Live three-dimensional transthoracic echocardiographic assessment of thrombus in the innominate veins and superior vena cava utilizing right parasternal and supraclavicular approaches

We report the usefulness of right parasternal and supraclavicular live three-dimensional transthoracic echocardiography in the delineation and follow-up of a thrombus involving a catheter placed in superior vena cava for dialysis in an adult patient with chronic renal disease.     

Live/real time three-dimensional transthoracic echocardiographic assessment of pulmonary regurgitation

There is no gold standard for the measurement of pulmonary regurgitation (PR) severity. Two-dimensional (2D) transthoracic echocardiography is most commonly used to quantify PR severity using color Doppler criteria for aortic regurgitation. However, this method is limited by visualization of only one or two dimensions of the proximal PR jet or vena contracta (VC) precluding accurate assessment of its shape or size. This limitation would be expected to be obviated by three-dimensional (3D) transthoracic echocardiography, which could provide a more accurate quantitative assessment of PR severity. This study evaluated 82 adult patients with PR using 2D and 3D. PR VC area by 3D was obtained by planimetry by positioning the cropping plane exactly parallel to the VC, which was viewed en face by cropping of the 3D data set. Regurgitant volumes were calculated by 2D (assuming a circular VC) and by 3D as a product of the VC and velocity time integral obtained by color Doppler-guided conventional Doppler interrogation of the PR jet.The 3D VC area correlated with 2D jet width (JW)/right ventricular outflow tract (RVOT) width (r = 0.71) and 2D VC area (r = 0.79). 3D JW/RVOT width correlated with 2D JW/RVOT (r = 0.87). 3D regurgitant volumes also correlated with 2D regurgitant volumes (r = 0.76). The 3D VC values of <0.20, 0.20-0.45, 0.46-1.15, and >1.15 cm(2) and regurgitant volumes of <15 ml, 15-50 ml, 51-115 ml, and >115 ml were effective as cutoffs for grades 1, 2, 3, and 4 PR, respectively. In conclusion, quantification of 3D VC area and regurgitant volumes correlate reasonably well with the current 2D methods for measurement of PR. Since 3D visualizes PR VC in three dimensions, it would be expected to provide a more accurate and more quantitative assessment of PR severity as compared to 2D.     

Live/real time three-dimensional transthoracic echocardiographic identification of quadricuspid aortic valve

We describe an adult in whom live/real time three-dimensional echocardiography was able to make a definite diagnosis of a quadricuspid aortic valve which was misdiagnosed as bicuspid by live two-dimensional transthoracic echocardiography (2DTTE).     

A case of absent right superior vena cava with persistent left superior vena cava: Cross-sectional echocardiographic diagnosis

Summary We report a case of absence of the right superior vena cava. Hitherto, the findings in this condition have only been obtained using invasive methods; this report is the first in which the diagnosis was made by means of echocardiography. The findings include a markedly enlarged coronary sinus draining into the right atrium and a specific finding of contrast echocardiography in which contrast material injected into the right antecubital vein can be seen in the enlarged coronary sinus. The contrast echo flows into the right atrium from the coronary sinusonly. The size of the coronary sinus was far beyond the range (91±38 mm²/m²) in patients with persistent left superior vena cava with the presence of the right superior vena cava.     

Real time/three-dimensional transthoracic echocardiographic visualization of the valve of foramen ovale

We describe an adult patient in whom the valve of foramen ovale and its opening and closing movements were well visualized by live/real time three-dimensional transthoracic echocardiography.     

Live/real time three-dimensional transthoracic echocardiographic assessment of mycotic pseudoaneurysm involving the descending thoracic aorta

We describe a patient in whom a mycotic aneurysm involving the distal descending thoracic aorta could be definitively diagnosed by live/real time three-dimensional transthoracic echocardiography.     

Live/real time three-dimensional transthoracic echocardiographic description of chordoma metastatic to the heart

We describe live/real time three-dimensional transthoracic echocardiographic features of a chordoma metastatic to the heart and correlate its appearance with the surgical pathology.     

Usefulness of interatrial conduction time to distinguish between focal atrial tachyarrhythmias originating from the superior vena cava and the right superior pulmonary vein

Objective: Differentiation of the tachycardia originating from the superior vena cava (SVC) or the right superior pulmonary vein (RSPV) is limited by the similar surface P‐wave morphology and intraatrial activation pattern during tachycardia. We sought to find a simple method to distinguish between the two tachycardias by analyzing the interatrial conduction time. Methods: Sixteen consecutive patients consisting of 8 with SVC tachycardia and the other 8 with RSPV tachycardia were studied. The interatrial conduction time from the high right atrium (HRA) to the distal coronary sinus (DCS) and the intraatrial conduction time from the HRA to the atrial electrogram at the His bundle region (HIS) were measured during the sinus beat (SR) and during the tachycardia‐triggering ectopic atrial premature beat (APB). The differences of interatrial (Δ[HRA‐DCS]_SR‐APB) and intraatrial (Δ[HRA‐HIS]_SR‐APB) conduction time between SR and APB were then obtained. Results: The mean Δ[HRA‐DCS]_SR‐APB was 1.0 ± 5.2 ms (95% confident interval [CI]–3.3–5.3 ms) in SVC tachycardia and 38.5 ± 8.8 ms (95% CI 31.1–45.9 ms) in RSPV tachycardia. The mean Δ[HRA‐HIS]_SR‐APB was 1.5 ± 5.3 ms (95% CI –2.9–5.9 ms) in SVC tachycardia and 19.9 ± 12.0 ms (95% CI 9.9–29.9 ms) in RSPV tachycardia. The difference of Δ[HRA‐DCS]_SR‐APB between SVC and RSPV tachycardias was wider than that of Δ[HRA‐HIS]_SR‐APB (37.5 ± 9.3 ms vs. 18.4 ± 15.4 ms, P < 0.01). Conclusions: The wide difference of the interatrial conduction time Δ[HRA‐DCS]_SR‐APB between SVC and RSPV tachycardias is a useful parameter to distinguish the two tachycardias and may avoid unnecessary atrial transseptal puncture.     

Papillary fibroelastoma of the pulmonary valve: assessment by live/real time three-dimensional transthoracic echocardiography

The differential diagnosis of a cardiac valve mass includes fibroelastoma, myxoma, lipoma, Lambl's excrescences, thrombus, and vegetation. Fibroelastomas are extremely rare primary cardiac tumors. Their incidence is 0.00017-0.033% in autopsy series and 0.019% in clinical series identified on echocardiography. Although rare, fibroelastomas are the most common tumors affecting the cardiac valves with aortic, mitral, tricuspid, and pulmonary valves being involved in this order. In the current report we describe a case of pulmonary valve mass in which a confident prospective diagnosis of fibroelastoma could be made utilizing the technique of three-dimensional transthoracic echocardiography.     

Live three-dimensional transthoracic echocardiographic assessment of anomalous origin of left coronary artery from the pulmonary artery

We describe live three-dimensional transthoracic echocardiographic (3DTTE) findings in a 52-year-old female who had previously undergone an aortopulmonary tunnel operation for anomalous origin of the left coronary artery (ACA) from the pulmonary artery. Three-dimensional transthoracic echocardiography clearly delineated the origin of the ACA from the posterolateral aspect of the main pulmonary artery just above the pulmonary valve, the surgically created tunnel, as well as a small defect in the tunnel near the aortic end communicating with the pulmonary artery.     

Unusual collateral vessel from right subclavian vein to left atrium,a rare complication of superior vena cava obstruction

The most commonly reported collateral systems in the setting of superior vena cava obstruction are azygos venous system, vertebral venous system, external and internal thoracic venous system based on McLntire and Sykes classification. A 49‐year‐old female with renal disease complained dyspnea on exertion. Transesophageal echocardiography showed significant mitral annular calcification, large multi‐lobulated mass at posterior aspect of RA, and complete obstruction of superior vena cava by thrombus formation. Computed tomography angiography showed a collateral vein to the left atrium (LA) roof. This case report is the first one which shows development of collateral vein from right subclavian to LA.     

Analysis of Doppler flow spectra of the superior vena cava in a canine model of acute thromboembolic pulmonary hypertension

We aimed to establish a canine model of acute thromboembolic pulmonary hypertension (ATEPH) and to explore the feasibility of diagnosing pulmonary hypertension (PH) through the Doppler flow spectra of the superior vena cava (SVC). A canine model of ATEPH was developed by infusing thrombus into the right femoral vein. The pulmonary arterial pressure was simultaneously measured via a right heart catheter with the guidance of ultrasound. The maximum systolic peak flow velocity (SPV), ventricular reverse peak flow velocity (VRPV), diastolic peak flow velocity (DPV), and atrial reverse peak flow velocity (ARPV) of the SVC were measured by transthoracic echocardiography. ATEPH was successfully established in 24 dogs (88.9%) with the pulmonary arterial systolic pressure (PASP) greater than 30 mmHg. ARPV increased significantly with the increase of PASP, and was positively correlated with PASP (P<0.001). The ARPV/SPV larger than 0.8 could be better adopted to identify all the subjects with PH in this study. The Doppler flow spectra of the SVC could be employed to assess the severity of ATEPH.     

Live/real time three-dimensional transthoracic echocardiographic assessment of left ventricular volumes, ejection fraction, and mass compared with magnetic resonance imaging

Due to reliance upon geometric assumptions and foreshortening issues, the traditionally utilized transthoracic two-dimensional echocardiography (2DTTE) has shown limitations in assessing left ventricular (LV) volume, mass, and function. Cardiac magnetic resonance imaging (MRI) has shown potential in accurately defining these LV characteristics. Recently, the emergence of live/real time three-dimensional (3D) TTE has demonstrated incremental value over 2DTTE and comparable value with MRI in assessing LV parameters. Here we report 58 consecutive patients with diverse cardiac disorders and clinical characteristics, referred for clinical MRI studies, who were evaluated by cardiac MRI and 3DTTE. Our results show good correlation between the two modalities.     

The dilated coronary sinus: utility of coronary sinus cross-sectional area and eccentricity index in differentiating right atrial pressure overload from persistent left superior vena cava

Background: Pulmonary hypertension and right atrial pressure overload (RAPO) cause dilation of the coronary sinus (CS). Persistent connection of the left superior vena cava (LSVC) to the CS is another cause of CS dilation. The purpose of this study was to evaluate the usefulness of coronary sinus cross‐sectional area (CSA) and eccentricity index (EI) in differentiating persistent LSVC from right heart overload and RAPO in patients with dilated CS. Methods: We identified 15 patients with a dilated CS by echocardiography. Offline analysis was used to measure CS‐CSA and CS‐EI at end‐diastole in the parasternal long axis plane. EI was defined as B/A, where A is the widest diameter and major axis of the CS, and B is the diameter of the minor axis (perpendicular to and bisecting A at its midpoint). Persistent LSVC was confirmed by either computed tomography or injection of agitated saline in the left antecubital vein. Results: CS‐CSA was significantly larger in PLSVC group than in group with RAPO. Also, CS‐EI was lower in PLSVC than in RAPO group (P = 0.0003). EI was the most sensitive and specific discriminator between patients with persistent LSVC vs. RAPO. CS‐EI was <0.8 in all PLSVC patients and >0.8 in all RAPO patients (sensitivity and specificity = 100%). Conclusion: Patients with persistent LSVC have a significantly higher CS‐CSA than those with elevated RA pressure. When dilated CS is present, a CS‐EI <0.8 is 100% sensitive and specific for persistent LSVC. Thus, the CS‐EI can be used in cases of dilated CS to diagnose the presence of persistent LSVC with a very high degree of certainty, and can help differentiate this congenital anomaly from RAPO. (Echocardiography 2011;28:829‐832)