Real-time three-dimensional echocardiography in diagnosis of right ventricular pseudoaneurysm after pacemaker implantation

Right ventricular rupture is a critical cardiac complication associated with cardiac tamponade and death. Occasionally, the site of rupture may be contained by the parietal pericardium and thrombus, thus forming a pseudoaneurysm. Cases of traumatic pseudoaneurysm of the right ventricle have been reported. However, right ventricular pseudoaneurysm following pacemaker implantation has not been previously reported. This case demonstrates two right ventricular pseudoaneurysms following perforation of the right ventricular wall using real-time three-dimensional echocardiography (3DE) after pacemaker implantation although only one definite pseudoaneurysm was diagnosed by routine two-dimensional echocardiography (2DE). We also found that color Doppler 3DE enhanced visualization of the connections between the right ventricle and the pseudoaneurysm. Color Doppler 3DE allowed us to peel away the myocardial tissue and rotate the image to study the jets from different angles. In summary, real-time 3DE and color Doppler 3DE provided excellent visualization of the right ventricular pseudoaneurysm, flow between the ventricle and the pseudoaneurysm, and additional information to that obtained by 2DE.     

Reproducibility of Transmitral Pulsed Doppler Parameters of Left Ventricular Filling During Dobutamine Stress Test

The aim of this study was to investigate the reproducibility of transmitral Doppler parameters of left ventricular filling in subjects undergoing dobutamine stress and to estimate threshold values, which can be used as a reference to detect significant changes in Doppler measurements from baseline to peak dobutamine in an individual patient. The study groups included 11 male volunteers and 26 patients with coronary artery disease. Intra-and interobserver tests were performed on 14 randomly selected tracings. The random variation of measurements (beat-to-beat variations plus random observer error) was estimated at baseline and peak dobutamine both in normals and patients. The parameters studied were: peak early (E) and atrial (A) filling velocities and their ratio (ElA), early filling acceleration (E-AC) and deceleration (E-DC) rates, and diastolic time-velocity integral (TVI). Intra-and interobserver mean differences were generally small (lt; 5%) with the largest found in the interobserver differences in E-AC (12%) and TVI (7%). The random variation of measurements at baseline were similar in normals and patients with the smallest (lt; 5%) variation in E and the largest in E-AC (12%) and El A (8%). There was a significant (P lt; 0.01) increase in the coefficient of variation from baseline to peak dobutamine for E (4.5% vs 7.6%), E-AC (11% vs 14.8%), and E-DC (6.5% vs 9.3%) in the patient group. The threshold values were calculated based on the random variation in a single patient and with the assumption that 3, 5, or 8 beats were analyzed at both instances. Conclusions: When Doppler evaluation of left ventricular filling is used during dobutamine stress, the following points should be considered: (1) peak E has the smallest variability among Doppler indices that assess early filling phase; (2) the variability of Doppler measurements of early filling increases with stress intervention in patients with CAD; (3) increasing the number of beats averaged from 3–8 reduces the threshold needed to decide significant differences in Doppler measurements between baseline and peak dobutamine by more than the half.     

The role of Doppler echocardiography in the diagnosis, follow-up, and management of ventricular septal defects

The defects of the ventricular septum have received special attention from investigators working in echocardiography. The method showed an incomparable capability to identify all the morphological features of the defects. The increasing improvement in definition of transducers associated with conventional and color Doppler contributed significantly to the reliability to detect most of the defects. The great majority of associated lesions can be easily identified and serial examinations allow prediction of which defect may become smaller or even close spontaneously as well as which have acquired deleterious changes in the heart. Several authors have shown very good statistical correlations between echocardiographic indices and hemodynamic parameters in patients with this type of defect. Doppler echocardiography has become an invaluable tool in the diagnosis and follow-up of ventricular septal defect reducing the need for cardiac catheterization and helping management of these patients.     

L wave in echo Doppler

62-Year-old female presented with progressive dyspnea NYHA class III for six months. Echocardiography showed normal left ventricular (LV) systolic function, mild biatrial enlargement, an L wave in pulse wave Doppler at mitral inflow and in M mode echocardiography across mitral valve. Tissue Doppler imaging at medial mitral annulus showed an L′ wave in mid diastole in addition to E′ and A′ wave. An L wave in pulse wave Doppler and M mode echocardiography represents continued pulmonary vein mid diastolic flow through the left atrium in to LV across mitral valve after early rapid filling. Presence of an L′ wave in these patients associated with higher E/E′ is indicative of advance diastolic dysfunction with elevated filling pressures.     

Color Doppler echocardiography in the diagnosis of aortic dissection and aortic wall abscesses

In eleven patients with aortic dissection or perforated endocarditic aortic wall abscess cavity, the diagnostic usefulness of Color Doppler Echocardiography (CDE) for the identification of true and false lumen as well as the perforation jet was assessed by comparison with the findings of angiography, digital subtraction angiography, computed tomography and surgery. The information gained in addition to that of these procedures, as well as to that of the four conventional echocardiographic techniques was evaluated. Six patients had aortic dissections of DeBakey type I or III; in all of them the diagnosis had been established with conventional ultrasonic techniques. Similarly, in all patients with aortic dissection of DeBakey type I, a clear differentiation between true and false lumen in the aortic root and ascending aorta could already be made by grey-scaled echocardiography. In these patients, however, CDE made the additional demonstration of the perforation jet into the false lumen possible. In those three patients with aortic dissection of DeBakey type III as well as in the abdominal aortic region of DeBakey type I, color Doppler echocardiography was the only method to define true and false lumen and to clearly localize the perforation sites. Two further patients were found to have a small, local dissection, which could only be assumed by conventional echocardiography; the color Doppler M-mode image led to a clear diagnosis. In three patients an endocarditic abscess cavity of the aortic wall could be detected by conventional echocardiography. Two-dimensional color Doppler echocardiography additionally enabled us to visualize the presence and the course of perforation flows. In two patients color-coded Doppler echocardiography made it possible to detect perforations in regions which could not be localized either with conventional echocardiographic techniques or the above-mentioned control procedures.     

Diagnosis of mitral valve perforation by real-time two-dimensional Doppler flow imaging technique

It has been difficult to diagnose mitral regurgitation due to valve perforation using either noninvasive or invasive methods, differentiating it from that resulting from incomplete coaptation of the mitral valve. This report describes three patients with infective endocarditis and mitral valve perforation, which was definitively diagnosed by the real-time two-dimensional Doppler flow imaging technique. In these three patients, B-mode echocardiography demonstrated an echo interruption on the anterior mitral leaflet. However, it was not certain whether this interruption was simply an echo dropout or indicated an interruption of the valve tissue. Doppler flow imaging then demonstrated unusual flow in the vicinity of the echo interruption, which appeared to flow from the left ventricular cavity into the left atrial cavity across the midportion of the anterior mitral valve leaflet during systole and in the opposite direction during diastole. This was interpreted as mitral valve perforation. In general, Doppler flow imaging may play a complementary role with B-mode echocardiography in cardiac diagnosis.     

Changes in tissue Doppler characteristics in a patient with pulmonary atresia and intact ventricular septum

Tissue Doppler measurements of the right and left lateral ventricular walls were made before and after perforation of the pulmonary valve using radiofrequency energy in a patient with pulmonary atresia and intact ventricular septum. The ratio of peak tissue velocity during rapid ventricular filling to atrial contraction increased for both atrioventricular valves after perforation of the pulmonary valve, and the patient was able to be weaned off prostaglandins without further intervention. Such measurements made using tissue Doppler may aid in the management of patients with pulmonary atresia and intact ventricular septum by predicting improvements in right ventricular relaxation.     

Radiofrequency perforation of the right ventricular outflow tract as a palliative strategy for pulmonary atresia with ventricular septal defect.

BACKGROUND: Radiofrequency perforation (RF) of the right ventricular outflow tract (RVOT), while an effective management strategy in children with an intact ventricular septum, has not been fully detailed in those presenting with a ventricular septal defect. OBJECTIVE: To determine whether transcatheter perforation of the atretic pulmonary valve is an acceptable management strategy prior to surgical repair. RESULTS: Valve perforation was attempted in eight children seen between May 2000 and March 2006, five being infants between 1 and 9 days of age. In five children, this was the first of two procedures, the second a planned surgical correction. The RF was successful in six children with one child requiring additional stenting of the RVOT. Of these children, three attained a biventricular repair within the next year without additional palliative surgical procedures. Of the remaining three patients, one is awaiting surgical correction, one did not require further surgery, and one had this procedure as the only planned palliation. The two children in whom RF was not possible were referred for surgical augmentation of pulmonary blood flow. CONCLUSION: A treatment strategy that includes pulmonary valve perforation as initial palliation to increase pulmonary blood flow may be effective. Additional experience to better define those children who would benefit from this treatment algorithm is required.     

Doppler transmitral and pulmonary venous flow in young orienteers and sedentary young adults

Doppler filling indices may provide important information on left ventricular diastole and possibly diastolic adaptation in endurance athletes. We therefore undertook a comparative study to obtain reference values for transmitral and pulmonary venous Doppler flow velocities and to characterize differences between young orienteers and young sedentary adults. Seventy-six elite orienteers (42 female and 34 male; 17-30 years old) and 61 sedentary young subjects (32 female and 29 male; 17-33 years old) underwent echocardiography. No significant differences between the athletes and sedentary controls regarding peak transmitral flow were found, although the athletes had significantly higher peak pulmonary flow velocity during diastole than the sedentary controls (0.69+/-0.13, 0.61+/-0.10, 0.78+/-0.12, and 0.57+/-0.09 m/sec for female athletes, female sedentary controls, male athletes, and male sedentary controls, respectively). Because no significant differences were revealed in the transmitral flow velocities between the athletes and the sedentary subjects, the relative force between the left atrium and the left ventricle should not diverge during early filling. An increase in pulmonary venous pressure or a decrease in left atrial pressure can augment the force between the pulmonary veins and the left atrium. A rise in pulmonary venous pressure is a hemodynamically unlikely adaptation in endurance athletes; therefore, to maintain the same transmitral pressure with an assumed lower left atrial pressure, the data suggest a more rapid relaxation and an improved left ventricular elastic recoil, which would enable the athletes to achieve a more rapid negative left ventricular pressure change during early filling.     

Mitral perforation: a rare cause of congenital mitral regurgitation

In a 4-year-old boy with severe mitral regurgitation, cross sectional echocardiography combined with Doppler interrogation confirmed the presence of isolated perforation of the aortic leaflet of the mitral valve. The perforation was closed with a patch of fresh autologous pericardium. Serial echocardiograms taken postoperatively showed no regurgitation across the mitral valve.     

多普勒组织成像与脉冲多普勒方法对比评价高血压患者舒张功能

目的应用脉冲多普勒组织成像测量二尖瓣环平均舒张速度,以鉴别高血压患者舒张功能假性正常。方法在健康者(正常组200例)与高血压患者(高血压组47例)中,应用脉冲多普勒技术分别测量二尖瓣口舒张早期峰值速度(E)、舒张晚期峰值速度(A),肺静脉收缩波(S)、舒张波(D)及心房收缩波(Ar)。应用脉冲多普勒组织成像测量二尖瓣环各点舒张早期峰值速率(Ea)、舒张晚期峰值速率(Aa)。结果正常组与对照组患者二尖瓣E、A、E/A差异无显著性意义,肺静脉S、S/D、Ar差异有显著性意义,二尖瓣环平均Ea间差异有显著性意义,Aa间差异无显著性意义。结论二尖瓣环舒张早期速率可用于鉴别高血压舒张功能假性正常。     

Sensitivity of the Doppler rate of pressure rise to changes in the inotropic state: an experimental comparison with invasively obtained dP/dt.

AIMS: To investigate the sensitivity of the rate of pressure rise obtained by Doppler to changes in the inotropic state by comparing it to simultaneous invasive measurements of dP/dt under different conditions of contractility. METHODS AND RESULTS: Mitral regurgitation was provoked in five pigs, and simultaneous measurements of dP/dt and the Doppler-estimated rate of pressure rise were made with a micro-manometer and with continuous-wave Doppler. Changes in the inotropic state were induced by drug infusion and by ischaemia. One hundred and twenty-seven simultaneous measurements were made with a correlation coefficient between the Doppler-estimated rate of pressure rise and dP/dt of 0.85 (P<0.001). Sensitivity to inotropic changes was estimated as the percentage change of each parameter in each condition of contractility, and showed that the Doppler-estimated rate of pressure rise had better sensitivity than dP/dt. CONCLUSION: The sensitivity of Doppler-estimated rate of pressure rise to changes in the inotropic state is greater than that of dP/dt. The correlation between the rate of pressure rise obtained by Doppler and dP/dt is maintained even in extreme conditions of contractility. Therefore, the rate of pressure rise can be considered a good parameter to assess linear changes of contractility.     

Transcatheter repair of iatrogenic left ventricular free-wall perforation.

Left ventricular free-wall perforation can complicate catheter-based diagnostic or interventional procedures and may require immediate needle pericardiocentesis followed by surgical repair in about 20% of the cases. We describe the transcatheter closure of a left ventricular free-wall perforation as an option in the event of maintained access to the perforation site after defect creation.     

Assessment of Left Ventricular Systolic Function Using Color-Coded Tissue Doppler Echocardiography

Tissue Doppler echocardiography can be used to measure myocardial velocity data by using the Doppler shift data of ultrasound waves. Two methods have recently been described to calculate velocity data: pulsed tissue Doppler and color-coded tissue Doppler. This article focuses on color-coded tissue Doppler data to evaluate left ventricular systolic function. Technical considerations and validation studies are reviewed. Potential clinical applications of color-coded tissue Doppler are presented, including dobutamine stress echocardiography, assessment of left ventricular ejection dynamics using mitral annular velocity, and tissue Doppler assessment of cardiac transplant rejection.     

经胸多普勒超声心动图半定量评估左室舒张末压

目的 :探讨经胸多普勒超声心动图半定量评估左室舒张末压 （L VEDP,EDP）的有效指标。方法 :对 88例患者由左心导管介入性检测 L VEDP,经胸多普勒超声心动图记录二尖瓣及肺静脉血流参数。以 EDP实测值作为金标准 ,进行无创与有创性检测的对比研究。结果 :直线相关分析显示 ,肺静脉 A波与二尖瓣 A波时限差值 （PAd- Ad）与 EDP相关最佳 （r=0 .73,P<0 .0 1） ;肺静脉 A波时限等于或超过二尖瓣 A波时限 （即 PAd- Ad≥ 0 ）估测 EDP≥15 m m Hg（1mm Hg=0 .133k Pa）的敏感性为 85 .1% ,特异性为 90 .2 % ,阳性预测值为 90 .9% ,阴性预测值为84.1%。结论 :由多普勒超声心动图血流参数 PAd- Ad≥ 0可作为临床判断 L VEDP≥ 15 mm Hg的一项简便而可靠的半定量指标。     

Contribution of long axis motion of left ventricular outflow to calculation of left ventricular stroke volume

Stroke volume can be calculated by using noninvasive Doppler techniques. The products of pulsed Doppler stroke distance of left ventricular outflow and left ventricular outflow area can often be used to calculate stroke volume. However, left ventricular outflow also moves longitudinally toward the apex of the ventricle during systole, so that zero velocity flow cannot be detected by the usual pulsed Doppler studies. We evaluated the contribution of these zero velocity flow to the noninvasive estimation of left ventricular stroke volume in 20 patients with left ventricular disease and in 20 age matched healthy controls. Left ventricular stroke distance was calculated by summing the Doppler stroke distance and the outflow long axis motion. The percentage of zero velocity flow for total stroke volume was calculated in each group. Cardiac output was also measured by thermo-dilution technique. The percentage of zero velocity flow for total noninvasive stroke volume in patients with left ventricular disease was 2.5±1.1 ml (4.0±1.5%), significantly lower than in normal subjects, 3.6±1.0 ml (5.5±1.5%) (p<0.05). These long axis motions are significantly reduced, especially in left ventricular disease. Amplitudes of the left ventricular outflow long axis motion were correlated with Doppler stroke distance in all (r=0.54, p<0.01). In patients with myocardial infarction, stroke volume by thermo-dilution methods and calculated stroke volume showed good correlation both only by Doppler stroke distance (y=1.044x+0.547, r=0.968) and by Doppler and long axis motion (y=0.989x+0.521, r=0.974). Compared with stroke volume measured by thermodilution method, stroke volume calculated only by Doppler stroke distance was underestimated. We thus demonstrated the influence of zero velocity flow on left ventricular outflow both in patients with left ventricular disease and in normal subjects.     

组织多普勒成像评价老年单纯舒张功能不全患者左心室收缩功能的变化

目的采用组织多普勒(TDI)成像技术评价老年单纯舒张功能不全患者左心室长轴收缩功能的变化。方法选取老年无症状舒张功能不全患者(老年ADD组)157例、老年舒张性心力衰竭患者(老年DHF组)130例及健康老年人(正常对照组)89例,应用TDI成像技术测量二尖瓣环水平左心室室间隔、侧壁、前壁、下壁心肌长轴方向收缩期心肌峰值运动速度(Sm);Simpson法测量左心室射血分数(LVEF)。结果与正常对照组比较,老年ADD组与老年DHF组二尖瓣环水平心肌侧壁、前壁、下壁Sm值、Sm均值及老年DHF组室间隔Sm值显著降低(P<0.05~0.001),且老年DHF组Sm值降低幅度更大(P<0.05~0.001)。结论老年单纯舒张功能不全患者存在左心室长轴收缩功能降低,Sm较LVEF能更敏感地检测到轻度收缩功能不全的存在。     

Newer doppler measures of left ventricular diastolic function

Left ventricular (LV) diastolic dysfunction is an important cause of heart failure, and recent advances in the application of Doppler techniques allow a semiquantitative assessment of LV diastolic performance. This review discusses the use of Doppler echocardiography in the comprehensive assessment of LV diastolic function and performance in terms of the normal mitral and pulmonary venous flow profiles, their physiologic basis, and alteration in diseased states. There is also a discussion on the newer aspects of mitral flows such as relative durations of mitral A and pulmonary vein AR waves, E- and A-wave propagation inside the LV with their hemodynamic correlates, and derivation of ventricular dP/dt and Tau from the mitral regurgitation velocity profile. Analysis of these flow profiles and the other Doppler measures alluded to above allow one to make a fairly precise hemodynamic assessment of a patient in terms of left atrial pressure, LV relaxation and stiffness and the profile of LV diastolic pressure in terms of pre-‘a’ wave and ‘a’ wave pressures and ventricular end-diastolic pressure.     

Doppler evaluation of left ventricular filling: effect of verapamil on non-obstructive hypertrophic cardiomyopathy

Impaired left ventricular (LV) filling is known to be a major determinant of non-obstructive hypertrophic cardiomyopathy (HCM). Seventeen patients with non-obstructive HCM (mean age 71 years) were investigated by Doppler echocardiography, before and after oral treatment with verapamil (mean daily doses: 335 mg). Diagnosis was based on clinical and echocardiographic data. Mitral regurgitation was absent or mild. Heart rate, PQ interval and mitral regurgitation did not change after treatment. All calculated values of Doppler LV filling improved significantly: corrected relaxation time, ratio of atrial to early velocity, EF slope and pressure half-time (P less than 0.005) showed more significant differences than more sophisticated indices using time-velocity integrals of Doppler LV filling flow (P less than 0.005). Results appear to reflect an effect of verapamil on LV relaxation; a slight effect of a modified load was nevertheless not excluded. We conclude that all parameters of Doppler LV filling show marked improvement in this elderly group with non-obstructive HCM, after oral verapamil. Doppler echocardiography is an easy and useful clinical method to assess the effect of a drug on ventricular relaxation of non-obstructive HCM.     

单纯急性下壁心肌梗死及其合并右心室心肌梗死对右心长轴功能的影响

目的应用心肌组织多普勒技术结合M型超声心动图,评价单纯急性下壁心肌梗死及其合并右心室心肌梗死对右心室长轴功能的影响。方法选择首次急性下壁心肌梗死患者28例,分为单纯急性下壁心肌梗死18例(Ⅰ组),急性下壁心肌梗死伴右心室心肌梗死10例(Ⅱ组),另选健康体检者20例(Ⅲ组)。在标准心尖四腔心切面二维图像指引下,应用M型超声记录右心房室环右心室游离壁及中心纤维支架处运动曲线,测量收缩期、舒张早期、舒张晚期最大运动幅度(SD,DED,DAD)及收缩期、舒张早期、舒张晚期平均运动速度(SMV,DEMV,DAMV),计算DED/DAD比值。心肌组织多普勒记录该处运动速度曲线,测量上述各期最大运动速度(Sm、Em、Am)及Em/Am比值。结果与Ⅲ组比较,Ⅰ组和Ⅱ组右心房室环右心室游离壁处SD、DED、DED/DAD、SMV、DEMV、Sm及Em均明显下降。DAD、DAMV、Am虽有下降,但差异无统计学意义。结论急性下壁心肌梗死无论是否合并右心室心肌梗死均可影响右心室长轴功能,导致右心室整体功能降低。