Echocardiography from the gastric fundus. Description of new projections]

Two new transgastric echocardiographic views obtained using the transesophageal probe are described. The first one (RVOT-MPA view) presents RVOT, pulmonic valve and proximal MPA. The second one (LVOT--Ao view) shows ascending aorta, aortic valve, LVOT, perimembranous area and anterior part of the trabecular septum, mitral valve with its attachment to the anterior papillary muscle and LA. The latter view corresponds to the standard subcostal view. Repeatability and applicability of these two scans were investigated on 25 pts: 10 with valvular heart disease (including 2 after valve replacement and 1 intraoperative study), 3-VSD, 2-TF, 2-ASD II, 5 with aortic aneurysm (including 1 after surgery), 3 after MI. RVOT-MPA view was obtainable in 76% pts, whereas LVOT-Ao view in 84% pts. This latter scan appeared to be very helpful in detecting VSD--either isolated perimembranous or malalignment in TF. In one pt with TF the detailed anatomy of RVOT, MPA and pulmonic arteries could be clearly imaged in fashion resembling standard echocardiographic subcostal short axis view. Left ventricular--right atrial communication was also readily appreciated in one of the pts. This view confirmed also some other informations, previously achieved by means of TEE planes (eg thrombus in LAA, aortic intimal flap protruding into LVOT). RVOT-MPA projection did not reveal more anatomical data than standard TEE planes in the investigated group. However, it should be useful in diagnosing subpulmonic VSD because of its similarity to the corresponding view available with newer TEE probes which provide longitudinal scans of the heart. The results presented proved usefulness of the new echocardiographic views, particularly in detecting VSD and more complex heart defects.     

Massive mitral and pulmonary valve incompetence in a patient with left ventricular, non-compacted myocardium

The case is reported of a patient who underwent cardiac surgery for pulmonary valve stenosis as a child, and presented as an adult with signs and symptoms of severe congestive heart failure. The left ventricle showed an increased trabecular pattern in the region of the apex, the mitral annulus was severely dilated with mitral incompetence, the right ventricular out-flow tract (RVOT) was largely dilated with aneurysm of both pulmonary arteries, and there was evidence of pulmonary valve incompetence. Previously, rare cases have been reported of persistent left ventricular non-compaction in patients with congenital left or RVOT obstruction. Non-compaction of the ventricular myocardium is an inherited autosomal dominant disorder; to date, four genes and one genetic locus have been found to be associated with non-compacted ventricular myocardium. The condition is characterized by arrhythmias, thromboembolic events and heart failure, but affected individuals may not be symptomatic. The present case represented a strange association between non-compacted left ventricle, mitral annular dilation with persistence of a normal leaflet and subvalvular mitral valve apparatus, and RVOT dilation with pulmonary artery aneurysms.     

Causes of reoperations and their outcomes in patients with the Marfan's syndrome after correction of the ascending aorta aneurysm and aortic insufficiency

Aim of the study was to elucidate causes of repeat operations and their outcomes in patients with the Marfan's syndrome. Between December 1972 and January 2009 60 patients with Marfan's syndrome were operated for aneurysm of the ascending aorta and aortic insufficiency. All patients were subjected to ascending aorta and aortic valve replacement with valve containing conduit. Five of 60 patients (8.3%) were subjected to 7 repeat operations (2 patients were reoperated twice). Causes of repeat interventions were: conduit dysfunction (n=3), abdominal aortic aneurysm (n=3), mitral valve prolapse (n=1). Three patients died: 2 during surgery because of impaired conduit function, one - in 1 year after repeat operation of mitral valve replacement for mitral valve prolapse with pronounced mitral insufficiency. In all cases cause of death was progressive heart failure. As an example a case of a female patient who had been subjected to repetitive surgeries because of malfunctioning conduit is presented in this paper. Main reason for reoperations was the Marfan's syndrome itself. Progression of this disease might continue after operation, alteration of the aortic wall promote dissection in regions not subjected to prosthetics. Application of prostheses especially designed for replacement of the ascending aorta excludes such causes of reoperations and death as disruption of old sutured of two parts conduits.     

Clinical usefulness of transesophageal Doppler echocardiography

The usefulness of transesophageal Doppler echocardiography (TEE) was assessed in patients with various cardiovascular diseases including 15 patients with dissecting aortic aneurysm (DAA), two with thoracic aneurysm, 16 with ischemic heart disease and 14 with acquired valvular diseases. In dissecting aortic aneurysms, TEE provided clear images of the intimal flaps even in the aortic arch and descending aorta in which clear images could not be obtained by conventional external Doppler echocardiography. The entry site was detected in 11 of the 15 (73%) cases using TEE, but in only three of the 15 cases using conventional Doppler technique. In two cases of true aortic aneurysms, TEE provided clear images of the aneurysm in the descending thoracic aorta, which was discriminated precisely from DAA. In valvular disease, all four valves (aortic, pulmonary and atrio-ventricular valves) were easily observed without disturbance by any other tissues using a transesophageal approach. In addition, valve aneurysms in the posterior mitral leaflets were detected using TEE in two cases. In two cases of mitral stenosis, a thrombus was observed in the left atrial appendage. These findings were confirmed during surgery, but could not be obtained by the conventional external studies. In 16 cases, TEE was performed during aorto-coronary bypass surgery under general anesthesia. In two of these cases, left ventricular assist devices were applied after surgery. In these cases, where conventional Doppler echocardiography was not applicable, cardiac function could be monitored by TEE. Thus, TEE is useful not only in evaluating morphological function in the cardiovascular system but also in monitoring cardiac hemodynamics during and after heart surgery.     

Color flow and conventional echocardiography of the Marfan syndrome

Imaging and color flow Doppler echocardiography are an integral part of any evaluation of a patient with the Marfan syndrome. The major cardiovascular manifestations of this condition are aortic dilation, which may involve the proximal and distal aorta, aortic regurgitation, aortic dissection, mitral valve prolapse, and mitral regurgitation. Patients who have the Marfan syndrome should have serial echocardiograms to measure aortic root diameter carefully at the sinuses of Valsalva and subsequent levels (sinotubular junction, arch, descending and abdominal aorta). Additionally, color Doppler echocardiography assists in the diagnosis of aortic dissection and facilitates evaluation of the severity of aortic and mitral regurgitation that commonly complicate the Marfan syndrome. The risk of aortic dissection, which is the most serious manifestation of the Marfan syndrome, increases as the aorta enlarges. Therefore, elective composite graft surgery is recommended when the aortic root size reaches 60 mm, regardless of symptom status, or 55 mm in the presence of severe aortic regurgitation. Surgical replacement of the aortic root with a composite graft does not end the disease process. Color flow Doppler is useful in the diagnosis of dehiscence of the conduit sewing ring, coronary artery aneurysm, distal aortic dissections, and prosthetic valve dysfunction.     

Survival and complications in remote period of follow-up in patients with Marfan syndrome after correction of aneurism of the ascending aorta and aortic insufficiency

Patients with Marfan syndrome (n=44) and ascending aorta aneurism combined with aortic insufficiency were followed up for 1 month - 16 years after graft repair of the ascending aorta aneurysm and replacement of aortic valve. Patients were divided into two groups: with dissecting aneurism (n=25) and chronic nondissecting aneurism (n=19). In remote postoperative period 11 patients had 13 complications (2 patients had 2 complications each - graft dysfunction and arterial thromboembolism). Repetitive surgery was carried out in 5 patients after 67.2 +/- 19.4 months because of expansion of dissection to the abdominal aorta, dysfunction of mitral valve prosthesis. In remote period of follow up 15 patients (34.1%) died. Causes of death were graft dysfunction, extension of aortic dissection, myocardial failure. Total survival was 80, 54 and 46% for 1 month, 10 and 15 years, respectively.     

Pulmonary hypertension in Takayasu arteritis

Takayasu arteritis (TA) is a rare chronic vasculitis primarily involving the aorta and its main branches. The disease affects women much more frequently than men, the ratio being 8:1. The onset occurs in the teenage years, always before age of 40. Aortic regurgitation is rare. The pulmonary artery stenosis may also rarely occur. We report the case of a 49-year old female patient with Takayasu arteritis who presented with severe left pulmonary trunk stenosis resulting in pulmonary hypertension, severe aortic regurgitation due to the dilatation of the ascending aorta, mitral insufficiency, critical left renal artery stenosis, and probably with left main coronary artery stenosis. No severe stenosis or occlusion in the mid portion of mid subclavian artery lesion were present. Because the patient presented with serious congestive heart failure, she underwent mitral valvuloplasty and aortic valve replacement. However, the patient died in early postoperative period due to pulmonary hypertension which failed to respond to pharmacotherapy.     

Thrombosis and endocarditis in prosthetic heart valves, a case report.

The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy.     

Should a Regurgitant Mitral Valve Be Replaced Simultaneously with a Stenotic Aortic Valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.     

Severe Right Ventricular Outflow Obstruction by Right Sinus of Valsalva Aneurysm

Aneurysms of the sinus of Valsalva are rarely diagnosed cardiac anomalies, occurring in 0.14%–0.96% of patients who have undergone open heart surgical procedures. The most common congenital anomalies accompanying sinus of Valsalva aneurysm (SVA) are ventricular septal defect, bicuspid aortic valve, atrial septal defect, and coarctation of aorta. We report a patient with an unruptured right SVA presenting with severe right ventricular outflow tract (RVOT) obstruction, and coexisting patent foramen ovale (PFO) with a right to left shunt. It could be assumed that the increase in right atrial pressure due to RVOT obstruction had led to a right to left shunt across the patent foramen ovale. (Echocardiography 2010;27:341‐343)     

Surgical correction and prognostic factors for ascending aortic lesions involving coronary arteries

The prognostic factors following aortic root reconstruction were studied in 19 patients including 13 with annuloaortic ectasia (AAE) and 6 without AAE (non-AAE). The preoperative diagnosis of six non-AAE patients was a dissecting aneurysm in five of the patients and supravalvular aortic stenosis associated with stenosis of the right coronary ostia in one patients. In the AAE group, the Bentall's method was initially selected in 11 patients and the Cabrol's method in the remaining 2 patients. In the non-AAE group, ascending aortic replacement was performed in 4 patients, patch plasty of the ascending aorta in 1 patient, and entry closure in the other patient. In this group, aorto-coronary bypass grafting using a saphenous vein graft was performed in 4 patients, ostioplasty of the right coronary artery (RCA) in 1, and the Bentall's method in 1. During the postoperative acute phase, one AAE patient died of acute myocardial infarction 3 days after surgery; the remaining 18 patients survived. In the follow-up study, 3 patients died of cardiac events which included two cardiac failures and one arrhythmia. The preoperative left ventricular diameter in the end-diastolic phase (LVDd) of 2 AAE patients who died of cardiac failure was 80 mm or larger and the left ventricular function remained unchanged after surgery. One non-AAE patient who underwent RCA ostioplasty suddenly died of arrhythmia. Postanastomotic leakage around the left coronary ostia associated with the patent Cabrol's trick occurred in 1 AAE patient and mitral valve regurgitation occurred in the other non-AAE patient. Reoperation using Cabrol's procedure and mitral valve replacement were performed for these 2 patients, respectively. Preoperative low cardiac function and large LVDd may influence the late results in AAE patients, therefore, earlier operations should be recommended.     

Nongenetically transmitted disproportionate ventricular septal thickening associated with left ventricular outflow obstruction.

Clinical, haemodynamic, and morphological features are described in 2 patients with disproportionate ventricular septal thickening, left ventricular outflow obstruction with systolic anterior motion of the anterior mitral leaflet, and either acquired or congenital heart disease. The disproportionate septal thickening in these patients appeared to be secondary to their underlying cardiac disease rather than a manifestation of genetically transmitted hypertrophic cardiomyopathy. One patient with combined aortic and mitral stenosis had severe systolic anterior motion of the anterior mitral leaflet and a residual large systolic pressure gradient between left ventricle and systemic artery after aortic valve replacement. In this patient the systolic anterior motion was evident in the presence of mitral valve stenosis. The other patient with mild aortic stenosis and a previously repaired coarctation of the aorta also had mild systolic anterior motion and a small subaortic systolic pressure gradient. Hence, these 2 patients demonstrate that disproportionate septal thickening secondary to acquired or congenital heart disease may be associated with left ventricular outflow obstruction and systolic anterior motion of the anterior mitral leaflet.     

Ascending aorta dissecting aneurysm in a teenager with isolated systemic hypertension

A teenager with longstanding arterial hypertension was admitted for acute pneumonia treatment. New onset atypical chest pain for the last months and aortic valve regurgitation were also present. A dissecting aneurysm of the ascending aorta with moderate aortic valve regurgitation was evidenced by laboratorial diagnostic. Aneurismectomy with aortic valve preservation and coronary artery reimplantation was carried out.     

Type A quadricuspid aortic valve and ascending aorta aneurysm: a rare combination

Quadricuspid aortic valve (QAV) is a rare congenital anomaly associated with aortic valve insufficiency and significant morbidity, and requires the replacement or, rarely, the repair of the malfunctioning heart valve. A QAV associated with an ascending aorta aneurysm is an extremely rare anatomic combination with a hypothetical, but not clear, shared embryological etiology. To date, only two cases of type B QAV with ascending aorta aneurysm have been reported. Herein is described the first ever case of a 38-year-old male suffering from severe symptomatic aortic valve regurgitation due to a type A QAV, associated with an ascending aorta aneurism, who underwent a successful combined replacement of the aortic valve and ascending aorta.     

Aortic root dissection. Another cause of early systolic closure of the aortic valve.

An early systolic closure of the aortic valve was recorded in the echocardiogram in two patients with aortic root dissection. This sign, initially described in discrete subaortic stenosis and occasionally observed in mitral regurgitation and interventricular septal defect, has not so far been described in dissecting aneurysm of the aorta.     

超声心动图技术评价人工瓣机能的临床研究

目的 应用经胸(TTE)和经食管超声心动图(TEE)评价二尖瓣(MV)或/和主动脉瓣(AV)置换术后人工机械瓣机能。方法 对201例MV或/和AV置换者频谱测量血流峰值速度和跨瓣压差,评估人工瓣反流及瓣周漏程度;二维超声观察人工瓣,测量手术前后左心房、左心室内径和左心室射血分数(LVEF)。结果 (1)相同瓣位StJude、G-K、On-x人工瓣前向峰值血流速度(Vmax)和跨瓣压差(△P)之间无显著差异。(2)164枚人工MV出现0级反流131例(79.88%),I级反流29例(17.68%);Ⅱ级2例(1.22%);瓣周漏2例(1.22%)。81枚人工AV69例(85.18%)无反流,12例(14.82%)轻度反流。(3)术后左心房、左心室较术前明显缩小,LVEF较术前减低。结论TTE对人工瓣活动、瓣周异常和血流动力学的评判简便易行,TEE具有进一步评价病变部位、程度及术中即刻评价手术效果的优点。     

Nongenetically transmitted disproportionate ventricular septal thickening associated with left ventricular outflow obstruction.

Clinical, haemodynamic, and morphological features are described in 2 patients with disproportionate ventricular septal thickening, left ventricular outflow obstruction with systolic anterior motion of the anterior mitral leaflet, and either acquired or congenital heart disease. The disproportionate septal thickening in these patients appeared to be secondary to their underlying cardiac disease rather than a manifestation of genetically transmitted hypertrophic cardiomyopathy. One patient with combined aortic and mitral stenosis had severe systolic anterior motion of the anterior mitral leaflet and a residual large systolic pressure gradient between left ventricle and systemic artery after aortic valve replacement. In this patient the systolic anterior motion was evident in the presence of mitral valve stenosis. The other patient with mild aortic stenosis and a previously repaired coarctation of the aorta also had mild systolic anterior motion and a small subaortic systolic pressure gradient. Hence, these 2 patients demonstrate that disproportionate septal thickening secondary to acquired or congenital heart disease may be associated with left ventricular outflow obstruction and systolic anterior motion of the anterior mitral leaflet.     

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.     

Ascending aortic aneurysms: composite conduit replacement

From July 1980 to February 1984, 26 patients underwent composite replacement of ascending aortic aneurysm and aortic valve with coronary reimplantation. This group included 14 patients with dissecting aneurysm (ten and four respectively, belonging to Types I and II), and 12 patients with chronic aneurysm (six atherosclerotic aneurysms, two Marfan's syndrome and four annuloaortic ectasia cases). Hospital mortality was 35.7% (5/14) in the dissection subgroups and 16.6% (2/12) in the chronic aneurysm subgroup (difference NS). No operative risk factor was recognized. The 19 survivors have been followed up for a total of 393 patient-months (range 5 to 49 months). Controls included echocardiography and computed tomography scanning. Two patients died because of rupture of a persistently dissected aorta; another patient died of an unknown cause. Total actuarial survival rate at 4 years was 58.3 +/- 10.4% (83.3 +/- 10.7% for chronic aneurysms and 42.3 +/- 13.4% for dissecting aneurysms). Among late survivors, there were no paravalvular leaks, new dissections, or thromboembolisms, although two perigraft hematomas and a persistent dissection were later disclosed. When appropriate, composite conduit replacement of the ascending aorta can increase the survival rate, and can also be useful in high-risk patients.     

Images in cardiovascular medicine: prosthetic aortic valve and conduit dehiscence with large periconduit cavity, ascending aortic aneurysm and severe mitral regurgitation

Prosthetic aortic valve and conduit dehiscence with periconduitcavity and ascending aortic aneurysm is an uncommon complicationof aortic root surgery. It is usually recognizable at echocardiographydue to an abnormal position of the prosthetic valve and conduitin relation to the native aortic annulus in conjunction withan abnormal echolucent periconduit space that fills with colorflow. Mitral regurgitation is an unusual complication of thiscondition. We present a patient with severe mitral regurgitation secondaryto prosthetic aortic valve and conduit dehiscence with a largepericonduit cavity and aneurysm of the intervalvular fibrosa.The mechanism of mitral regurgitation is secondary to functionalinvolvement of the anterior mitral valve leaflet and intervalvularfibrosa with anterior mitral leaflet restriction in conjunctionwith mild left ventricular remodeling. Significant mitral regurgitationpersisted post resection of the periconduit cavity and aorticvalve replacement, requiring mitral valve replacement. This case study reports a new mechanism of mitral regurgitationin the setting of prosthetic aortic valve and conduit dehiscence.