article introduces the clinical application of biplanar imaging, which incorporates a second orthogonal longitudinal plane. Our clinical experience with 291 patients who underwent biplanar transesophageal echocardiography is presented. The examination, technique, and resultant anatomic correlations unique to this new examination are discussed and illustrated. The anatomy is displayed in a familiar format comparable to the precordial examination. Biplanar imaging adds substantially to the comprehensive anatomic delineation of certain cardiac structures.
Adolescent↗