Assessment of transesophageal Doppler echography in dissecting aortic aneurysm

To assess the clinical value of transesophageal Doppler echography in the diagnosis of dissecting aortic aneurysm, both transesophageal and conventional echograms were performed in 22 cases of dissecting aortic aneurysm. Of the 22 patients, 17 underwent angiography; 8, X-ray computed tomography; 4, both; and 12, surgery. The performance of each method was assessed in the following four segments: A, ascending aorta; B, aortic arch; C, thoracic descending aorta; and D, upper abdominal aorta. The results by angiography were presumed to be correct. In the group of 17 patients who underwent angiography, the rate of correct detection of an intimal flap using the transesophageal approach was 100% in all four segments, significantly better than detection by the conventional approach (segment A, 65%; segment B, 47%; segment C, 35%; segment D, 53%) (p less than 0.01), and the rate of correct detection of the entry sites using the transesophageal approach was 100%, significantly better than that by conventional approach (42%) (p less than 0.05). X-ray computed tomography was not capable of detecting the site of entry in all cases. The presence of thrombus, aortic regurgitation and pericardial hemorrhage were all revealed clearly by the transesophageal approach, and the results were partly proved by other methods. In conclusion, transesophageal Doppler echography provides a rapid and accurate method of diagnosing and evaluating dissecting aortic aneurysm and permits prompt initiation of appropriate treatment.     

The utility of color Doppler in dissecting aortic aneurysm

We inform about the utility of Color-Doppler to identify dissection in aortic aneurysm. We studied five patients, fourth with dissection and one without dissection. All of them were in the fourth decade of life, except the patient without dissection, who developed symptoms at the age of 62. Two-dimensional echocardiography displayed the alterations of the aorta, such as dilatation of the walls, the presence or absence of dissection and in the cases with dissection the extension of it (three patients had DeBakey Type I, one DeBakey Type III an other DeBakey Type II). In all patients with dissection the Doppler study determined the presence or absence of flow through the false channel, in particular in the second and fifth patient and with Color-Doppler we observed that the flow was bidirectional. Also the degree of aortic incompetence could be quantified. It is concluded that with two-dimentional echocardiography it is possible to identify the anatomical features of aortic aneurysm and that Doppler study gives additional hemodynamic information which has importance in therapy and prognosis.     

Evaluation of aortic insufficiency by Doppler color flow mapping

The color Doppler echocardiographic studies and aortic angiograms of all patients who had these procedures performed within 2 weeks of each other between October 1984 and August 1985 were reviewed to determine whether any parameters of the regurgitant jet visualized by color Doppler study predicted the severity of aortic insufficiency as assessed by angiographic grading. Patients with an aortic valve prosthesis were excluded. Twenty-nine patients had aortic insufficiency and had adequate color Doppler studies for analysis. The mean time between color Doppler examination and angiography was 2.3 days (range 0 to 12). The maximal length and area of the regurgitant jet were poorly predictive of the angiographic grade of aortic insufficiency. The short-axis area of the regurgitant jet from the parasternal short-axis view at the level of the high left ventricular outflow tract relative to the short-axis area of the left ventricular outflow tract at the same location best predicted angiographic grade, correctly classifying 23 of 24 patients. However, the jet could be seen from this view in only 24 of the 29 patients. The height of the regurgitant jet relative to left ventricular outflow tract height measured from the parasternal long-axis view just beneath the aortic valve correctly classified 23 of the 29 patients. Mitral stenosis or valve prosthesis, which was present in 10 patients, did not interfere with the diagnosis or quantitation of aortic insufficiency by these methods.(ABSTRACT TRUNCATED AT 250 WORDS)     

Assessment of mitral regurgitation by biplane transesophageal color Doppler flow mapping

To test the role of recently developed biplane transesophageal color Doppler echocardiography in the assessment of severity of mitral regurgitation, we examined 51 patients undergoing cardiac catheterization and left ventriculography. Transesophageal color Doppler flow imaging detected mitral regurgitation in all 32 patients proved to have this lesion. In 10 of 16 patients without mitral regurgitation by angiography, mitral regurgitation signals were detected by transesophageal color Doppler flow imaging. Thus, the sensitivity and specificity of transesophageal color Doppler echocardiography for the detection of mitral regurgitation were 100% and 38%, respectively. There was some correlation between the regurgitant jet area from the longitudinal plane and angiographic grading. An improved angiographic correlation was achieved with the regurgitant jet area from the transverse plane. The best correlation with angiography was obtained when the maximum regurgitant jet area from two planes (the greater of the two measurements, each from a different plane) was considered. There was a significant difference in the maximum regurgitant jet area between none and mild (p less than 0.01), mild and moderate (p less than 0.001), and moderate and severe (p less than 0.01) mitral regurgitation. The maximum regurgitant jet area of less than 1.5 cm2 predicted the angiographic grading as none with a sensitivity and specificity of 88% and 94%, respectively. The maximum regurgitant jet of between 1.5 and 4 cm2 predicted the angiographic grading as mild with a sensitivity and specificity of 82% and 95%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

彩色多普勒超声对主动脉夹层动脉瘤的诊断价值

目的　探讨主动脉夹层动脉瘤的声像图特点及其诊断价值。方法　 5 8例主动脉夹层动脉瘤患者行经胸彩色多普勒超声( TTE)检查 ,其中 12例行经食管彩色多普勒超声 ( TEE)检查 ,将超声检查结果与 CT、MRI、血管造影对照分析。结果　 5 8例主动脉夹层动脉瘤依照 Debacky分型为 型 12例 , 型 14例 , 型 32例。其中 5 5例经手术证实 ,另 3例经尸检证实。TTE、TEE、CT、MRI及造影对主动脉夹层动脉瘤的诊断率分别为 84.48%、10 0 %、89.47%、80 .0 0 %及 10 0 %。结论　 TTE对主动脉夹层动脉瘤的诊断具有较高的敏感性 ,可作为无创性检查的首选方法     

Visualization of coronary blood flow by color Doppler imaging with a transesophageal approach

To examine whether CBF can be imaged by color Doppler technique, we visualized CBF using a transesophageal color Doppler imaging system. In 36 of 39 patients with normal coronary arteriograms after heart surgery, the LMT and the proximal LAD were clearly imaged by 2-dimensional echocardiography. Among them, CBF was coded mainly in blue in 32 patients, showing that the flow runs from proximal to distal. In some cases, yellowish and/or reddish components were seen, suggesting the occurrence of aliasing associated with augmentation of flow velocity or flow turbulence. The fast Fourier transformation spectrogram of the pulsed Doppler sampled in the colored flow showed a typical flow velocity pattern of the LAD, which mainly consisted of a predominantly diastolic component. These results indicate that the transesophageal color Doppler technique is advantageous in noninvasively imaging CBF. It should be further sought whether flow abnormality due to coronary stenosis could be determined by this technique.     

彩色多普勒超声诊断主动脉瘤的观察与分析

目的 探讨超声诊断主动脉瘤的可靠性和准确性,评价其临床价值。方法 应用HP2500及TOSHIBA SSA-380A超声诊断仪,检查36例主动脉瘤患者,并将其部分超声检查结果与CT、核磁(MRI)、数字减影血管造影(DSA)及手术结果进行比较。结果 夹层动脉瘤与CT、MRI、DSA检查结果的符合率分别为86%、80%、89%;腹主动脉瘤与MRI、DSA及手术结果的符合率为100%。结论 彩色多普勒超声检查可发现有无主动脉瘤、动脉瘤的大小、范围、搏动和血流状态,对于夹层动脉瘤破裂口的观察、指导临床手术方案的选择有重要意义。     

Quantification of mitral regurgitation: comparison between transthoracic and transesophageal color Doppler flow mapping

We reviewed transthoracic (TTE) and transesophageal (TEE) echocardiograms of 100 consecutive patients: 63 male, 37 female, mean age 50 years (range 16-83 years), 32 with neoplastic disease, 18 aortic disease, 28 mitral valve disease, and 22 with other diseases. Absence or presence of mitral regurgitation (defined as mild, moderate, or severe) was assessed. TEE showed mild mitral regurgitation in 26 patients where TTE was negative. The overall estimate of regurgitant lesion severity was concordant at TEE and TTE in 64% of cases. The overall estimate of regurgitant lesion severity was also greater by one grade in 1% of cases at TTE, and in 35% of cases at TEE. Maximal digitized jet areas were 3.60 +/- 6.35 cm 2 at TTE and 3.04 +/- 3.79 cm 2 at TEE (P = NS). Correlation was r = 0.69 (TEE = 0.41 TTE + 1.55; P less than 0.001). TEE yielded a higher prevalence of mitral regurgitation than TTE with a trend toward greater overall estimate of mitral regurgitation at the semi-quantitative analysis. TTE and TEE showed similar mean results at the quantitative assessment of maximal jet areas. However, a highly significant random variability was observed in quantifying mitral regurgitation at TEE.     

Transesophageal Doppler echocardiography in the diagnosis of dissecting aortic aneurysm

Transesophageal Doppler echocardiography (TEDE) was performed in three patients with proven or suspected DeBakey type I and type III aortic dissection. Case 1: A 66-year-old woman, with DeBakey type I aortic dissection. Clear images of a widened dissected aorta and an intimal flap were obtained in both the ascending and descending aorta, including the aortic arch. The site of an entry into the false lumen was identified by the defect of the intimal flap and the pulsatile entry flow through it. The reentry into the true lumen was also identified near the orifice of the celiac trunk. In this case, the observation was performed using this technique during the operation; i.e., replacement of the ascending aorta with an artificial graft. Case 2: A 77-year-old man, DeBakey type III aortic dissection. The study was performed after surgery which consisted of replacement of the descending aorta with an artificial graft. TEDE provided clear images of the artificial graft, the aorta, and their boundaries. The remaining intimal flap was clearly confirmed. Case 3: An 80-year-old man, DeBakey type III aortic dissection. In this case, though abdominal echography suggested aortic dissection, angiography and X-ray CT failed to facilitate the diagnosis. Only TEDE confirmed the diagnosis. The abnormal flow via the entry directing toward the false lumen was clearly demonstrated on the color Doppler images. We therefore conclude that TEDE is a useful and reliable means of diagnosing dissecting aortic aneurysm.     

The flail mitral valve: echocardiographic findings by precordial and transesophageal imaging and Doppler color flow mapping

To determine the echocardiographic and Doppler characteristics of mitral regurgitation associated with a flail mitral valve, precordial and transesophageal echocardiography with pulsed wave and Doppler color flow mapping was performed in 17 patients with a flail mitral valve leaflet due to ruptured chordae tendineae (Group I) and 22 patients with moderate or severe mitral regurgitation due to other causes (Group II). Echocardiograms were performed before or during cardiac surgery; cardiac catheterization was also performed in 28 patients (72%). Mitral valve disease was confirmed at cardiac surgery in all patients. By echocardiography, the presence of a flail mitral valve leaflet was defined by the presence of abnormal mitral leaflet coaptation or ruptured chordae. Using these criteria, transesophageal imaging showed a trend toward greater sensitivity and specificity than precordial imaging in the diagnosis of flail mitral valve leaflet. By Doppler color flow mapping, a flail mitral valve leaflet was also characterized by an eccentric, peripheral, circular mitral regurgitant jet that closely adhered to the walls of the left atrium. The direction of flow of the eccentric jet in the left atrium distinguished a flail anterior from a flail posterior leaflet. By transesophageal echocardiography with Doppler color flow mapping, the ratio of mitral regurgitant jet arc length to radius of curvature was significantly higher in Group I than Group II patients (5.0 +/- 2.3 versus 0.7 +/- 0.6, p less than 0.001); all of the Group I patients and none of the Group II patients had a ratio greater than 2.5.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of transthoracic and intraoperative transesophageal color flow Doppler assessment of mitral and aortic regurgitation

BACKGROUND: We examined the agreement between transthoracic echocardiography (TTE) and intraoperative prepump transesophageal echocardiography (TEE) in the assessment of left-sided regurgitant lesions and echocardiographic variables associated with grading discrepancies. METHODS: The TTE and prepump TEE studies of 54 patients undergoing aortic-valve replacement for aortic stenosis were reviewed. Agreement and correlation in assessment of aortic (AR) and mitral regurgitation (MR) severity were evaluated. RESULTS: There was no significant difference between mean TTE and prepump TEE grading of MR (0.23 +/- 0.19 vs. 0.21 +/- 0.15 jet area/area of the left atrium, p = 0.49), but the correlation between the two methods was weak (r = 0.40, p = 0.003), with an exact agreement of 54%. Prepump TEE tended to grade AR as more severe (mean grade 1.43 +/- 0.94 vs. 1.24 +/- 0.75, p = 0.058). The correlation between the two methods in AR assessment was fair (r = 0.70, p = 0.0001) with an agreement of 59%. For MR and AR grading, no significant correlations between valvular regurgitation severity and blood pressure differences between preoperative TTE and prepump TEE were found. In 17% of cases, discrepancies in identifying severe mitral or aortic valve regurgitation could have affected patient management. CONCLUSIONS: There is modest agreement in MR and AR assessment between TTE and prepump TEE. Cardiologists, cardiac surgeons, and anesthesiologists must be aware of differences between these methods when using prepump TEE to guide intraoperative decisions.     

Familial aortic dissecting aneurysm

A family is described in which nine members over two generations had an aortic dissecting aneurysm or aortic or arterial dilation at a young age. The family has been followed up since 1977 after the death of a second teenager from a kindred of 11. None of the patients had the Marfan syndrome or a history of systemic hypertension. Three members died of ruptured aortic dissecting aneurysm and acute hemopericardium at 14, 18 and 24 years of age, respectively; a fourth member died suddenly at age 48 years, a few years after aortic repair for aneurysmal dilation. One member underwent surgical repair of an ascending aortic dissecting aneurysm at age 18 years and is still alive. Four members are currently under close medical observation for aortic or arterial dilation. Histologic examination of the aortic wall at autopsy or surgery in three patients revealed a loss of elastic fibers, deposition of mucopolysaccharide-like material in the media and cystic medial changes. Types I and III collagen from cultured fibroblasts appeared normal on gel electrophoresis. Results of indirect immunofluorescent studies of the elastin-associated microfibrillar fiber array in skin and fibroblast culture from multiple family members were also normal. This dramatic familial cluster of aortic dissecting aneurysm and aortic or arterial dilation suggests a genetically determined disease of autosomal dominant inheritance although the basic defect remains unknown.     

Acute dissecting thoracic aortic aneurysm in a patient with polymyalgia rheumatica

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related disorders found in older patients, and vasculitis has been proposed as a part of the pathogenesis of PMR. We describe a female patient with PMR plus aortitis, both of which were well controlled on maintenance steroid therapy. Six months after the onset of her condition, however, she suddenly presented with chest pain. A diagnosis of dissecting aortic aneurysm was confirmed, and the aorta was successfully resected. Histology revealed infiltration of mononuclear cells including giant cells around the vaso vasorum with disruption of elastic lamina of the resected aorta. PMR or GCA may indicate an increased risk for aortic dissection in patients with normal erythrocyte sedimentation rate or C-reactive protein, and prompt recognition and therapy, not only during the active disease but also after symptoms of PMR have resolved, are needed.     

Assessment of aortic regurgitation by transesophageal color Doppler imaging of the vena contracta: validation against an intraoperative aortic flow probe

OBJECTIVES: This study was performed to validate the accuracy of color flow vena contracta (VC) measurements of aortic regurgitation (AR) severity by comparing them to simultaneous intraoperative flow probe measurements of regurgitant fraction (RgF) and regurgitant volume (RgV). BACKGROUND: Color Doppler imaging of the vena contracta has emerged as a simple and reliable measure of the severity of valvular regurgitation. This study evaluated the accuracy of VC imaging of AR by transesophageal echocardiography (TEE). METHODS: A transit-time flow probe was placed on the ascending aorta during cardiac surgery in 24 patients with AR. The flow probe was used to measure RgF and RgV simultaneously during VC imaging by TEE. Flow probe and VC imaging were interpreted separately and in blinded fashion. RESULTS: A good correlation was found between VC width and RgF (r = 0.85) and RgV (r = 0.79). All six patients with VC width >6 mm had a RgF >0.50. All 18 patients with VC width <5 mm had a RgF <0.50. Vena contracta area also correlated well with both RgF (r = 0.81) and RgV (r = 0.84). All six patients with VC area >7.5 mm2 had a RgF >0.50, and all 18 patients with a VC area <7.5 mm2 had a RgF <0.50. In a subset of nine patients who underwent afterload manipulation to increase diastolic blood pressure, RgV increased significantly (34 +/- 26 ml to 41 +/- 27 ml, p = 0.042) while VC width remained unchanged (5.4 +/- 2.8 mm to 5.4 +/- 2.8 mm, p = 0.41). CONCLUSIONS: Vena contracta imaging by TEE color flow mapping is an accurate marker of AR severity. Vena contracta width and VC area correlate well with RgF and RgV obtained by intraoperative flow probe. Vena contracta width appears to be less afterload-dependent than RgV.     

Visualization of mitral valve aneurysm by transesophageal echocardiography

This article describes the transesophageal echocardiographic findings in a patient with pathologically proven mitral valve aneurysm. This aneurysm probably occurred as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a saccular structure attached to the left atrial side of the anterior mitral leaflet with systolic expansion and diastolic collapse, and its orifice was visualized with excellent resolution. Transesophageal echocardiography is a useful diagnostic tool for evaluation of mitral valve aneurysm.