In response to: The echocardiographic assessment of replacement heart valves: high time for a consensus by Chambers JB.
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Echocardiography, Doppler↗
Biomedical subjects
W Fehske
Publications and source records attributed to W Fehske.
Left systolic atrioventricular plane displacement in the assessment of myocardial viability in patients with previous myocardial infarction.
UNLABELLED: In order to detect myocardial viability in coronary artery disease patients (CAD) with a previous myocardial infarction and dysfunction of the left ventricle (LV), the reliability of the left atrioventricular plane displacement (LAVPD) during low dose dobutamine stress echocardiography (DSE), was validated. The study population consisted of 70 CAD patients and 35 age and sex matched healthy subjects. From the apical four and two chamber views the LAVPD was recorded and measured by M-mode echocardiography, at four sites corresponding to the septal, lateral, anterior and inferior walls of the LV, prior and during the DSE (5-10 micrograms/kg/min). All patients underwent exercise SPECT Thallium-201 with four-hour redistribution and rest-reinjection, in order to determine tissue viability. Intraobserver and interobserver variability for the LAVPD was insignificant (5.8% and 7.2%, respectively). Healthy subjects exhibited a significant and equally distributed maximal increase of the LAVPD, at all sites during dobutamine infusion (DI) (p < 0.001). Patients also, showed a significant maximal increase of the LAVPD during DI, at all asynergic sites in which viable tissue was found (p < 0.001). However, in the asynergic sites without viable tissue the LAVPD did not significantly change (p < 0.05). Selecting a LAVPD increase of > 2 mm to detect viable myocardium at any asynergic site of LV, resulted in a sensitivity of 91% and specificity of 89%. When DSE was used for the detection of viable myocardium, sensitivity and specificity were found to be 80% and 87% respectively. The proportion of agreement between the two above mentioned methods was 82%. When the two methods were in agreement, the positive and negative predictive values were 94% and 97%, respectively. The validity of the above mentioned increase of the LAVPD was also prospectively examined in a similar group of 35 CAD patients exhibiting myocardial dysfunction as a result of a previous myocardial infarction (sensitivity 85% and specificity 90%, respectively). CONCLUSIONS: 1) The assessment of left LAVPD during DI is a new quantitative, accurate method with a low intraobserver and interobserver variability, in detecting viable myocardium. 2) Combination of this method and DSE proved good diagnostic markers of myocardial viability.
Dobutamine↗
Paraprosthetic regurgitation in aortic prostheses: determination of the hemodynamic significance by pulsed Doppler examination of the subclavian artery flow.
Paraprosthetic leaks in aortic prostheses may cause significant aortic regurgitation. Color flow Doppler echocardiography is the method of choice for detecting paraprosthetic leaks, but quantitation of regurgitation is limited by this method. This study investigated the value of pulsed Doppler of the left subclavian artery flow for assessing the hemodynamic significance of paraprosthetic regurgitation in aortic prostheses in 32 patients with, and in 77 control subjects without paraprosthetic leaks. Paraprosthetic leaks were either detected by transthoracic or transesophageal color flow echocardiography. The hemodynamic significance of paraprosthetic regurgitation was determined by means of a dichotomous angiographic classification - significant versus insignificant regurgitation. Pulsed Doppler was performed to measure the maximal diastolic and systolic velocities, and diastolic and systolic velocity-time-integrals (VTI) and their ratios in the subclavian artery flow. The accuracy of these parameters for differentiating significant versus insignificant regurgitation was assessed. Angiography revealed 13 significant and 19 insignificant forms of aortic regurgitation. In all patients, examination of the subclavian artery was feasible by pulsed Doppler. The highest correlation between Doppler derived parameters and regurgitation was calculated for the ratios of diastolic and systolic VTI (r = 0.84), diastolic VTI (r = 0.82) and ratio of diastolic and systolic velocities (r = 0.80). An increase of the ratio of diastolic and systolic VTI (> 45%) and ratio of diastolic to systolic velocity (> 0.4), and increased diastolic VTI (> 60 cm) in the subclavian artery velocity profile identified significant paraprosthetic regurgitation with a sensitivity of 94%, 75% and 87%, and specificity of 87%, 80% and 87%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
Aortic Valve Insufficiency↗
Multiplane transesophageal echocardiographic assessment of mitral regurgitation by Doppler color flow mapping of the vena contracta.
Assessment of the severity of mitral regurgitation (MR) by Doppler color flow mapping is limited by dependence of jet area on hemodynamic and technical variables. The width of the MR jet at its origin may be less dependent on hemodynamic variables, and thus should more accurately reflect the severity of MR. Doppler color flow mapping was performed in 80 subjects by transesophageal echocardiography (TEE) within 48 hours of catheterization. Width of the MR jet at its vena contracta was measured by both single plane and multiplane TEE and compared with the angiographic grade of MR and regurgitant volume. The width of the MR jet correlated closely with angiographic grade by both methods. A jet width > or = 6 mm identified angiographically severe MR with a sensitivity and specificity of 100% and 83% by single-plane TEE, and 95% and 98% by multiplane TEE. The sensitivity and specificity for detecting a regurgitant volume > or = 80 ml was 93% and 76% for single-plane TEE, and 86% and 95% for multiplane TEE. Thus, the width of the MR jet at its vena contracta by Doppler color flow mapping is an accurate marker of the severity of MR. By virtue of its ability to obtain orthogonal views specifically oriented to mitral leaflet coaptation, multiplane TEE is superior to single-plane TEE in assessing MR jet width.
Blood Flow Velocity↗
[Cardiac manifestations in advanced HIV infection].
Incidence, type and clinical significance of cardiac involvement in advanced HIV infection was determined in 32 patients (30 men, two women; mean age 34.2 [21-52] years; mean CD4-cell number 52.2 [0-192]/microliters) over a period of 31 months. Any cardiac involvement was assessed diagnostically by one- and two-dimensional and Doppler echocardiography, complemented by other examinations and results of treatment. 14 patients (43.8%) had abnormal cardiac findings, presumably AIDS-associated. This included left ventricular pump dysfunction of various degrees of severity (n = 11), left ventricular dilatation (n = 2), pericardial effusion (n = 11), as well as cor pulmonale in primary pulmonary arterial hypertension (n = 2). In one patient the first manifestation of AIDS was tubercular pericarditis; in two patients there was a likely connection to disseminated pneumocystis infection and toxoplasmosis, respectively. In 11 patients no specific cause was found for the cardiac involvement. Nine of the 14 patients (64%) had symptoms due to the cardiac involvement. These findings indicate that the incidence and clinical significance of cardiac involvement must be taken into account in any treatment concept for AIDS.
AIDS-Related Complex↗
Color-coded Doppler imaging of the vena contracta as a basis for quantification of pure mitral regurgitation.
The narrowest central flow region of a jet is defined as the vena contracta. This term is applied also to the contracted zone of the Doppler color flow image of a jet at its passage through an incompetent mitral valve. The clinical applicability of measuring the size of the vena contracta by transthoracic color-coded Doppler echocardiography for estimating the severity of mitral regurgitation (MR) was evaluated. In 78 of 82 patients with angiographically proved MR, a coherent flow image across the valve was visualized. The maximal diameter in the apical long-axis view was considered as a representative value for the size of the vena contracta. In comparison with the maximal left atrial velocity pixel area, this parameter revealed higher correlations to the angiographic degree of MR and to the regurgitant volume (r = 0.94 vs 0.72, and 0.83 vs 0.71, respectively). The highest positive and negative predictive accuracies for differentiating mild-to-moderate from severe MR were determined for a diameter of 6.5 mm (88 and 96%, respectively). Because the vena contracta is directly related to the severity of MR, it is concluded that it is helpful to use this parameter instead of the maximal velocity pixel area for semiquantitative grading.
Adult↗
Undifferentiated (embryonal) sarcoma of the liver in an adult patient with metastasis of the heart and brain.
A 26-year-old woman with a tumor of the left liver lobe was admitted to the hospital. After incomplete resection of the tumor and histological diagnosis of an undifferentiated (embryonal) sarcoma of the liver a combination chemotherapy with ifosfamide and epidoxorubicine was started. 11 months later brain metastases were diagnosed. Routine ultrasound examination of the heart disclosed a pericardial tumor infiltrating the left atrium of the heart. After radiation therapy of the brain metastases the patient was treated with two cycles of high-dose ifosfamide and epidoxorubicin. Two years after diagnosis the patient developed signs of cardiac failure and died. Postmortem autopsy confirmed the local recurrence of the liver neoplasm and revealed its continuous spread to the pericardium via the diaphragm and infiltration of the left atrium.
Adult↗
Complications of pacemaker-defibrillator devices: diagnosis and management.
Treatment of resuscitated patients with implantable cardioverter defibrillators has become increasingly more common as a method for the prevention of sudden cardiac death. Major complications such as perioperative death (incidence 2% to 8%), infection (2% to 11%); and lead-related problems (3% to 27%) have been described in previous trials. In our experience with 140 patients, problems were related to leads (n = 11), the device (n = 2), pacing (n = 1), sensing (n = 13), and defibrillation function (n = 5). Additional problems that occurred during the perioperative period included infection (n = 11), hematoma, and seroma (n = 2). Thrombus formation along endocardial leads was observed in 13 of 62 (21%) patients. Different arrhythmias (n = 10), such as sinus tachycardia, atrial fibrillation, and nonsustained, slow or incessant ventricular tachycardia with shock delivery, were also detected. Surgical management (predominantly for the major problems) was used in 31 (48%) patients, drug treatment in 25 (39%), and reprogramming of the device in 24 (38%) patients. All of these problems can result in an increase in mortality rates. This article provides an overview of the complications of cardioverter defibrillator treatment and is based on both published data and our series.
Arrhythmias, Cardiac↗
Apical hypertrophic cardiomyopathy with unusual features in a Greek woman.
We present a Mediterranean female patient with abnormal electrocardiographic findings and a history of shortness of breath during excessive effort (NYHA I) in whom apical hypertrophic cardiomyopathy with unusual features was detected by echocardiography and magnetic resonance imaging. There was a single fused apical hypertrophic papillary muscle and akinesia of the left ventricular apical segment. Abnormal left ventricular filling was also detected by Doppler echocardiography.
Adult↗
[Cerebral circulation in patients with dilated cardiomyopathy and aortic valve diseases].
The present study was performed in order to investigate the effect of dilated cardiomyopathy and severe aortic valve disease on cerebral blood flow. Cerebral perfusion was determined in 39 healthy volunteers representing two control groups of different age (77.7 +/- 8.7; 79.7 +/- 8.1 ml/100 g/min), in 7 patients with dilated cardiomyopathy (64.0 +/- 4.7 ml/100 g/min), in 11 patients with severe aortic stenosis (71.1 +/- 14.8 ml/100 g/min), and in 6 patients with severe aortic regurgitation (54.6 +/- 5.8 ml/100 g/min). Regional cerebral blood flow was measured with the 133Xenon inhalation method. Cerebral blood flow in severe aortic regurgitation patients (p = 0.006) was markedly and significantly reduced versus controls, whereas in dilated cardiomyopathy patients (p = 0.197) and in patients with severe aortic stenosis (p = 0.111) cerebral blood flow was not significantly reduced. A chronic adaptation of cerebral blood flow to the profound reduction of cardiac output is assumed in dilated cardiomyopathy patients. The collapsing pulse and the maximal reduction of mean arterial blood pressure in severe aortic regurgitation patients cause the reduction of autoregulatory capacity of cerebral blood flow with subsequent decrease of brain perfusion. Measurement of cerebral blood flow appears to be suitable for evaluation of perfusion deficits due to cardiac abnormalities. It provides an additional parameter for estimating the indication of valve replacement in patients with aortic valve disease.
Adult↗
Doppler echocardiographic study of pulmonary venous flow in mitral stenosis and early after mitral valve replacement.
The aim of the study was Doppler echocardiographic assessment of the effect of mitral stenosis (MS) on pulmonary venous flow (PVF), and of any changes occurring after mitral valve replacement. Fifty patients with MS (22 in atrial fibrillation (AF)) and 28 healthy subjects (control group) underwent transthoracic echocardiographic evaluation of PVF. Fourteen of the 22 patients in AF were submitted in addition to transesophageal echo study before and after mitral valve replacement. Pulmonary wedge pressure was measured in 18 patients. Patients in sinus rhythm (SR) and more than mild MS showed significantly decreased peak velocity and flow velocity time integral of the systolic forward PVF. This finding was more exaggerated in MS with AF. Concerning diastolic forward PVF, patients in SR showed significantly decreased peak velocity and velocity time integral, irrelevant of the degree of MS, while patients with AF exhibited adequate signs of flow. In all patients duration, deceleration time (D-DT) and pressure half-time (D-PHT) of the diastolic forward PVF were significantly increased. The last two parameters correlated with the corresponding variables of mitral flow and with echocardiographically determined mitral valve area and the D-DT of the pulmonary wedge pressure. Concerning reversed PVF, patients with more than mild MS exhibited significantly increased peak velocity and velocity time integral. After mitral valve replacement, a significant increase of diastolic forward peak velocity and velocity time of the PVF were detected. The duration of diastolic forward peak velocity of PVF, D-DT and D-PHT decreased. The systolic forward phase did not change significntly after the valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Hemodynamics effects of continuous infusion of molsidomine and nitrates and subsequent oral medication in therapy of acute myocardial infarct].
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Administration, Oral↗
Echocardiographic profile of the normally functioning Omnicarbon valve.
Transthoracic echocardiography was performed in 141 patients with 90 Omnicarbon valves in the aortic and 66 in the mitral position. Additionally, 53 of them were investigated by transesophageal echocardiography comparing monoplane and multiplane facilities. The opening direction of the disc and the location of the pivot axis could be correctly determined by transthoracic, monoplane, and multiplane transesophageal echocardiography, respectively, in 100%, 80%, and 100% of the mitral and in 53%, 21%, and 82% of the aortic prostheses. Small regurgitation jets were detected in 90% of the aortic valves (1.6 +/- 0.4 cm2) by transthoracic and in all mitral prostheses (2.3 +/- 0.8 cm2) by transesophageal echocardiography. Based on morphological identification of the pivot points structures, origins of leakage jets were clearly identified as "design-related" in 12% (transthoracic echocardiography of aortic valves) to 100% (multiplane transesophageal echocardiography of mitral valves). In the aortic position, values obtained for transprosthetic forward flow velocity measurements exhibited wide scatter which did not allow a firm separation between valve sizes. No better differentiation was possible by using the calculated Doppler gradients or the velocity time integrals, either. Mean gradients and velocity time integrals showed even smaller differences between groups in the mitral valve patients. It is concluded that the Omnicarbon valve has a suitable design for morphological echocardiographic examination, and multiplane transesophageal technique expands the diagnostic capability. Forward flow measurements do not appear to be suited for detecting a beginning obstruction of this mechanical prosthesis.
Adult↗
[Effect of nisoldipine and diltiazem on systolic and diastolic function of the left ventricle in patients with coronary heart disease].
OBJECTIVES AND BACKGROUND: Calcium channel blockers have a negative inotropic effect and protract the relaxation of the normal myocardium. These effects may vary in patients with coronary artery disease (CAD) and with the different kinds of calcium antagonists. In the present study we therefore compared the hemodynamic effects of intravenously given equihypotensive dosages of diltiazem (D) and nisoldipine (N) in patients with CAD. METHODS AND RESULTS: Each group contained 10 patients. After administration of a bolus of 300 micrograms/kg (D) and 5 micrograms/kg (N) respectively and following continuous infusion of 5.4 micrograms/kg/min (D) and 0.2 micrograms/kg/min (N) respectively, the mean arterial pressure was reduced by 15.5 +/- 6.0 (D) and 16.6 +/- 4.1 (N) mm Hg. Atrial pacing was performed in all patients to avoid reflectory heart rate effects. The pulmonary artery pressure decreased slightly with both drugs, whereas the cardiac index increased only with the use of N from 3.44 l/min x m2 to 3.93 l/min x m2. A significant change in the maximal rate of rise of left ventricular pressure (dP/dt max) as an index for inotropy was not detected for N or for D. The parameters of the diastolic function (the time constant of ventricular relaxation (tau) and the maximum rate of left ventricular isovolumic pressure decline (dP/dt min)) also did not indicate unequivocal drug effects. Doppler echocardiography of the mitral valve flow was performed simultaneously with invasive pressure measurements. The flow propagation derived from the color-M-mode correlated significantly with tau and was slightly improved by D.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Semiquantitation of aortic regurgitation by pulsed Doppler examination of the subclavian artery velocity contour.
The reflux of aortic regurgitation causes an increased and longer diastolic reverse flow in the aorta and its branching vessels as compared to the normal flow contour. The changes of the aortic flow are related to the severity of aortic regurgitation and can be demonstrated by Doppler ultrasound. As Doppler examinations are often restricted in the aorta, a prospective study was designed to determine the feasibility and accuracy of Doppler measurements in the subclavian artery for the identification of severe forms of aortic regurgitation. Fifty-five patients with and 40 patients without aortic regurgitation were examined both by aortography and pulsed Doppler flow analysis of the subclavian artery. Two age groups were differentiated: patients below and those over 60 years of age, respectively. A high quality Doppler signal was recorded in all patients. In patients below 60 years, the best predictors of severe aortic regurgitation proved to be a pandiastolic reverse flow and an increased regurgitant fraction (77%) with a sensitivity of 100% and specificity of 75% and 92%, respectively. Since a pandiastolic reverse flow was detected in most patients in the control group over 60 years, it was not indicative of aortic regurgitation in these cases. However, an increased maximal diastolic velocity (> -37 cm/s) identified severe forms of aortic regurgitation in this age group with a sensitivity of 89% and a specificity of 100%. Therefore, severe forms of aortic regurgitation may be reliably identified by analysing the subclavian artery Doppler spectrum. In conclusion, the method is a useful adjunctive technique to other Doppler echocardiographic methods to assess the severity of aortic regurgitation.
Adult↗
[The diagnosis of mitral valve insufficiency by echocardiography].
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Echocardiography↗
[Doppler echocardiography imaging of construction-induced regurgitation of technical heart valve prostheses].
The normal leakage flow in modern technical heart valve prostheses can be visualized by color-coded Doppler-echocardiography, provided that an adequate ultrasonic image quality can be achieved. Sometimes it may be difficult, however, to distinguish such a normal leakage flow from pathological regurgitation. We therefore mounted new specimens of five different types of prostheses (Bjørk-Shiley monostrut, Medtronic-Hall, Omnicarbon, Saint Jude Medical, Duromedics) into an invitro model, where the leakage flows could directly be visualized as emerging water jets. When the system was completely filled, the jets could also be registered by two-dimensional Doppler-echocardiography. For each valve, characteristic patterns for the localization of the principal jets were found. Besides the relative broad central jet in the Medtronic-Hall valve, all other jets arose mainly at the ring. They were detected at the hinges or the basis of the larger struts, respectively, and with asymmetrical mono-disc valves at the side of the smaller opening. The length and the orientation of the jets were found to change significantly with minimal variations of the position of the closing discs. This variability could be confirmed, when in a separate model the overall leakage flows were repeatedly measured. For patient examinations it seems useful to refer mainly to the localization of the jet origins. The comparison with reference values of jet-dimensions in Doppler images will rarely enable the examiner to distinguish between normal and pathological jets.
Echocardiography, Doppler↗
[Doppler echocardiographic determination of the effective orifice area of mechanical heart valve prostheses in a flow model].
In a flow model the effective orifice areas (Ae) of 17 mechanical heart valve prostheses were determined. We measured the Ae-values of several sizes of three types of mechanical prostheses (Medtronic-Hall, St. Jude Medical, and Omnicarbon) under quasi-steady flow conditions using the continuity equation: Ae = flow/maximal transprosthetic velocity. The flow through the model could be determined exactly by directly measuring the decreasing fluid level within the feed tank, while the maximal velocities were calculated from CW-Doppler echocardiographic spectra. It was found that 1) over a range of 200-800 cm3/s Ae was constant for all prostheses and 2) in small aortic prostheses the Ae could be determined with only little scattering of the obtained values, while in large mitral prostheses there was a considerable variation within the results of repeated investigations. For example, in the 21- and 31-Omnicarbon-valves mean values of Ae were calculated as 1.41 and 4.03 cm2, respectively, with standard deviations of 0.05 and 0.49 cm2 as a result of about 70 single calculations in each valve. 3) The absolute values of Ae were smaller than those of comparable in vitro studies based on the Gorlin formula. We conclude that the effective orifice areas of prosthetic heart valves can be easily determined in a flow model by the combination of flow and Doppler echocardiographic measurements. As determinations are based on the same principle, the obtained values should clinically be referred to patients where the corresponding continuity equation for pulsatile flow is used as Ae = stroke volume/time integral of the maximal transvalvular velocity.
Aortic Valve↗