解剖M型超声心动图评价经皮腔内冠状动脉成形术及支架置入术的临床疗效

目的 解剖M型超声心动图(AMM)评价经皮腔内冠状动脉成形术(PTCA)及支架置入术前后左室室壁运动的改变.方法 本组45例,为进行冠状动脉左前降支(LAD)PTCA的患者,在手术前72 h、术后72 h以及3个月时分别进行超声心动图检查,AMM测量左室短轴基底段(二尖瓣水平)和中段(乳头肌水平)前间隔、前壁的收缩期增厚率及室壁运动幅度.结果 45例患者术后72 h及术后3个月检查显示,LAD对应节段(前壁和前间隔)的收缩期增厚率及室壁运动幅度均较术前显著增高(P＜0.05,P＜0.01).结论 PTCA及支架置入术能迅速改善狭窄冠状动脉供血区域的室壁运动且采用AMM测量对应室壁节段的收缩期增厚率及室壁运动幅度能准确评价PTCA及支架置入术的疗效.     

Two-dimensional and M-mode echocardiography of the fetal coronary sinus.

OBJECTIVE: To document fetal coronary sinus dimensions in normal pregnancy. METHODS: Two hundred and sixty-five normal fetuses in which congenital cardiac defects had been excluded were examined cross-sectionally between 21 and 38 weeks of gestation. From the apical or basal four-chamber view the transducer was tilted towards the inferior cardiac surface in order to visualize the coronary sinus by real-time ultrasound. Maximum systolic and diastolic diameters were measured using M-mode. Reference ranges were constructed and the ratio of systolic and diastolic diameters calculated. Data from two fetuses, one with supraventricular tachycardia and a second one with hydrops secondary to anemia, were also compared. RESULTS: Visualization and measurement of the coronary sinus were successful in 258 (97.4%) patients. The coronary sinus systolic and diastolic diameters increased significantly with gestational age (maximum systolic diameter, 1.6 mm at 21 weeks to 4 mm at 38 weeks; maximum diastolic diameter, 0.9 mm at 20 weeks to 2.2 mm at 38 weeks). The ratio of systolic to diastolic diameters remained relatively constant (range, 1.7-2.1) and therefore was unrelated to gestational age. In the fetuses with supraventricular tachycardia and hydrops, both diameters of the coronary sinus were increased and diminished fluctuation in size during the cardiac cycle was observed. CONCLUSIONS: The described sonographic approach provides an effective method for measurement of coronary sinus dimensions. The normative data may facilitate the detection of coronary sinus dilation as an indirect marker for abnormalities in venous return to the heart.     

Diagnosis of subarachnoid hemorrhage indicated by transthoracic echocardiography.

We report the case of a 63-year-old woman who presented to her local emergency department unresponsive and in a state of cardiogenic shock 4 hours after the sudden onset of a severe headache. Her electrocardiogram revealed nonprogressive 1-mm S-T elevation in leads V(5) to V(6) and a prolonged QTc. A transthoracic echocardiogram performed at the time of her resuscitation revealed regional wall-motion abnormalities not consistent with any known coronary artery territory but consistent with a diagnosis of acute subarachnoid hemorrhage. This diagnosis was subsequently confirmed on computed tomography brain imaging. Although subarachnoid hemorrhage is known to be associated with cardiopulmonary dysfunction, and electrocardiogram and echocardiogram abnormalities, the diagnosis of subarachnoid hemorrhage suspected by echocardiography before brain imaging has not previously been described.     

Induction of wide QRS tachycardia during transthoracic echocardiography.

A wide QRS tachycardia was repeatedly triggered during transthoracic echocardiographic examination in a critically ill premature infant with bilateral chest tubes. The left-sided tube was anterior to the heart. The arrhythmia was not induced after removal of the chest tubes at the follow-up ultrasonographic evaluation. Compression of the thoracic wall and chest tube, and subsequently the heart, by the ultrasound transducer is postulated as the cause for this wide QRS tachycardia.     

Detection of prosthetic mitral valve leak: a comparative study using transesophageal echocardiography, transthoracic echocardiography, and auscultation

Paravalvular leakage is a major complication of prosthetic valve dysfunction. Sixty-one subjects with valvular heart disease who had received prosthetic mitral valve replacement 5 months to 5 years before (43 received a porcine prosthesis and 18 received Bjork-Shiley valve prostheses) were evaluated for this complication. Careful auscultation was performed by two experienced cardiologists followed by transthoracic and transesophageal echocardiography. Physiologic leaks were detected in all Bjork-Shiley valves, but in only 30% of porcine valves using transesophageal echocardiography. These regurgitant jets were flame-like, with mean low velocities of 50 +/- 12.3 cm/sec and 48 +/- 18.2 cm/sec in the two types of valves. Neither transthoracic echocardiography nor auscultation could detect physiological regurgitant jets. Ten cases with paravalvular leak were detected by transesophageal echocardiography and subsequently demonstrated by left ventriculography (7 porcine, 3 Bjork-Shiley valves). Pathologic regurgitant jets were seen as high-velocity, systolic-retrograde turbulent flow across the prosthesis. However, only 6 cases of prosthetic valve dysfunction were detected by transthoracic echocardiography, 4 cases of mild paravalvular leakage went undetected. Thirteen of the 61 subjects had an apical systolic murmur and suspected prosthetic valve leakage; in 10 of the 13 cases the findings corresponded to those obtained by transesophageal echocardiography. In 3 cases of double valve replacement with Bjork-Shiley valves the magnitude of the leakage was overestimated by auscultation.     

Demonstration of coronary artery flow using transthoracic Doppler echocardiography.

Transthoracic Doppler echocardiography is emerging as a promising method for evaluating coronary artery disease. After a period of training, detection and measurement of distal left anterior descending coronary artery flow with transthoracic Doppler echocardiography is feasible in more than 90% of the patients. Using transthoracic Doppler echocardiography with a high-frequency transducer and special setting of low Nyquist limits, pathologic coronary flow dynamics can be demonstrated. Measurement of coronary flow reserve may impact diagnosis or clinical treatment in those: (1) with anginal chest pain and angiographically normal coronary arteries; (2) with intermediate-grade coronary obstruction where the physiologic significance is in doubt; and (3) who have had an attempt at revascularization and the effectiveness of the therapy is uncertain.     

Multi-view approach for the diagnosis of pulmonary hypertension using transthoracic echocardiography

Pulmonary hypertension (PH) is a disease with severe morbidity and mortality. Echocardiography plays an essential role in the screening of PH. The quality of the acquired continuous wave Doppler signal is the major limitation of the method and can greatly affect the accuracy of estimated pulmonary pressures. The aim of this study was to evaluate the clinical need to image from multiple ultrasound windows in patients with suspected pulmonary hypertension. We prospectively evaluated 65 patients (43% male, mean age 67.2 years) with echocardiography and right heart catheterization. 17% had invasively normal pulmonary pressures, 83% had pulmonary hypertension. Peak tricuspid regurgitation (TR) velocity was imaged in five echocardiographic views. Sufficient Doppler signal was recorded in 94% of the patients. Correlation for overall peak TR velocity with invasively measured systolic pulmonary artery pressure was r?=?0.83 (p?<?0.001). Considering all five imaging windows resulted in a sensitivity of 87%, and a specificity of 91% for correct diagnosis of PH with an AUC of 0.89, which was significantly better as compared to sole imaging from the right ventricular modified apical four-chamber view (AUC 0.85, p?=?0.0395). Additional imaging from atypical views changed the overall peak TR velocity in 32% of the patients. A multiple-view approach changed the echocardiographic diagnosis of PH in 11% of the patients as opposed to sole imaging from an apical four-chamber view. This study comprehensively assessed the impact on clinical decision making when evaluating patients with an echocardiographic multiplane approach for suspected PH. This approach substantially increased sensitivity without a decrease in specificity.     

Comparison of left atrial dimensions by transesophageal and transthoracic echocardiography.

Left atrial (LA) size, as determined by transthoracic echocardiography (TTE), predicts the risk of atrial fibrillation and stroke and the success of cardioversion. Transesophageal echocardiography (TEE) is increasingly used in these clinical situations. However, unlike TTE, measurement of LA size by TEE has not been standardized. To validate TEE measurement, we determined LA dimensions in 4 standard views by TTE at the same time in 121 patients undergoing TEE. The mid-esophageal basal short-axis view at the level of the aortic valve (TEE 30-60) was the only view in which complete visualization of a LA axis of measurement could be obtained with an acceptably high yield (97.2%). The measurement from this view provided a value that had the highest correlation between TTE and TEE (r = 0.758, P <.0001, 95% confidence interval 0.68-0.86; bias 0.37 +/- 1 cm). Overall, TEE underestimated the LA dimension by 9% compared with TTE. These results suggest that the short-axis view at the level of the aortic valve is the preferred site for measuring the LA dimension by TEE.     

Potential use of transthoracic echocardiography in the assessment of coronary flow reserve.

Coronary flow reserve provides a gold standard assessment of the epicardial and microvascular coronary circulation. However, measurement of coronary flow reserve is limited by the invasiveness or complexity of the methods hitherto available. We investigated whether transthoracic echocardiography could be used to assess coronary flow reserve. We imaged distal left anterior descending coronary artery diameter and flow in 14 healthy volunteers, both at rest and during intravenous infusion of adenosine (140 microg/kg per minute). Volunteers were men, with an average (+/-SD) age of 28.4 +/- 6.3 years. Complete data were acquired in 11 cases. Average distal left anterior descending coronary artery diameter was 0.213 +/- 0.03 cm. Velocity time integral rose from 8.6 +/- 2.1 cm to 27.7 +/- 5.6 cm with adenosine infusion. Heart rate rose from 64.7 +/- 9. 8 to 75.3 +/- 11.7 bpm. The Doppler angle of incidence to flow was 42.4 +/- 8.7 degrees. Resting distal left anterior descending coronary artery flow was therefore calculated as 13.4 +/- 3.2 mL/min and hyperemic flow as 51.2 +/- 16.2 mL/min, yielding a coronary flow reserve of 3.81 +/- 0.6. We conclude that coronary flow reserve can be assessed in a selected population with the use of transthoracic echocardiography and an intravenous infusion of adenosine. The simplicity of this noninvasive technique suggests that it could become a useful tool for measurement of coronary flow reserve if imaging success rates can be optimized.     

经胸超声心动图评价先天性冠状动脉瘘

目的探讨经胸超声心动图对先天性冠状动脉瘘病变的诊断价值。方法回顾性分析43例先天性冠状动脉瘘手术病例的经胸超声心动图检查结果,并与手术病理结果相对照,计算超声诊断准确率及瘘管走行、瘘口显示率。结果43例患者包括右冠状动脉瘘21例,左冠状动脉瘘19例及双冠状动脉瘘3例。经胸超声诊断准确率为88.4%。瘘管走行的总显示率为68.2%,其中肺动脉瘘瘘管多细小,其瘘管走行显示率为21.4%,瘘至其他心腔的瘘管走行显示率为92.6%。瘘口的总显示率为86.8%,其中单发瘘口的显示率为96.6%,多发瘘口的显示率为75.0%。先天性冠状动脉瘘超声表现为病变冠状动脉起始段增宽、瘘管走行迂曲扩张并瘘入心腔或大血管、瘘口处异常血流信号等。结论经胸超声心动图可作为无创性诊断先天性冠状动脉瘘的首选方法,但对细小瘘管及多发瘘口仍应建议结合冠状动脉造影检查。     

Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era.

BACKGROUND: Thirteen years ago, transthoracic echocardiography (TTE) was found to be less sensitive than transesophageal echocardiography (TEE) for native valve vegetations. Since then, harmonic imaging and other advances have improved TTE. How this affects the sensitivity of TTE is unknown. METHODS: Fifty patients with echocardiography-diagnosed endocarditis had TTE and TEE examinations on high-end machines. These were matched for date of study with 50 patients who had TTE and TEE examinations that were negative for vegetations. RESULTS: A total of 51 vegetations were seen on TEE. The sensitivity of TTE for vegetations was only 55% (aortic 50% [12/24]; mitral 62% [16/26]; tricuspid 0% [0/1]). Anatomic valvular abnormalities did not alter the sensitivity of TTE (P =.42 for mitral; P =.97 for aortic valves). However, larger vegetations were more likely to be found by TTE. CONCLUSION: Despite advances in imaging during 12 years, TTE is still insensitive compared with TEE for the detection of native valve vegetations, and fails to demonstrate nearly half of them.     

Three-dimensional multiplanar time-motion ultrasound or anatomical M-mode of the fetal heart: a new technique in fetal echocardiography.

OBJECTIVE: To assess the application of a three-dimensional multiplanar rendering technique for examination of the fetal heart. MATERIAL AND METHODS: Free-hand acquisition of a three-dimensional volume was performed without moving or tilting the transducer. While the anatomical plane shows the four cardiac chambers, the two other orthogonal planes show vertical and horizontal time-axis planes as M-mode traces. Because off-line plane positioning is possible on three-dimensional multiplanar reconstruction, M-mode traces can be obtained from different stored cardiac structures independently of the fetal position. Fifty-two women with normal singleton pregnancies at 22-40 weeks underwent transabdominal ultrasound examination and five women with singleton fetuses between 13 and 15 weeks were assessed transvaginally. Clinical application of the echocardiographic technique was tested in a further two fetuses with arrhythmia. RESULTS: Off-line M-mode traces from atrioventricular valve excursions and myocardial contractions were possible in 45/52 (86.5%) cases examined at 22-40 weeks. Among the 32 fetuses in which visualization of the outflow tracts was attempted, M-mode traces of the aortic and pulmonary valves were possible in 22 (68.7%) and 20 (62.5%) cases, respectively. In three of five cases examined transvaginally, M-mode traces could be registered. Both cases with supraventricular extrasystoles (26 and 31 weeks) were easily diagnosed using this technique. CONCLUSION: The new technique presented here enables the easy acquisition of optimal M-mode traces from different fetal heart structures. Based on our promising findings we would recommend that, in the future, three-dimensional multiplanar imaging should not be limited to automatic volume acquisition but should include the free-hand technique.     

Anatomic correlation of left atrial appendage by 3-dimensional echocardiography.

The adequate study of the left atrial appendage is an echocardiographic challenge. The purpose of this study was to assess the ability of 3-dimensional echocardiography in reconstructing this potentially complex structure.     

Noninvasive assessment of coronary flow reserve with transthoracic signal-enhanced Doppler echocardiography.

OBJECTIVES: The feasibility of noninvasive assessment of coronary flow reserve (CFR) in the distal left anterior descending artery (LAD) with echocardiography-enhanced transthoracic pulsed wave Doppler guided by high-resolution transthoracic color Doppler (TTCD) was investigated. The results were compared with the degree of coronary diameter stenosis obtained during cardiac catheterization. BACKGROUND: Assessment of CFR has proven to be useful in the selection of patients undergoing invasive treatment of coronary artery disease and in estimating their prognosis. However, CFR could only be determined invasively in everyday practice during catheterization procedures. Recent development of high-resolution TTCD allows transthoracic visualization of distal LAD and supra-apical intramyocardial perforator branches and noninvasive measurement of CFR with pulsed wave Doppler technique. METHODS: CFR was determined by measuring the ratio of pulsed wave Doppler time velocity integral during adenosine-induced hyperemia (140 microgram/kg/min intravenously) to baseline value. If the baseline Doppler signal of LAD flow was insufficient, an echocardiography (echo) enhancer (Levovist) was used. Forty-five patients were examined by TTCD (7-MHz B-mode, 5-MHz color Doppler, and 3.5-MHz pulsed wave Doppler) after coronary angiography had been performed. Group 1 consisted of 15 patients without heart disease, group 2 of 15 patients with 50% to 85% isolated LAD diameter stenosis, and group 3 of 15 patients with >85% LAD diameter stenosis. RESULTS: Peripheral LAD coronary flow at baseline condition was assessed in 40 (88%) patients with TTCD. CFR could be quantified in 36 (80%) of the 45 patients: in 18 patients without echo enhancer, and in 18 patients with echo-enhancing agent. CFR could not be assessed in 9 (20%) patients. CFR in the various groups was as follows: group 1, 3. 13 +/- 0.57; group 2, 2.23 +/- 0.20 (vs group 1: P <.01); and group 3, 1.64 +/- 0.30 (vs group 2: P <.02). CONCLUSION: CFR in the LAD can be determined in 80% of patients with pulsed wave Doppler guided by high-resolution TTCD combined with intravenously administered echo-enhancing agent.     

Blood cyst of the mitral valve: detection by transthoracic and transesophageal echocardiography.

Two-dimensional transthoracic and transesophageal echocardiography have become important modalities in the evaluation of the mechanism of symptomatic mitral regurgitation. We report the use of echocardiography in the detection of an unusual cause of mitral regurgitation, that of multiple large blood cysts involving the posterior leaflet of the mitral valve.     

A case of a quadricuspid aortic valve identified preoperatively using transthoracic echocardiography

Quadricuspid aortic valve is an extremely rare congenital heart anomaly that often causes valve incompetence, requiring surgical intervention. Care must be taken to avoid surgical complications in patients with quadricuspid aortic valve; thus, preoperative diagnosis is important. A 76-year-old man presented with exertional dyspnea due to aortic regurgitation. Transthoracic and transesophageal echocardiography revealed severe aortic regurgitation caused by quadricuspid aortic valve. To avoid interference with the cardiac conduction system, we performed aortic valve replacement using an ingenious technique, in which pledgeted sutures on the accessory leaflet were placed from outside the sinus of Valsalva to above the aortic annulus. The patient recovered uneventfully and was discharged from the hospital without any complications. While preoperative diagnosis of quadricuspid aortic valve is considered difficult, we identified it preoperatively using transthoracic echocardiography; we were, thus, able to properly prepare for complete atrioventricular block.