The echocardiographic spectrum of atrial myxoma: a ten-year experience

We analyzed the echocardiograms of 28 patients with a left atrial myxoma and two with a right atrial myxoma. Our purpose was to evaluate the value of echocardiography for the diagnosis of these cardiac masses. Only 59% of the m-mode echocardiograms in patients with a left atrial myxoma showed the characteristic findings of multiple diastolic echoes within the mitral orifice as well as abnormal systolic echoes within the left atrium. M-mode echocardiograms were atypical for left atrial myxoma in the remaining patients, and a definitive diagnosis could not be established on the basis of this procedure in six of the patients (22%). Two-dimensional echocardiography showed the presence of a left atrial mass in all 16 patients who had the procedure, and aided in understanding the atypical m-mode recordings. There was a close relationship (r =.82) between two-dimensional echocardiographic measurements of the myxomas' size and pathologic measurements. Both right atrial myxomas could be identified on the m-mode echocardiogram. Our experience indicates that two-dimensional echocardiography is superior to the m-mode technique for the diagnosis and characterization of left atrial myxomas.     

State of the atrial myocardium in patients with paroxysmal form of fibrillation arrhythmia

Seven two patients with coronary heart disease complicated with paroxysmal atrial fibrillation were studied by using accelerated atrial vector cardiography and M-mode echocardiography. Vector cardiography made it possible to reveal the signs of left atrial hyperfunction with normal left atrial echocardiographic dimensions. There were lower values for left ventricular myocardial contractility in parallel with higher echocardiographic dimensions of the left atrium. In the patients examined, progression of cardiosclerosis was accompanied by decreased amplitude values for the P loop on the vector cardiogram strip along with slower intraatrial conduction with an increase in the size of the left atrial cavity.     

Unusual and intraoperative epicardial echocardiographic features of a papillary tumour of the aortic valve

A mass with a diameter of 0.8 cm was detected in the aortic root of a 53 year old woman during routine preoperative cross sectional echocardiographic assessment of a secundum atrial septal defect. Intraoperative epicardial echocardiography showed that the mass was attached by a slender stalk to the tip of the left coronary cusp of the aortic valve, and histological examination showed that it was a papillary tumour. Intraoperative epicardial echocardiography can help in planning the excision of papillary tumours, and excision is advised even when there are no symptoms.     

Unusual and intraoperative epicardial echocardiographic features of a papillary tumour of the aortic valve.

A mass with a diameter of 0.8 cm was detected in the aortic root of a 53 year old woman during routine preoperative cross sectional echocardiographic assessment of a secundum atrial septal defect. Intraoperative epicardial echocardiography showed that the mass was attached by a slender stalk to the tip of the left coronary cusp of the aortic valve, and histological examination showed that it was a papillary tumour. Intraoperative epicardial echocardiography can help in planning the excision of papillary tumours, and excision is advised even when there are no symptoms.     

Left atrial volume estimation by two-dimensional echocardiography

We examined 12 patients aged six months to 76 years by echocardiography to determine left atrial volume. The results were compared with angiographic left atrial volumes calculated by the biplane Simpson's rule method. Three two-dimensional planes were used: precordial long axis, apical two-chamber, and four-chamber. Area outlines were traced using a light pen computational system providing single plane area length estimates of left atrial volume. The two apical left atrial outlines were combined, and Simpson's rule method was used to calculate left atrial volume. M-mode echocardio-grams performed on these patients were used to estimate left atrial volume. As the resuits of covariance analysis showed that there was no significant difference in the line of regression in systole and diastole, these data were pooled for subsequent comparison with angiography. The closest correlation with angiography was the biplane Simpson rule method with the echocardiographic left atrial volume (Y) = 1.0, angiographic volume (X) + 6.3 ml, r = 0.86. The single plane area length estimates also correlated well with angiography, but correction factors were required. M-mode estimates of left atrial volume could only correlate to angiography using a power function y = 3.7 X^1.80, r = 0.69. We conclude that left atrial volume can be determined by two-dimensional echocardiography and that this technique is superior to M-mode echocardiography.     

Comparison of cardiac dimensions by transesophageal and transthoracic echocardiography.

Transesophageal echocardiography (TEE) has advanced rapidly as a valuable cardiovascular diagnostic technique. As the use of TEE increases, so does the importance of well-defined normal cardiac measurements. Presently, few data exist on the accuracy of M-mode TEE-derived measurements. Therefore in 81 adult patients, TEE-derived M-mode measurements were compared with analogous measurements that were made by standard M-mode transthoracic echocardiography (TTE). The TTE and TEE measurements did not differ in aortic root diameter, end-diastolic left ventricular diameter, end-diastolic septal wall versus anterior wall thickness, or end-diastolic posterior wall versus inferior wall thickness. These TEE measurements were within 95% confidence limits of TTE measurements. TEE-derived left atrial diameter (3.5 +/- 0.8 cm) was less than that derived by TTE (3.8 +/- 0.8 cm; p less than 0.001) and fell outside of the 95% confidence interval. TTE left atrial size could be estimated as follows: TTE-derived left atrial diameter = TEE-derived left atrial diameter x 0.6 + 1.5 cm. In conclusion, M-mode measurements of aortic root diameter, left ventricular diameter, and wall thicknesses as derived by TTE and TEE are comparable. TEE-derived left atrial diameter may be used to estimate the left atrial TTE measurement. TEE-derived M-mode measurements are likely to be most useful when results of TTE are technically inadequate.     

Significance of echo- and vectorcardiographic studies of the heart atrium in the assessment of intracardiac hemodynamics and myocardial contractility

Seventy three patients with coronary heart disease (CHD) complicated by paroxysmal atrial fibrillation (PAF) were examined. Vectorcardiography developed by I. A. Akulinichev and M-mode echocardiography were used to assess the status of left atrial and ventricular myocardia. An interrelationship was examined between the electrophysiological and echocardiographic parameters of myocardial performance, depending on the stage of circulatory insufficiency (CI). The patients with PAF-complicated CHD, unlike those with CHD alone, showed more severe myocardial conduction abnormalities despite the stage of CI. There were signs of compensatory left ventricular overload in the absence of clinical signs of CI. Comparison of ultrasound examination findings with high performance atrial vectorcardiographic ones increases the possibility of accurately assessing the cardiac performance by using noninvasive tools of examinations.     

The valve of the foramen ovale in interatrial right-to-left shunt: Echocardiographic cineangiocardiographic and hemodynamic observations

In postpartum persistent right-to-left shunt at the atrial level, the valve of the foramen ovale fails to close. As a thin valve-flap the septum primum is pushed to the left during the phases of right atrial pressure predominance and closes to the septum secundum, when left atrial pressure exceeds right atrial pressure. Thus, it performs a marked movement during the cardiac cycle, reflecting the interatrial pressure-flow dynamics. With use of M-mode echocardiography, this movement pattern was studied in 24 patients: 13 with cyanotic heart disease (age 2 days to 21 years) and 11 newborns with persistent transatrial right-to-left shunt due to noncardiac disease. Cardiac defects were confirmed by cardiac catheterization and cineangiocardiography. Interatrial right-to-left shunts were proved by M-mode and 2-dimensional contrast echocardiography. The comparison of the M-mode echocardiographic findings in our patient groups with normal atrial septal movement studied in 20 healthy infants and children revealed considerable differences. The characteristic movement of the valve of the foramen ovale also was compared with results obtained by cineangiography and 2-dimensional echocardiography. Analysis of interatrial blood pressure difference provided a pathophysiologic explanation of the septum primum movement in transatrial right-to-left shunt.     

Mitral valve echocardiographic pattern within the left atrium

Summary: In a patient with a left atrial myxoma, the tumor adhered to the anterior leaflet of the mitral valve. This caused movement of the tumor's stalk in the left atrium in a pattern similar to that of a mitral valve in M-mode echocardiography. An accurate diagnosis was made by cross-sectional echocardiography and confirmed at surgery.     

M-mode and two-dimensional contrast echocardiography in adult patients with atrial septal defects

M-mode and two-dimensional echocardiographic studies, with and without contrast injection, were performed in 14 adult patients with clinical and radiological signs of atrial septal defects. Two-dimensional contrast echocardiography was found to be the most sensitive technique, allowing a definitive diagnosis to be made noninvasively in 12 patients (86%) of those patients studied. M-mode contrast echocardiography demonstrated an atrial shunt in 6 patients (43%). Regular two-dimensional echocardiography produced a high proportion of false-positive and false-negative results, while the findings on M-mode echocardiography are sensitive but nonspecific. All 14 patients described had the diagnosis confirmed on cardiac catheterization. Performance of the Valsalva maneuver during contrast echocardiography was found to be diagnostically unhelpful. The findings suggest that contrast echocardiography, particularly two-dimensional, is an effective, noninvasive diagnostic technique to be applied on clinical suspicion of atrial septal defects.     

Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation

Previous studies have suggested that success of elective direct-current cardioversion for atrial fibrillation (AF) can be predicted from clinical features and M-mode echocardiographic left atrial diameter. We evaluated clinical variables as well as M-mode and 2-dimensional echocardiographic measurements of atrial size in 85 patients undergoing electrical cardioversion for AF. Of 65 patients who were initially converted to sinus rhythm, 45 (69%) and 38 (58%) remained in sinus rhythm at 1 and 6 months, respectively. No historical feature predicted initial success, although patients with cardiomyopathy or pulmonary disease underlying their AF had significantly lower success rates compared with those having other etiologies. Furthermore, no M-mode or 2-dimensional echocardiographic measurements of atrial size predicted initial success of cardioversion. Maintenance of sinus rhythm at 1 month was related to short duration of AF before cardioversion (less than 3 months vs greater than 12 months, p less than 0.05). Left atrial area and long axis dimension by 2-dimensional echocardiography were significantly larger in patients remaining in sinus rhythm than in those who had reverted to AF at 1 month (28 +/- 7 vs 24 +/- 5 cm2 and 65 +/- 9 vs 59 +/- 8 mm, respectively, both p less than 0.05), but overlap was great. No significant difference in atrial dimensions was noted at 6-month follow-up. It appears that, although no clinical or echocardiographic variable predicts initial success for cardioversion of AF, duration of AF does predict maintenance of sinus rhythm 1 month after initial success.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left and right atrial volume by freehand three-dimensional echocardiography: in vivo validation using magnetic resonance imaging.

INTRODUCTION: Measurement of left and right atrial size is important for the management of arrhythmias, valvular and congenital heart disease. We have demonstrated that freehand three-dimensional (3D) echocardiography is more accurate and reproducible than two-dimensional (2D) echocardiography for measurement of left ventricular mass and volume. However, no prior study has validated the accuracy of freehand 3D for the determination of left or right atrial volume. METHODS: End-systolic (maximum) left and right atrial volumes were determined in 21 volunteer patients and normal subjects by one, two, and freehand 3D transthoracic echocardiography and compared to volumes obtained by gradient recalled magnetic resonance imaging. Three-dimensional echocardiographic determination of atrial volume was obtained using an acoustic spatial locator, a line-of-intersection display, and a surface reconstruction algorithm. Two-dimensional echocardiographic atrial volumes were obtained from apical biplane images of the left atrium and an apical single plane image of the right atrium using a summation of disks method. One-dimensional (ID) estimates of left atrial volume were determined by cubing the M-mode ID antero-posterior dimension obtained on the parasternal long axis view. RESULTS: An excellent correlation was Obtained between freedhand 3D echocardiography and magnetic resonce imaging (MRI) for the left atrium (r = 0.90, SEE=9.6 ml) and for the right atrium (r = 0.91, SEE = 8.8 ml) with a small bias (left atrium 5.25 ml, right atrium 12.06 ml) and narrow limits of agreement (left atrium 22.14 ml, right atrium 25.54 ml). Two-dimensional echocardiography correlated less well (left atrium r = 0.87, SEE = 10.23 ml, right atrium r = 0.79, SEE = 19.74 ml), and had a higher bias (left atrium 14.46 ml, right atrium 8.99 ml) and larger limits of agreement (left atrium 24.37 ml, right atrium 41.16 ml). One-dimensional estimates of left atrial volume correlated poorly with magnetic resonance determined left atrial volume (r = 0.80, SEE = 6.61 ml) and had unacceptably high bias (45.09 ml) and limits of agreement (35.52 ml). Interobserver variability was lowest for 3D echocardiography (left atrium 7.2 ml, 11%, right atrium 8.7 ml, 16%). CONCLUSIONS: Freehand 3D echocardiography using the line of intersection display for guidance of image positioning and a polyhedral surface reconstruction algorithm is a valid, accurate, reproducible method for determining left and right atrial volume in humans that is comparable to magnetic resonance imaging and is superior to current ID and 2D echocardiographic techniques.     

Clinical presentation and non-invasive diagnosis of right heart masses.

Right-sided cardiac masses do not have a uniform clinical presentation. Successful diagnosis is dependent on a high index of suspicion and appropriate echocardiographic examination. Five cases of right sided intracardiac masses have been detected during the period that echocardiography has been routinely available to us--two of right atrial myxoma, one of right atrial thrombus, and two of right ventricular tumour. M-mode echocardiography identified four of the five cases. Two-dimensional echocardiography was necessary to establish the non-invasive diagnosis in the fifth case. Echocardiography should be used in any patient in whom a right sided mass is suspected, or in those patients presenting with signs of tricuspid regurgitation, tricuspid stenosis, pulmonary stenosis, cyanotic heart disease, progressive right heart failure, constrictive pericarditis, or pulmonary emboli without obvious source.     

Alcoholic cardiomyopathy in the preclinical stage: non-invasive clinico-instrumental research study on 112 chronic alcoholics

112 consecutive asymptomatic patients who assumed alcohol in excess (1-2 g/kg/die) for 5 years or more were admitted to our hospital for detoxication. They were examined both clinically and with chest x-rays, ecg, phonocardiography, external pulse recording, and M-mode/2-D echocardiography to detect myocardial involvement. Heart disease not related to alcohol abuse was found in 6 cases. In the remaining 106/112 patients electrocardiographic abnormalities (aspecific ST-T changes, left bundle branch block, intraventricular conduction defects, left ventricular strain pattern and atrial fibrillation) were present in 18 per cent of cases. PEP, LVET intervals and PEP/LVET, were calculated only in 39/106 patients and did not differ significantly from the control group. The echocardiographic study showed hypokinesis and left ventricular dilatation in 9/106 patients. In other 5 cases echocardiographic findings were at upper limits of normal for left ventricular dimension and motility. Therefore in 13 per cent of cases a dilated cardiomyopathy was revealed by the echocardiographic study. In 6 of these 13/106 patients ecg was either normal or showed only aspecific ST-T changes. Echocardiography failed to confirm augmented left ventricular thickness and mass as reported in asymptomatic alcoholic patients in the literature. Probably several factors (different interval of time between the interruption of the alcoholic abuse and the time of examination, the quantity of alcohol in excess and the echocardiographic technique) may influence the results of such studies. The present report nevertheless points out to the validity of the echocardiographic study in the detection of subclinical myocardial involvement in alcoholic patients and should be performed in such cases.     

Changes in left atrial size in patients with lone atrial fibrillation

A retrospective analysis was performed on 23 subjects with lone atrial fibrillation who were followed for an average of 6.2 years (1.1-12.8 years). In all patients, underlying organic heart disease was excluded based on history, physical exam, electrocardiogram, echocardiogram, and Doppler ultrasound interrogation. All patients had at least two echocardiographic studies during the period of observation. Atrial fibrillation was chronic in 11 subjects and paroxysmal in 12. All echocardiographic measurements were obtained by averaging the measurements of two blinded investigators. Left atrial size increased an average of 5.6 mm which translates into a 14.7% increase over the baseline measurement. This increase in size was not associated with a change in left ventricular mass or fractional shortening as determined by echocardiography. Subjects with chronic atrial fibrillation had a larger percent increase than subjects with paroxysmal atrial fibrillation (18.9 vs. 10.8%), although this relative change in size failed to reach statistical significance. The only variable which significantly contributed to the change in left atrial size was the duration of follow-up. We conclude that atrial fibrillation occurring in patients with lone atrial fibrillation may cause a slow and progressive increase in left atrial size independent of changes in left ventricular size or function.     

Left atrial diameter in nonvalvular atrial fibrillation: An echocardiographic study. Stroke Prevention in Atrial Fibrillation Investigators

BACKGROUND: The left atrium (LA) is usually enlarged in patients with nonvalvular atrial fibrillation (AF), but factors associated with LA diameter are incompletely defined. METHODS AND RESULTS: This transthoracic echocardiographic cohort study includes 3465 participants with nonvalvular AF in 3 multicenter clinical trials. LA diameter determined by M-mode echocardiography was correlated with clinical and echocardiographic features by cross-sectional multivariate regression analyses. The mean LA diameter was 47 +/- 8 mm, on average 6 mm larger in those with AF at the time of echocardiography than in those with sinus rhythm (48 vs 42 mm, P <. 001). Patient age and body weight were independently predictive of LA diameter (P <.0001), but sex, body surface area, and body mass index were not. The estimated independent contribution of atrial rhythm to LA diameter was approximately 2.5 mm. Prolonged duration of AF, left ventricular dilatation and increased muscle mass, mitral regurgitation, annular calcification, and hypertension were additional independent predictors of LA diameter. CONCLUSIONS: Multiple factors appear to contribute to LA enlargement in patients with nonvalvular AF, including the presence and persistence of the dysrhythmia.     

Association between echocardiographic parameters and brain natriuretic peptide levels in treated hypertensive patients

We examined which echocardiographic parameter correlated best with plasma brain natriuteric peptide (BNP) levels in treated hypertensive patients. Enrolled in the study were 122 treated hypertensive patients (70 ± 9 y). The left ventricular mass index and left atrial dimension (LAD) were measured using echocardiography as indexes of left ventricular hypertrophy and left atrial enlargement, respectively. Among all the echocardiographic parameters, LAD correlated best with BNP (r = 0.343, p < 0.001). Stepwise regression analysis showed that LAD (β coefficient = 0.513, p < 0.001) was independently associated with BNP. Left atrial enlargement, rather than left ventricular hypertrophy, may be clinically useful for predicting elevated BNP levels in treated hypertensive patients.     

Morphological quantification and differentiation of left ventricular hypertrophy in hypertrophic cardiomyopathy and hypertensive heart disease. A two dimensional echocardiographic study

Differentiation between hypertrophic cardiomyopathy and hypertensive heart disease is a diagnostic challenge. M-mode echocardiography only permits assessment of hypertrophy in limited areas of the left ventricular wall. 2-D echocardiography allows visualization of most of the myocardium. To assess the reliability of conventional M-mode echocardiographic and 2-D echocardiographic criteria in patients with hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HY), 30 patients with hypertrophic cardiomyopathy and 30 patients with hypertension and severe cardiac hypertrophy were examined using M-mode and 2-D echocardiography. Although the M-mode echocardiographic features showed statistically significant differences between the mean values in the two groups, the degree of overlap made the differentiation of the individual patients difficult. The diagnostic sensitivity and specificity of classic echocardiographic features were assessed: ventricular septal thickness greater than or equal to 1.5 cm, 90% and 43% (sensitivity and specificity, respectively); ventricular septal thickness to posterior wall ratio greater than or equal to 1.5, 83% and 56%; cross-sectional area at papillary level greater than 21 cm2m-2, 80% and 73%; septal segment of the myocardial ring at papillary level greater than 6.5 cm2m-2, 80% and 87%; and the combined criteria of cross-sectional area at papillary level greater than 21 cm2m-2 and septal segment greater than 6.5 cm2m-2, 77% and 93%. Quantitative 2-D echocardiography is useful to differentiate patients with hypertrophic cardiomyopathy from those with secondary myocardial hypertrophy due to hypertension. Hypertrophic cardiomyopathy is characterized by a spectrum of different morphological patterns of hypertrophy. Patients with the predominant region of hypertrophy in the anterolateral free wall or the apical region of the left ventricle were not detected with our quantitative method. Patients with this type of hypertrophy are relatively rare in the western population.     

Bilateral atrial myxomas. Echocardiographic considerations

In this report we describe a patient with bilateral atrial myxomas, which were diagnosed preoperatively by echocardiography and angiography, and successfully removed. The excised tumor mass consisted of mobile right and left atrial myxomas connected by a common stalk which passed through the atrial septum, collectively resembling the shape of a dumbbell. Preoperative echocardiographic and angiographic observations were instrumental in planning the surgical approach, and correlated well with intraoperative findings and with the anatomic configuration of the intact pathologic specimen. Diagnostic aspects of echocardiography are emphasized as they relate to both isolated and bilaterally-occurring atrial myxomas.     

Pulmonary wedge injections yielding left-sided echocardiographic contrast.

Ultrasound contrast on the left side of the heart without the need for left heart catheterisation was achieved by hand injections of 8 to 10 ml 5 per cent dextrose solution through a catheter in the pulmonary wedge position. Injections were performed in 18 patients undergoing routine cardiac catheterisation and M-mode or two-dimensional echocardiography was used. An adequate wedge position was attained in 17 of the 18 patients. Nine had injections through Cournand catheters, three through Swan-Ganz catheters, and five through both. In 11 of these 17 patients left atrial or left ventricular echocardiographic contrast was seen immediately after wedge injection. Two patients showed diminished or absent contrast on later injections from the same position. Better results were obtained with the Cournand catheter (11/15 positive) than with the Swan-Ganz (1/8 positive) catheter. Pulmonary artery injections proximal to the wedge position did not cause left-sided contrast. No complications were observed. The safety of this method remains to be determined.