A rare case of Ewing's sarcoma/primitive neuroectodermal tumor metastasizing to left atrium through left inferior pulmonary vein

Cardiac metastasis of Ewing's sarcoma is exceedingly rare. A 40‐year‐old male was admitted with complaints of nonproductive cough, exertional dyspnea, and fatigue since 4 months with a history of abdominal wall swelling which was excised and proven to be Ewing's sarcoma/primitive neuroectodermal tumor (PNET). A transthoracic echocardiography demonstrated inhomogeneous mass located posterior to the left ventricle and a solitary mass protruding into the left atrium through the left inferior pulmonary vein. Due to accompanying pulmonary metastasis and possible poor outcome of the surgery, surgical resection was not considered.     

Assessment of left atrium and diastolic dysfunction in patients with hypertensive retinopathy: A real-time three-dimensional echocardiography-based study

The fundoscopic examination of hypertensive patients, which is established hypertension-related target organ damage (TOD), tends to be underutilized in clinical practice. We sought to investigate the relationship between retinal alterations and left atrium (LA) volumes by means of real-time three-dimensional echocardiography (RT3DE). Our population consisted of 88 consecutive essential hypertensive patients (age 59.2 ± 1.2 years, 35 males). All subjects underwent a fundoscopy examination and were distributed into four groups according to the Keith-Wagener-Barker (KWB) classification. The four groups (KWB grades 0–3: including 26, 20, 26, and 16 patients, respectively) did not differ with regard to age, gender, or metabolic profile. There were no significant differences between groups with regard to parameters reflecting LV systolic function and diastolic dysfunction (DD) in two-dimensional echocardiography (2DE). Nevertheless, patients in the higher KWB category had higher values of LA volumes (LA maximal volume index, LA minimal volume index, preatrial contraction volume index, LA total stroke volume index, LA active stroke volume index, p < 0.001) regarding RT3DE. There is also a significant relationship between LA active stroke volume index (ASVI) and duration of hypertension (HT) (r: 0.68, p < 0.001). In the logistic regression analysis, ASVI was independent predictors of LV DD in patients with arterial hypertension (HT). Patients with arterial HT were found to have increased LA volumes and impaired diastolic functions. Assessment of the arterial HT patient by using RT3DE atrial volume analysis may facilitate early recognition of TOD, which is such a crucial determinant of cardiovascular mortality and morbidity.     

Evaluation of the left ventricular diastolic function using three-dimensional echocardiography

The aim of this study was to evaluate the left ventricular (LV) diastolic function parameter calculated using three‐dimensional (3D) echocardiography. Method: Using 3D echocardiography and an analysis software program, the left ventricular volume through the cardiac cycle was measured automatically. We therefore calculated 25%, 50%, and 75% of the subtraction end‐systolic volume (ESV) from the end‐diastolic volume (EDV). The period that the left ventricular volume reached those volumes was calculated from the ESV. Those periods divided all diastolic periods and those calculated values were named D1/4, D1/2, and D3/4, respectively. The peak‐filling rate and 1/3 filling fraction (FF) were calculated. E/A, mitral annulus velocities (E′), E/E′, ejection fraction (EF), and left ventricular end‐diastolic pressure (LVEDP) were also measured. Results: E/A significantly correlated with D3/4. E/E′significantly correlated with the D1/4, D1/2, and 1/3 filling fraction. E′had a significantly negative correlation with the D1/4, D1/2, D3/4, and 1/3 FF. DT significantly correlated with D1/4, D1/2, D3/4, 1/3 FF, and the mean filling rate and it had a significant negative correlation with the 1/3 filling fraction. EF showed a significant positive correlation with the peak filling ratio. LVEDP demonstrated a significant correlation with D1/4 and D1/2. Conclusion: This study suggests that the LV diastolic indexes as determined by 3D echocardiography provide useful information in the clinical assessment of the diastolic LV function.     

Quantification of the area and shunt volume of multiple,circular, and noncircular ventricular septal defects: A 2D/3D echocardiography comparison and real time 3D color Doppler feasibility determination study

Background

Quantification of defect size and shunt flow is an important aspect of ventricular septal defect (VSD) evaluation. This study compared three‐dimensional echocardiography (3DE) with the current clinical standard two‐dimensional echocardiography (2DE) for quantifying defect area and tested the feasibility of real time 3D color Doppler echocardiography (RT3D‐CDE) for quantifying shunt volume of irregular shaped and multiple VSDs.

Methods

Latex balloons were sutured into the ventricles of 32 freshly harvested porcine hearts and were connected with tubing placed in septal perforations. Tubing was varied in area (0.13–5.22 cm²), number (1–3), and shape (circle, oval, crescent, triangle). A pulsatile pump was used to pump “blood” through the VSD (LV to RV) at stroke volumes of 30–70 mL with a stroke rate of 60 bpm. Two‐dimensional echocardiography (2DE), 3DE, and RT3D‐CDE images were acquired from the right side of the phantom.

Results

For circular VSDs, both 2DE and 3DE area measurements were consistent with the actual areas (R² = 0.98 vs 0.99). For noncircular/multiple VSDs, 3DE correlated with the actual area more closely than 2DE (R² = 0.99 vs 0.44). Shunt volumes obtained using RT3D‐CDE positively correlated with pumped stroke volumes (R² = 0.96).

Conclusions

Three‐dimensional echocardiography (3DE) is a feasible method for determining VSD area and is more accurate than 2DE for evaluating the area of multiple or noncircular VSDs. Real‐time 3D color Doppler echocardiography (RT3D‐CDE) is a feasible method for quantifying the shunt volume of multiple or noncircular VSDs.     

Underestimation of left atrial volume by three-dimensional echocardiography validated by magnetic resonance imaging: a meta-analysis and investigation of the source of bias

Background: Left atrial volume (LAV) is a fundamental prognostic factor in a variety of cardiac diseases including atrial fibrillation, heart failure, and valvular diseases. Developing a repeatable, noninvasive, and accurate method of measuring LAV is crucial. Three‐dimensional echocardiography (3DE) has achieved better estimation of LAV than two‐dimensional echocardiography. However, underestimation of LAV by 3DE has often been reported and no previous study has synthesized these data. The present study aimed at revealing existence and extent of bias in LAV measurement by 3DE and investigating related factors affecting the bias. Methods: Studies comparing LAV between 3DE and magnetic resonance imaging published before August 15, 2011 were eligible. A meta‐analysis with random effects model was performed to evaluate the systematic bias. Factors affecting the bias were investigated by univariate followed by multivariate analysis. Results: A total of 14 studies including 395 subjects revealed underestimation of LAV by 3DE (?9.4 mL; 95% confidence interval, ?13.2 to ?5.6mL; P < 0.00001, Fig. 2 ). Existence of cardiac disease led to more underestimation, whereas increasing the number of plane included in the analysis counteracted the underestimation (P < 0.00001 for each comparison). Conclusions: Only by synthesizing a number of small studies as a meta‐analysis could we display underestimation of LAV by 3DE and factors influencing the systematic bias. These data provide a more detailed basis for analyzing and improving the accuracy of 3DE, an indispensable step toward further clinical application in LAV assessment. (Echocardiography 2012;29:385‐390)

Figure 2 Open in figure viewer PowerPoint Meta‐analysis of difference in left atrial volume between 3D‐echocardiography and magnetic resonance imaging. Note the significant underestimation of left atrial volume by 3D‐echocardiography. 3DE = three‐dimensional echocardiography; CI = confidence interval; Max = maximal volume; Min = minimal volume; MRI = magnetic resonance imaging; Nl = normal subjects; pl = planes; Pt = patients.     

Congenital submitral aneurysm with rupture into the left atrium: assessment by 2D and 3D transesophageal echocardiography

We describe two cases of congenital submitral aneurysms (SMAs) in which three-dimensional transesophageal echocardiography (3D TEE) proved useful to define the spatial extent of these aneurysms. In both cases, rupture into the left atrium was accurately delineated. 3D TEE was useful in case 1 as it depicted the precise site of rupture into the left atrium as well as pseudoprolapse of the P2 segment of the mitral valve. In case 2 it also localized the rupture into the left atrium in relation to the annulus to be adjacent to the anterolateral commissure. In addition, a cleft between the A1 and A2 scallops were identified and together with failure of the leaflets to coapt enabled the mechanisms contributing to the mitral regurgitation to be elucidated. Thus, imaging from the left atrial perspective using 3D TEE provided superior spatial anatomical delineation of the rupture and its relationship to the mitral valve, as well as accurate anatomical definition of the mitral leaflets. This information provides added benefit to the surgeon in planning a transatrial surgical repair of the SMAs. 3D TEE is superior to conventional 2D TEE in defining the spatial anatomy of SMAs as well as the mechanisms contributing to mitral regurgitation.     

Prenatal diagnosis of fetal absent pulmonary valve syndrome by two‐ and three‐dimensional echocardiography

Absent pulmonary valve syndrome (APVS) is a rare congenital cardiac anomaly characterized by hypoplastic or even absent pulmonary valve, to‐and‐fro flow across the pulmonary valve annulus, and dilatation of main pulmonary artery and branches. It is crucial to evaluate the degree of dilatation of pulmonary arteries and the presence of associated malformation and chromosomal anomalies affecting pregnancy decision. We described two‐ and three‐dimensional (3D) echocardiographic findings of one fetus with APVS and indicated the beneficial contribution of 3D technology in understanding the anatomy.     

Two-dimensional color Doppler echocardiography for left ventricular stroke volume assessment: a comparison study with three-dimensional echocardiography

Aim: Whether measurement of left ventricular outflow tract diameter (LVOTd) using color Doppler (CD) in order to more accurately define LVOTd is more accurate for determination of stroke volume (SV) than gray scale and compare it with direct measurement of LVOT area (a) using three‐dimensional echocardiography (3DE) for SV determination. Methods and Results: Twenty‐one volunteers were examined. LVOTa was calculated by two‐dimensional echocardiography (2DE) using the following formula: π× (d/2)², d = LVOT diameter by gray scale and CD, respectively. Planimetry of LVOTa was performed in parasternal long axis using 3DE. Eccentricity Index was calculated using the lateral and anterior‐posterior LVOTd. SV was obtained by four different methods: (1) 2D gray scale, (2) 2D color, (3) LVOTa × LVOT velocity time integral, and (4) SV by Simpson's biplane method. Gray scale LVOTd was significantly smaller compared to LVOTd obtained with CD (P < 0.05). Significant differences occurred between LVOTa gray scale and CD (3.29 ± 0.74 cm² vs 3.67 ± 0.70 cm², P < 0.05) and between LVOTa calculated by gray scale in comparison to 3DE planimetry; (3.29 ± 0.74 cm² vs 3.61 ± 0.89 cm², P = 0.011). Half of the subjects had at least 17% difference between the lateral and anterior‐posterior LVOTd. There were significant differences between SV by 2D gray scale and 2D CD (82.8 ± 17.1 mL vs 92.4 ± 16.8 mL, P < 0.05) and between 2D gray scale and 3DE planimetry (82.8 ± 17.1 mL vs 90.7 ± 19.8 mL, P = 0.025). Conclusion: Our study demonstrates LVOT being frequently elliptical. SV and LVOTa were found to be similar when comparing 2DE CD and 3DE planimetry and showed higher values in comparison to 2DE gray scale, which suggests 2DE CD to be an alternative approach for SV assessment.     

Delineation of the etiology of a mass-like echo density in the left ventricle using three-dimensional transthoracic echocardiography

Live/real time three-dimensional transthoracic echocardiography (3DTTE) provides an incremental value in the delineation of various cardiac pathologies. In this study, two-dimensional transthoracic echocardiography (2DTTE) of a 56-year-old patient showing a prominent echo density suggestive of a mass in the left ventricle probably attached to the ventricular side of the anterior mitral leaflet, is reported. Systematic cropping of the 3DTTE dataset showed the mass to be a calcified mitral strut chord viewed in cross section. This is well visualized in the accompanying movie clip. This case highlights the advantage of 3DTTE in which the whole of the ventricle including the mitral valve apparatus is captured in the dataset facilitating cropping at any desired angulation.     

Free-floating ball thrombus in the left atrium

 Free-floating ball thrombi in the left atrium are rarely seen. They can cause sudden death by occluding the mitral valve. A 47-year-old female patient who showed signs of mitral stenosis during a physical examination and atrial fibrillation by electrocardiography was not administered anticoagulant therapy. On the transthoracic echocardiogram, a stenotic mitral valve and a floating mobile mass were seen inside the large left atrium. This mass was rounded (ball-like), had smooth contours, and occasionally occluded the stenotic mitral valve. The patient underwent emergency surgery to remove the mass, which was later proven to be a thrombus pathologically. Additionally, mitral valve replacement was performed. The importance of anticoagulant therapy for patients with rheumatic mitral stenosis has been emphasized by this case. Received: January 30, 2002 / Accepted: March 23, 2002     

Incremental value of live/real time three‐dimensional transesophageal echocardiography over the two‐dimensional technique in the assessment of a tuberculoma involving the left atrium and appendage

Intracardiac tuberculomas are extremely rare, and cardiac involvement in tuberculosis accounts for only 0.5% of extrapulmonary tuberculosis. We report for the first time incremental value of live/real time three‐dimensional transesophageal echocardiography over two‐dimensional transesophageal echocardiography in the assessment of a tuberculoma involving the left atrium and left atrial appendage.