Role of echocardiography in patients with coronary artery disease.

Impaired left ventricular performance, one of the hallmarks of coronary artery disease, can be detected by echocardiography in various ways. One of these approaches is the recording of abnormal wall motion. Because of the way in which the left ventricle can be examined echocardiographically, this technique has the capability of detecting regional wall abnormalities. In fact echocardiography is probably the most sensitive technique available, including even contrast ventriculography, for the detection of akinetic, hypokinetic or dyskinetic wall segments. With increasing experience it is apparent that more areas of the left ventricle can be examined echocardiographically than had previously been thought possible. Newer techniques include directing the ultrasonic beam not only through the body of the left ventricle but also toward the apical portion of the ventricle near the vicinity of the papillary muscles. In addition the true anterior left ventricular wall can be examined by moving the transducer laterally away from the left sternal border. Yet another approach utilizes a subxiphoid position for the transducer while the ultrasonic beam is directed through the medial portion of the septum and posterolateral wall of the left ventricle. M-mode scanning techniques together with recently developed cross-sectional echocardiographic instruments give great promise of improved detection of abnormalities of ventricular shape, especially the presence of aneurysms. The cross-sectional approach makes it possible to examine the left ventricular apex, an area virtually impossible to record with M-mode echocardiography. Recording of left ventricular dimensions and abnormal mitral valve motion may help in assessing overall left ventricular performance. A dilated left ventricular dimension in the vicinity of the mitral valve seems to be an ominous finding both in patients with acute myocardial infarction and in patients with chronic coronary disease being considered for possible surgery. Another echocardiographic sign of abnormal ventricular performance is altered closure of the mitral valve, which reflects a significantly elevated left ventricular diastolic pressure. These echocardiographic techniques are still in the investigational stages and are more technically difficult than the usual echocardiographic applications. However, the preliminary data are encouraging and make us hopeful that echocardiography will prove to be an important tool in the overall evaluation of the left ventricle in patients with coronary artery disease.     

Rheumatic mitral stenosis: cross-sectional echocardiographic analysis

Twenty-one patients with rheumatic mitral stenosis diagnosed by both M-mode echocardiography and hemodynamic findings were subjected to detailed cross-sectional echocardiographic studies. The age of the patients ranged from 27 to 79 years with 76% females. Left ventricular longitudinal, short axis, and apical four-chamber cross-sectional echocardiographic views were obtained in each patient. Three predominant patterns of anterior mitral leaflet motion on left ventricular longitudinal view were observed and correlated with the severity of mitral stenosis: Pattern A (eight patients) with diastolic leaflet doming and restricted leaflet tip motion, Pattern B (eight patients) with restricted tip and body leaflet motion, and Pattern C (five patients) with the entire leaflet motion restricted. Mitral valve prolapse as a rebound phenomenon was observed in three patients who had marked leaflet doming in Pattern A and two had severe obstruction. The longitudinal cross-sectional echocardiography was superior to the apical view in assessing the diastolic doming motion of the anterior mitral leaflet. Thus, longitudinal cross-sectional echocardiographic analysis of the pliability and degree of doming of the anterior mitral leaflet is valuable in estimating the severity of mitral stenosis.     

Assessment of left ventricular dimensions and function by echocardiography

Left ventricular dimensions and function indexes were measured in 40 patients with cardiac disease by both angiocardiographic and echocardiographic techniques. Good correlation was obtained between echocardiographic and angiographic values in 18 patients with technically excellent studies obtained by both techniques. The left ventricular echogram appears to be an effective technique for the noninvasive determination of left ventricular dimensions and volume. Echocardiographic indexes of ventricular function, including percent shortening of internal diameter, mean shortening velocity of internal diameter, ejection fraction, percent thickening of posterior wall and mean posterior wall velocity, distinguished between groups of patients with normal and abnormal left ventricular function. However, a single echocardiographic or angiographie measurement does not appear to provide selective data for the accurate functional classification of most individual patients.     

Echocardiographic features of free floating thrombus mimicking right ventricular myxoma

M-mode and cross-sectional echocardiography performed in a patient with acute pulmonary embolism showed a sausage shaped, mobile mass in the right ventricular cavity highly suggestive of a right ventricular myxoma. Emergency thoracotomy 24 hours later showed the right ventricle to be free of tumour but both pulmonary arteries contained embolised venous thrombi, one or more of which were thought to have given rise to the false echocardiographic diagnosis of a right ventricular tumour.     

Echocardiographic features of free floating thrombus mimicking right ventricular myxoma.

M-mode and cross-sectional echocardiography performed in a patient with acute pulmonary embolism showed a sausage shaped, mobile mass in the right ventricular cavity highly suggestive of a right ventricular myxoma. Emergency thoracotomy 24 hours later showed the right ventricle to be free of tumour but both pulmonary arteries contained embolised venous thrombi, one or more of which were thought to have given rise to the false echocardiographic diagnosis of a right ventricular tumour.     

Echocardiographic classification of complete atrioventricular canal defects

M-mode echocardiographic records of 26 patients with surgically proven complete atrioventricular canal defect were reviewed. Fragmentation of the interventricular septum and anterior displacement of the mitral annulus into the left ventricular outflow tract were noted in all patients. In 25 of 26 a common atrioventricular valve leaflet echo could be identified in the left ventricular outflow tract at the area of the crest of the interventricular septum. Recordings of echographic scans performed in the area of the left ventricle demonstrated separate “mitral” and “tricuspid” contributions to atrioventricular valve echoes in all 13 patients with type A defect, and a single common atrioventricular valve leaflet in 10 of 11 patients with type C complete atrioventricular canal. Two patients with type B defect had findings intermediate between these two patterns. M-mode echocardiography presumptively diagnosed complete atrioventricular canal in all 26 patients and diagnosis was definitive in 25 of 26. In addition, echocardiographic atrioventricular valve patterns permitted anatomic classification in the large majority of cases.     

Two-dimensional echocardiography in the detection of noneffusive cardiac involvement by intrathoracic neoplasms

Two-dimensional echocardiographic (2DE) findings in four patients with predominantly noneffusive manifestations of intrathoracic neoplasms are presented. In cases Nos. 1 and 2 tumor masses were identified in the left atrioventricular groove area at a time when the left-heart border was obscured by a large pleural effusion on chest x-ray examination. Case No. 3 demonstrated distortion of right ventricular anatomy by a compressing extrinsic mass lesion. In these three cases the neoplasm itself or the complicating pleural effusion provided additional echocardiographic windows for visualizing the heart. Case No. 4 demonstrated dilation of the main pulmonary artery secondary to tumor compression of the left pulmonary artery with regression of the dilation following resection. The relative applicability of 2DE and M-mode techniques and their clinical relevance in tumor patients are delineated.     

Unusual echocardiographic appearances attributable to submitral calcification simulating left ventricular “masses”

Using M-mode and cross-sectional echocardiography, we visualized in five patients abnormal large echos attributable to anterior submitral calcification or sclerosis (on or near the ventricular aspect of the anterior mitral leaflet). Such abnormal echos on M-mode echocardiography could have been mistaken for a mass in the left ventricular chamber. Autopsy in two cases confirmed the presence of nonrheumatic anterior submitral calcification. Echocardiographic features of anterior submitral calcification which are helpful in differentiating it from neoplastic or thrombotic ventricular masses include (1) less diastolic mobility and more echo density; (2) continuity with the base of the anterior mitral leaflet and/or the posterior aortic root region, whereas tumors or thrombi are attached to the left ventricular wall; and (3) calcification in the region of posterior “mitral annulus.” Cross-sectional long-axis views and M-mode scanning from the left ventricle to the aortic root were particularly helpful in making the differentiation.     

Tissue acoustic properties of fresh left ventricular thrombi and visualization by two dimensional echocardiography: Experimental observations

Although two dimensional echocardiography can detect left ventricular thrombi In certain cardiovascular disease states, there Is theoretical concern that the acoustic Impedance properties of recently formed fresh thrombi may not allow their echocardiographic visualization. If such were the case, false negative studies might occur even with technically adequate echocardiographic examinations. To determine if the tissue acoustic properties of acute thrombi allow their visualization and differentiation from surrounding intracavitary blood and adjacent myocardium with two dimensional echocardiography, an in vivo canine model of acute left ventricular thrombus was studied. In 10 dogs left ventricular thrombus was induced using coronary ligation and subendocardial injection of a sclerosing agent, sodium rlclnoleate. Acoustically distinct left ventricular thrombi were imaged by two dimensional echocardiography within hours (mean ± standard deviation 121 ± 40 minutes, range 45 to 180), and the thrombi could easily be differentiated from surrounding blood and adjacent myocardium. Thrombi with a maximal dimension as small as 0.6 cm at autopsy were highly reflective and could be imaged with echocardiography. Histologic examination of the thrombi showed characteristic features of early thrombosis. In six dogs, echocardiographic imaging revealed two acoustically distinct areas of thrombi. Gross and microscopic examination of the thrombi in these animals confirmed two distinct types of thrombus with differing histologie features.Although technical aspects of the echocardiographic examination or certain biologic features of thrombi such as thrombus size may limit the detection of thrombi by echocardiography in certain situations, our data indicate that the tissue acoustic properties of recently formed thrombi are not a primary limitation to their echocardiographic detection. These findings support the use of two dimensional echocardiography in the investigation of the natural history, prevention and therapy of left ventricular thrombus in patients during the early course of acute myocardial Infarction.     

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.     

Echocardiographic recognition and implications of ventricular hypertrophic trabeculations and aberrant bands

The accuracy of two-dimensional echocardiography in the recognition of aberrant ventricular bands and pathologic trabeculations (hypertrophic, fibrotic, or both) was assessed in 35 patients who underwent cardiac transplantation and pathologic examination. At pathologic study the prevalence of specific intracavitary structures ranged from 28% to 43%. Left ventricular thrombi were found in 12 patients (34%) and right ventricular thrombi in three (9%). Echocardiography accurately defined left ventricular aberrant bands and left ventricular thickened or fibrotic trabeculations. Bands, trabeculations, and thrombi each showed characteristic echocardiographic patterns. In the right ventricle, these structures were recognized, but accurate discrimination among them was not possible by echocardiography. Aberrant bands and pathologic trabeculations mimicked or obscured fresh or organized thrombi in three patients on two-dimensional echocardiography. Left ventricular longitudinal bands and pathologic right ventricular trabeculations obscured the interventricular septal border in four patients; the presence of these abnormalities could lead to the erroneous diagnosis of asymmetric septal hypertrophy on M mode echocardiography. By expressing the accuracy of two-dimensional echocardiography in the recognition of left ventricular anomalous bands, our results support the feasibility of prospective studies to clarify their clinical significance.     

Prognostic value of left ventricular size measured by echocardiography in infants with total anomalous pulmonary venous drainage

Left ventricular size may be a determinant of survival in infants with total anomalous pulmonary venous drainage. Right and left ventricular size were measured by M-mode and 2-dimensional (2-D) echocardiography in 13 patients aged 1 day to 4 months (mean weight 4.3 ± 0.42 kg [standard error of the estimate]) who underwent surgery before age 4 months because of severe cyanosis or cardiac failure. Seven patients had venous drainage to a vertical vein, 4 had drainage to the right atrium, and 2 had drainage to the inferior vena cava. Patients were divided into 2 groups: survivors (Group A, n = 8) and nonsurvivors (Group B, n = 5). Death was not statistically related to pulmonary artery pressure, pulmonary venous obstruction, age, or weight at the time of surgery. Right and left ventricular sizes at end-diastole measured from M-mode traces and 2-D echocardiographic 4-chamber views were compared with those from 15 weight-matched control infants. On M-mode and 2-D echocardiography, nonsurvivors had significantly larger right ventricles and smaller left ventricular dimensions than did either control subjects or surviving patients with total anomalous pulmonary venous drainage. The ratio of right to left ventricular size on M-mode and 2-D echocardiography also differed among the 3 infant groups (p < 0.001). The ratio of right to left ventricular size differentiated nonsurvivors from survivors and control subjects. Postmortem examinations available in 4 of the 5 nonsurvivors demonstrated that the ratio of right to left ventricular size in the specimens closely agreed with the 2-D echocardiographic ratios. Our study agrees with the impression of other investigators that left ventricular size may be a determinant of survival after repair of total anomalous pulmonary venous drainage.     

Left ventricular function at rest and during Raynaud's phenomenon in patients with scleroderma

We evaluated left ventricular function in 10 scleroderma patients with signs and symptoms suggestive of congestive heart failure. M-mode and two-dimensional echocardiography demonstrated normal to increased systolic function in all patients. The presence of pulmonary venous congestion on the chest radiograph was not useful in assessing left ventricular systolic function. Five of nine patients with normal to increased left ventricular ejection fraction (LVEF) had increased cardiothoracic ratios and increased pulmonary vascular markings. Left ventricular hypertrophy was associated with a worse New York Heart Association functional class, more pulmonary vascular congestion, and greater left atrial size. In the presence of normal systolic function and ventricular hypertrophy, diminished left ventricular diastolic compliance may account for the cardiac dysfunction in these patients. Cold pressor testing induced peripheral Raynaud's phenomenon in nine of nine patients; however, no ST segment changes or chest pain was provoked. In seven of nine patients there was no abnormal fall in LVEF. The mechanism for the fall in ejection fraction seen in two patients may be related to an increase in afterload or myocardial ischemia secondary to coronary atherosclerosis. We found little to suggest that a myocardial Raynaud's phenomenon affects left ventricular perfusion or systolic function. Clinical signs and symptoms of congestive failure as well as chest radiographs are poor indicators of impaired systolic function in scleroderma patients. Based on these findings, it appears that evaluation of left ventricular systolic function should include echocardiographic or angiographic study before such patients are treated for heart failure with inotropic agents.     

Left ventricular thrombi: In vivo detection by indium-111 platelet imaging and two dimensional echocardiography

Indium-111 platelet Imaging, which can Identify sites of active intravascular platelet deposition, and two dimensional echocardlography, which can identify intracardiac masses, can both be used to detect left ventricular thrombi noninvasively. We compared these techniques in 44 men at risk for thrombi from remote transmural myocardial infarction (31 patients) or cardiomyopathy (13 patients). All 44 patients underwent platelet imaging; 35 underwent echocardlography.On platelet imaging nine patients had thrombi and one had a possible thrombus. Of these 10 studies, none were positive at 2 hours, 5 were positive at 24 hours and all were positive 48 or 72 hours after platelet labeling. Nine of these patients underwent echocardlography, and all had an intraventricular mass. The findings on platelet scanning were negative in six patients who had positive (four patients) or equivocally positive (two patients) findings on echocardiography. All patients with thrombi detected by either noninvasive method had transmural anterior myocardial infarction with ventricular aneurysm. Of the seven patients who underwent cardiac surgery or autopsy, three had thrombi. Platelet imaging failed to Identify one thrombus in a patient in whom imaging was performed only at 24 hours after labeling. There were no false positive platelet images in this group. Five of these seven patients (two with thrombi, three without) underwent echocardiography; in all cases the echocardiographic findings agreed with the pathologic findings.Both platelet Imaging and echocardiography detect ventricular thrombi. Platelet imaging may detect only the most hematologically active thrombi. Both techniques may help define patients at risk of embolization and may be useful for in vivo assessment of antithrombotic drugs.     

Echocardiographic characterization of the reversible cardiomyopathy of hypothyroidism

Nineteen patients with untreated hypothyroidism were evaluated by M-mode echocardiography. Asymmetric septal hypertrophy (ASH), defined as a ratio of interventricular septal thickness to left ventricular posterior wall thickness (IVS/LVPW) equal to or greater than 1.3, was identified in 17 cases. Additional abnormalities recognized by echocardiography included reduced amplitude of systolic septal excursion (SSex) [13 patients], reduced per cent of systolic septal thickening (%SST)[19 patients], reduced left ventricular outflow tract dimension (LVOT)[five patients] and systolic anterior motion of the mitral valve (SAM)[five patients]. These findings are similar to some of the echocardiographic features of idiopathic hypertrophic subaortic stenosis (IHSS). In 10 patients who returned to euthyroid state with L-thyroxine therapy, these abnormalities resolved. We conclude that long-standing hypothyroidism leads to a reversible cardiomyopathy, manifested by asymmetric septal hypertrophy with or without other echocardiographic features of a hypertrophic obstructive cardiomyopathy. This previously unrecognized features of hypothyroidism has important diagnostic and therapeutic implications.     

Two-dimensional echocardiographic study of right ventricular outflow and great artery anatomy in pulmonary atresia with ventricular septal defects and in truncus arteriosus

In this study, we reviewed M-mode and two-dimensional (2DE) echocardiographic observations in 13 patients with pulmonary atresia with ventricular septal defect and in six patients with truncus arteriosus in order to attempt to identify echocardiographic features distinguishing these two abnormalities in which no anatomic connection exists between the right ventricle and the pulmonary artery. M-mode features compatible with the diagnosis of pulmonary atresia with a ventricular septal defect (VSD) were a small but identifiable space anterior to the aorta and/or immobile pulmonic valve echoes appearing to open during diastole rather than systole. By 2DE, the proximal and distal segments of the right ventricular outflow tract could be imaged and the length of the atretic segment estimated. In truncus arteriosus, no outflow tract of the right ventricle could be identified by 2DE or M-mode echocardiography, and the origin of the pulmonary artery from the truncus could be imaged directly in four patients with type I and in one patient with type II truncus. Abnormalities of the truncal valve were also present and were imaged by 2DE in three of our five patients. Our study identified specific echocardiographic criteria for diagnosing truncus arteriosus and pulmonary atresia with VSD and for differentiation between them.     

Echocardiographic findings in myocarditis

This study analyzes morphologic and functional alterations detected by M-mode and 2-dimensional echocardiography in 41 patients with histologically proven myocarditis and different clinical presentations: congestive heart failure (63%), atrioventricular block (17%), chest pain (15%) and supraventricular arrhythmias (5%). Left ventricular dysfunction was common (69%), particularly in patients with congestive heart failure (88%), often without or with minor cavity dilatation. Patients with atrioventricular block or chest pain had usually preserved ventricular function. Right ventricular dysfunction was present in 23%. Additional findings included asynergic ventricular areas (64%), left ventricular "hypertrophy" sometimes reversible (20%), hyperrefractile myocardial areas (23%), ventricular thrombi (15%) and "restrictive" ventricular filling (7%). It is concluded that echocardiographic features of myocarditis are polymorphous and nonspecific. The echocardiographic pattern can simulate alternatively dilated, hypertrophic, restrictive or "right" ventricular cardiomyopathy, as well as coronary artery disease. In an appropriate clinical context, echocardiography can be helpful in the diagnosis of myocarditis and in the selection of patients for endomyocardial biopsy.     

In vivo and in vitro evaluation of left ventricular thrombi by two-dimensional echocardiography. Comparison with cineventriculography

The purpose of this study was to assess the capability of two-dimensional echocardiography to identify left ventricular thrombi as compared to standard single plane cineventriculography in 284 patients, who underwent both procedures within 24 hours for diagnostic purposes. In order to obtain informations about the degree of thrombus organization and diagnostic accuracy of the echocardiographic technique, two-dimensional echocardiographic examinations were also performed in 31 thrombi from 16 autopsy specimens. In 249 cases the results were negative and in 14 cases positive by both techniques. Seven cases were positive by cineventriculography but negative by 2D-echocardiography. In seven cases the findings were equivocal by two-dimensional echocardiography; three of them were negative, two positive, and two equivocal by cineventriculography. In two cases the results were negative by two-dimensional echocardiography but equivocal by cineventriculography. Finally five cases were diagnosed to have a thrombus but two-dimensional echocardiography but not by cineventriculography. In two patients, positive by two-dimensional echocardiography, who were on anticoagulant therapy, follow-up studies showed the disappearance of left ventricular thrombi. In all of them the thrombi showed tissue characteristics similar to those of fresh thrombi examined in vitro. Two-dimensional echocardiography seems to be more reliable than cineventriculography for assessing the presence, extension, number, and morphology of left ventricular thrombi. In vitro studies suggest that two-dimensional echocardiography cannot visualize small thrombi, that fibrotic areas may simulate a thrombus and that in some cases under or overestimation is possible.     

Echocardiographic evaluation of ventricular septal aneurysms.

The spontaneous closure of ventricular septal defects is frequently associated with septal aneurysm formation. In this paper we discuss the M-mode and two-dimensional echocardiographic findings in nine children with aneurysms of the ventricular septum in association with ventricular septal defects. In all patients the diagnosis was confirmed by angiography. The ventricular septal aneurysms were detected by both M-mode and two-dimensional echocardiography. With M-mode echocardiography, septal aneurysms could be recognized by a pattern of multiple systolic echoes within the right ventricle. With two-dimensional echocardiography, the protrusion of the septal aneurysm into the right ventricle could be seen from several views and the location and the relative size of the aneurysm assessed. Echocardiographic techniques useful in the detection of ventricular septal aneurysms are discussed and examples presented.     

Functional consequences of interventricular septal involvement in right ventricular infarction: Echocardiographic,clinical, and hemodynamic observations

Although ischemic involvement of the interventricular septum (IVS) may occur in patients with right ventricular infarction (RVI), the potential functional significance of such involvement has not been explored. In 10 patients with hemodynamically evident RVI, ischemic involvement of the IVS was assessed by measuring IVS systolic thickening on M-mode echocardiography. Six patients (group I) had decreased IVS systolic thickening, an echocardiographic indicator of ischemia, or infarction, while four (group II) did not. Group I had significantly higher right ventricular filling pressures (19 ± 3 vs 12 ± 5 mm Hg, p = 0.04) and right ventricular end-diastolic echocardiographic dimensions (32 ± 8 vs 20 ± 3 mm; p = 0.02) than group II. Paradoxic septal motion was noted only in group I patients (p = 0.01). Left ventricular filling pressures, left ventricular end-diastolic dimensions, and systolic thickening of the left ventricular posterior wall (LVPW) were not significantly different between the groups. Three group I patients died; all had decreased systolic thickening of both the IVS and LVPW. In each, autopsy confirmed infarction of the right ventricular free wall, IVS, and LVPW. In patients with right ventricular infarction, ischemic involvement of the interventricular septum may have important consequences for both right and left ventricular function.