Two-dimensional echocardiographic identification of left ventricular pseudoaneurysm

Nine patients with proved left ventricular pseudoaneurysm after transmural myocardial infarction were studied by two-dimensional echocardiography. In all patients two-dimensional echocardiography successfully displayed the pseudoaneurysm. The unique two-dimensional echocardiographic characteristics of pseudoaneurysm include: a sharp discontinuity of the endocardial image at the site of the pseudoaneurysm communication with the left ventricular cavity, and the presence of a relatively narrow orifice in comparison with the maximum diameter of the pseudoaneurysm fundus; visualization of the maximum diameter of the pseudoaneurysm fundus frequently required a slightly different tomographic view than that required for demonstration of the orifice. The distinctive echocardiographic features of pseudoaneurysm in these patients and technical implications for optimal visualization are described. Most of the pseudoaneurysms we encountered and many of those previously described were located posteriorly. We found the use of inferior angulated view modified from the standard apical four-chamber view extremely helpful in detecting the orifice in patients with posterior or posterolateral pseudoaneurysms. We conclude that two-dimensional echocardiography is an important technique for diagnosis of left ventricular pseudoaneurysm.     

Two-dimensional transthoracic contrast echocardiographic assessment of metastatic left ventricular tumors

To illustrate the usefulness of contrast echocardiography in the assessment of cardiac tumors, we present an 81-year-old female with pathological fracture of the right clavicle in whom biopsy showed poorly differentiated carcinoma. Two-dimensional transthoracic echocardiography found two masses in the left ventricle attached to mid-ventricular septum consistent with metastases. Echo contrast study with octafluoropropane (Optison) showed contrast enhancement of both the masses consistent with high vascularity seen in a malignant tumor.     

Two-dimensional echocardiographic assessment of left ventricular function in chronic obstructive pulmonary disease

In 10 patients undergoing therapy for a mild exacerbation of their chronic obstructive pulmonary disease (COPD), a quantitative two-dimensional echocardiographic (2DE) study was performed together with hemodynamics to assess left ventricular (LV) function. From the 2DE examination, which was made up of parasternal, subcostal, and apical views, measurements of LV short axis end-diastolic and end-systolic areas (A) at the high papillary muscle level and long axis end-diastolic and end-systolic length (L) permitted us to calculate LV end-systolic and end-diastolic volumes (V) using the formula V = 5/6 AL. Compared with the same measurements obtained in a group of 12 normal volunteers, patients with COPD exhibited a markedly reduced LV cavity (LVES, 28.9 +/- 14.6 ml/m2 versus 51.5 +/- 11.0 ml/m2; LVEDV, 67.7 +/- 24.6 ml/m2 versus 103.2 +/- 19.9 ml/m2). An increased thickness of both left ventricular free wall and interventricular septum was also evidenced in patients with COPD. Left ventricular systolic function, assessed using both peak systolic blood pressure/end-systolic volume ratio and calculated left ventricular ejection fraction, was found to be clearly enhanced in patients with COPD. The influence of right ventricular enlargement on left ventricular diastolic function was also investigated in patients with COPD using progressive volume loading and 2DE right ventricular measurements. After a given threshold of volume loading, reduction in stroke index, opposite variations in right and left ventricular size and septal flattening, suggested the occurrence of ventricular interaction.     

Two-dimensional echocardiographic assessment of regional left ventricular function and geometry following myocardial reperfusion

Two-dimensional echocardiography is ideally suited for the serial noninvasive assessment of regional function and geometry following reperfusion therapy. Patients with substantial myocardial salvage show slow but definite recovery in regional function within the first 2 weeks. The extent of recovery seems to be associated with the degree of necrosis. Patients with some salvage, which is not enough to cause recovery in regional function, may demonstrate lack of infarct expansion and left ventricular (LV) dilatation. In the future, newer approaches such as pharmacologic challenge may play a role in defining post-ischemic myocardium early after the ischemic event.     

Two-dimensional echocardiographic appearance of left ventricular thrombi with systemic emboli after myocardial infarction

To test the hypothesis that left ventricular (LV) thrombi that project into the lumen and are mobile are more likely to embolize than those that do not have these characteristics, the 2-dimensional echocardiograms of 16 patients with LV thrombi after myocardial infarction were retrospectively reviewed. Ten had evidence of peripheral embolization and 6 did not. The studies were reviewed in random order by an observer blinded to the clinical data. Each echocardiogram was graded as showing a protruding or nonprotruding thrombus and the presence or absence of increased mobility. The thrombus projected into the lumen on the echocardiograms of 8 of 10 patients who had had emboli and in 0 of 6 who had not. The thrombus had increased mobility in 4 of 10 patients with emboli and 0 of 6 without. Thus, LV thrombi that project into the lumen and have increased mobility are more likely to embolize than those without these characteristics.     

Two-dimensional echocardiographic determinants of interventricular septal configurations in right or left ventricular overload

Configurations of interventricular septum (IVS) and left ventricle were evaluated in 60 normal subjects and in 68 patients with congenital heart disease using two-dimensional short axis cross-sectional echocardiography (2DE). Patients were divided into four groups; right ventricular (RV) pressure overload (n = 21), RV volume overload (n = 12), left ventricular (LV) pressure overload (n = 10), and LV volume overload (n = 25). The radii of curvature of the IVS (IVSr) and LV free wall (FWr) were calculated in end systole and end diastole. Measured IVSr was normalized by dividing IVSr by FWr (IVSr/FWr). End-systolic flattening of IVS was a specific finding in patients with RV pressure overload, since this pattern was not observed in other hemodynamic groups. Echocardiographic determinants of IVSr/FWr in end systole correlated well with RV peak systolic pressure/LV peak systolic pressure ratio (r = 0.878). There was also correlation between IVSr/FWr in end diastole and RV end-diastolic pressure/LV end-diastolic pressure ratio (r = 0.579). Thus, the evaluation of IVS configuration is a useful 2DE method of estimating relative RV systolic pressure in infants and children with congenital heart disease.     

Two-dimensional echocardiographic diagnosis of left atrial myxoma

Two patients with left atrial myxomas detected with one-dimensional echocardiographic studies were evaluated before and after surgery with real-time phased-array two-dimensional echocardiographic studies. This latter technique provided relatively quantitative information regarding the size, shape, and mobility of the tumor and its effect on cardiac function. In case 1, the two-dimensional echocardiogram showed a relatively immobile tumor measuring 3 x 4.5 cm in diameter in the left atrium only. At surgery a 2 x 4.5-cm myxoma that was attached to the left atrium by a broad-based short stalk was removed. In case 2, the left atrial mass appeared to be 3 x 4 cm in diameter, with much movement during the cardiac cycle. At surgery a 3 x 4-cm left atrial myxoma that was attached to the interatrial septum by a long stalk was removed. In both cases, masses in other cardiac chambers were excluded, the mitral valves were normal, and left ventricular function was normal, all of which were confirmed at surgery and by postoperative echocardiograms. In one patient the information obtained by two-dimensional echocardiographic studies was believed to be sufficient to preempt the need for cardiac catheterization. These cases illutstrate that this new noninvasive technique may provide sufficient quantitative preoperative detail in patients with left atrial tumors to obivate the risk and expense of caridac catheterization.     

Two-dimensional echocardiographic imaging of left atrial appendage thrombi

The utility of two-dimensional echocardiography in the diagnosis of left atrial thrombi is well documented. One major limitation of this technique, however, has been the failure to successfully image left atrial appendage thrombi. This report discusses the presumptive diagnosis in three patients of pathologically confirmed left atrial appendage thrombi using a modified short-axis parasternal two-dimensional echocardiographic view.     

Two-dimensional echocardiographic recognition of an aortic intimal flap prolapsing into the left ventricular outflow tract

A 59 year old man presented with dyspnea and a new murmur of aortic regurgitation. Two-dimensional echocardiography demonstrated a to and fro motion of the intimal flap as it prolapsed into the left ventricle and was thrust into the aorta during diastole and systole, respectively. At surgery, the echocardiographic and angiographic findings were confirmed and a proximal aortic dissection was identified. Prolapse of an intimal flap from the aorta into the left ventricular outflow tract represents a new two-dimensional echocardiographic sign of aortic dissection.     

Two-dimensional echocardiographic detection of left ventricular posterior wall motion abnormalities using an inferior angulation view

Two-dimensional echocardiography is frequently used to detect left ventricular (LV) wall motion abnormalities. Modification of the apical 4-chamber view by inferior angulation of the transducer provides a superior image for detection of regional wall motion abnormalities of the LV posterior wall. The inferior angulation image was prospectively compared with the standard parasternal short-axis image for detection of posterior LV wall motion abnormalities as defined by contrast left ventriculography in 63 consecutive patients. Posterior wall akinesia was present on the contrast left ventriculogram in 22 of the 63 patients. The parasternal short-axis image was judged technically inadequate for interpretation in 7 patients (11%). The inferior angulation image was technically adequate for interpretation in all patients. The sensitivity, specificity and accuracy of the inferior angulation image for detection of LV posterior wall motion abnormality was 91%, 80% and 84%, respectively, vs 67%, 71% and 70% for the parasternal short-axis image. The differences between the sensitivity, specificity and accuracy for the 2 views were not statistically significant. These observations indicate that the inferior angulation image provides a useful plane for routine echocardiographic analysis of regional LV wall motion either as a primary method to detect posterior wall motion abnormality or as a confirmatory view to document posterior wall motion abnormality.     

Two-dimensional echocardiographic assessment of anticoagulant therapy in left ventricular thrombosis early after acute myocardial infarction

This study was designed to assess, by two-dimensional echocardiography,the effects of anticoagulant therapy on left ventricular thrombosisdetected after acute myocardial infarction. Thirty-eight patientswith left ventricular thrombi detected by two-dimensional echocardiologywithin 5 weeks (mean 4) of the onset of infarction were randomlyassigned to the following groups: group A consisted of 19 patientswho received oral anticoagulants (acenocoumarin 1.6 mg dailyregulated to keep prothrombin time within the range of 25 to35%) and group B which consisted of 19 non-treated control patients.Seventeen patients from both groups were restudied 15 days,3 months and one year later to evaluate the changes in sizeof thrombi. Echocardiographic examinations were read blindly;a significant decrease in ventricular thrombus size was takenas a 5 mm reduction of thickness in the apical views. In Group A, 9 patients showed a complete resolution of thrombusat the 15 day study; at one year, thrombus had resolved in 15and persisted unchanged in size in 2 patients. The mean dimensionof thrombi in patients of group A was 18±6.6 mm at thescreening examination and decreased to 6.6mm, 3.8mm and 2.2mm,respectively, at 15 days, 3 months and one year follow-up studies.Among 17 patients of group B at the 15 day study, two had resolutionof thrombus and 15 were unchanged; at the one year examinationthrombus was resolved in 4, decreased in size in 4 and persistedunchanged in 9 patients. Analysis of variance of the dimensionalchanges of thrombi in the two groups of patients confirmed asignificant efficacy of anticoagulant therapy (P<0.001). On the basis of our results we conclude that full-dose anticoagulanttherapy, started early (within 5 weeks) after acute myocardialinfarction, is effective in the resolution of left ventricularthrombosis.     

Two-dimensional echocardiographic assessment of left atrial size in children

The ability of 2-dimensional echocardiography (2-D echo) to estimate end-systolic left atrial (LA) size and volume was assessed in 140 infants and children. These subjects were divided into 2 groups. Group A included 91 patients with normal LA volume and Group B included 49 patients with LA volume overload. Five echocardiographic views (left parasternal long-axis, left parasternal short-axis, apical 4-chamber, apical 2-chamber and subcostal 4-chamber) were used. From these views, the LA long-axis and minor-axis lengths were measured and the area was planimetered. These echocardiographically derived measurements were compared with angiographically calculated LA volume. Although all echocardiographic measurements correlated well with angiographic LA volume measurements, the echocardiographic area tracked better than length measurements. Echo LA volume was calculated using 5 single-plane and 3 biplane area-length methods. LA volume calculated from either single- or biplane methods correlated well with angiographically determined LA volume. The degree of correlation depended on the method used. Echocardiographic area and estimated LA volume measured from the parasternal long-axis and apical 2-chamber views best separated patients with LA volume overload from normal. Two-dimensional echo using these views accurately segregated all patients with a LA volume >180% of normal and 15 of 21 patients (71%) with an LA volume between 138% and 179% of normal. Thus, 2-D echo is useful in the evaluation of LA size and volume in Infants and children.