Two-dimensional and Doppler echocardiography in the evaluation of penetrating cardiac injury

Two cases in which Doppler and cross-sectional echocardiography demonstrated intracardiac shunts acquired by stab wounds to the heart are reported. These cases demonstrate the utility of these noninvasive methods in assessing the anatomic residua of penetrating cardiac injuries. In particular, the value of Doppler echocardiography in detecting lesions that are small, irregularly oriented, and situated in locations not well seen in standard two-dimensional echocardiographic imaging views is emphasized.     

Comparison of magnetic resonance imaging, echocardiography and catheterization in the diagnosis of congenital heart diseases

The authors compared the diagnostic value of magnetic resonance imaging (MRI), echocardiography and cardiac catheterisation with angiography in 66 patients with congenital heart disease, to determine a diagnostic strategy in the use of these methods of cardiac imaging. The patients were 8 days to 44 years old. The congenital cardiac malformations were classified in three groups: 29 isolated vascular malformations (Group 1), 17 isolated intracardiac malformations (Group 2) and 20 complex malformations (Group 3). MRI was performed in all patients using a high field (1.5 tesla) magnet and spin-echo sequences in multiple incidences. The results were compared with those of echocardiography in 60 patients and/or cardiac catheterisation in 39 cases. Technical evaluation of MRI showed images of diagnostic quality in 62/66 cases (93.9%). MRI provided a diagnostic contribution in 56 cases (85%) which was less important in intracardiac malformations than in the other groups (p less than 0.05). In comparison with other imaging techniques, globally, the diagnostic value of MRI was lower than that of cardiac catheterisation (p less than 0.005) but there was no significant difference between MRI and echocardiography. When the type of malformation was taken into account, MRI was not as useful as catheterisation and echocardiography for the diagnosis of isolated intracardiac malformations (p less than 0.01) but gave comparable results in other malformations. On the other hand, MRI associated with echocardiography was more useful (p less than 0.05) than catheterisation in the diagnosis of complex congenital lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prevalence of Electrocardiographic and Echocardiographic Abnormalities in Ambulatory Ischemic Colitis

The aim of this study was to evaluate the prevalence of cardiac arrhythmia and intracardiac embolic process in ambulatory ischemic colitis. From November 1994 to November 1997, 33 consecutive cases of ambulatory ischemic colitis were detected. This study included 21 women and 12 men with a mean age of 71 years. All patients underwent a cardiovascular investigation including questioning, electrocardiogram, 24-hr ambulatory electrocardiography and transthoracic echocardiography. A prior history of ischemic colitis was found in four cases (12%). Cardiac arrhythmia was detected in eight cases. Transthoracic echocardiography showed an intracardiac process, potentially responsible for a peripheral embolism, in four cases. In conclusion, the aggregate, in 33% of the patients, there was potential cardiac etiology. This suggests that when ambulatory ischemic colitis occurs, it is necessary to perform an exhaustive cardiovascular evaluation similar to those performed in other ischemic diseases.     

Role of Three‐Dimensional Echocardiography in Management of Acquired Intracardiac Shunts

Gerbode defect and sinus of Valsalva aneurysm fistula are congenital and acquired forms of intracardiac shunt. The increasing prevalence of invasive, recurrent cardiovascular procedures cause tissue damage and has led to more iatrogenic and acquired cases of predominantly congenital shunt over time. We report 2 cases of acquired intracardiac fistula precisely defined by Real time three‐dimensional transesophageal echocardiography (3DTEE). The first case is a 70‐year‐old male with Gerbode defect after second aortic valve replacement surgery due to prosthetic valve endocarditis and the other case is a 41‐year‐old male with sinus of Valsalva aneurysm fistula between aorta and right atrium post subclinical infective endocarditis. Advanced cardiac imaging techniques such as cardiac computerized tomography, MRI and Real time three‐dimensional (3D) echocardiography help to precisely detect intracardiac fistula and provide detailed anatomic and physiologic information. The relatively low cost, lack of radiation exposure, portability and guiding characteristic make real time 3DTEE an imaging technique with arguably the most advantages. Surgical repair is the usual treatment for intracardiac shunt, and percutaneous catheter‐based closure is a less invasive alternative.     

Improved surgical approach to cardiac tumors with intraoperative two-dimensional echocardiography

Intraoperative two-dimensional echocardiography allows visualization of cardiac anatomy and function not possible by other techniques. Although preoperative evaluation by noninvasive methods is usually adequate for diagnosis of cardiac tumors, two-dimensional echocardiography can be beneficial intraoperatively. Intraoperative echocardiography provides an accurate evaluation of cardiac anatomy, extent of tumor invasion, valvular function and the possible presence of intracardiac communications. Importantly, following tumor resection and a complex operative reconstructive procedure, the echocardiogram can confirm complete intracardiac tumor excision, evaluate post-repair ventricular function, and exclude an intracardiac communication or valvular insufficiency.     

Secondary tumors of the right heart. Echocardiographic aspects. Apropos of 6 cases in the adult

Secondary cardiac tumours are rare but but are now more frequently diagnosed by echocardiography. We report 6 cases of intracardiac metastases affecting the right heart which were diagnosed by 2D echocardiography. In 3 cases, a very mobile, oval-shaped tumour was visualised within the right atrium prolapsing into the tricuspid orifice in diastole like a myxoma but associated in 2 cases with signs of invasion of the inferior vena cava. Two other non-mobile tumours were observed causing massive invasion of the right atrium and the last case was of an infiltrating tumour of the right ventricle resulting in pulmonary infundibular obstruction. In the light of our experience and a review of the literature, it is difficult to distinguish secondary tumours of the right atrium from myxomas especially when the tumours are mobile and when it is impossible to visualise a pedicle inserted on the interatrial septum or tumoral invasion of the inferior vena cava. At the ventricular level, the diagnostic signs differ according to whether there is tumoral invasion of the cavity or infiltration of the muscular wall. These cases illustrate the value of 2D echocardiography in the diagnosis of intracardiac metastases, sometimes even in the absence of clinical signs.     

First experience with "live" three-dimensional echocardiography in Russia

Revival of interest to three-dimensional echocardiography during recent years was invoked by introduction of essentially novel ultrasound technology of "live" three-dimensional imaging. We introduce here the first experience of the use of three-dimensional echocardiography in Russia comprising examination of 74 patients with various pathology of the heart. Positions and sections are described allowing best visualization of pathology of cardiac valves and other intracardiac structures. Our experience shows that at present three-dimensional echocardiography should be considered to be an important supplement to standard echocardiography. However in some cases it can be the only non-invasive technique able to provide complete information on the size of ventricular and atrial septal defects, valvular and other cardiac pathology.     

Intracardiac masses detected by echocardiography: case presentations and review of the literature

Intracardiac masses are often diagnosed by transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) improves overall visualization of masses, especially those located in the posterior cardiac structures. Masses in the heart are most commonly due to thrombi or valvular vegetations; however, a variety of tumors may also present as cardiac masses on echocardiography. Tumors of the heart most commonly occur in the setting of metastatic disease, usually from malignancies of the breast, lung, or from malignant melanoma. Primary cardiac tumors occur much less frequently and are usually benign. Atrial myxomas constitute nearly one-half of reported primary cardiac tumors. The following discussion details the findings of five cases that illustrate the spectrum of intracardiac tumors detected by echocardiography and reviews the relevant literature.     

Atrial level right to left intracardiac shunt associated with postoperative hypoxemia: demonstration with contrast two-dimensional echocardiography

Transient hypoxemia is not uncommon after major cardiac or thoracic surgery. The differential diagnosis includes atelectasis, pulmonary embolus, pneumonitis, congestive heart failure and several other diverse cardiovascular and pulmonary problems. Less well recognized is transient right to left intracardiac shunting through a patient foramen ovale or previously unsuspected atrial septal defect. Three cases of clinically important hypoxemia associated with right to left shunting after aortocoronary bypass surgery are presented. The right to left shunting was documented with contrast-enhanced echocardiography, which is a simple, inexpensive and accurate means of screening patients for intracardiac right to left shunts and may play a valuable role in the postoperative management of patients.     

Contrast echocardiography as a useful additional diagnostic tool in evaluating a primary cardiac tumor.

The current report describes a case of a primary cardiac lymphoma. For early and appropriate treatment of a cardiac mass it is not only important to determine its localization and extension but also to differentiate between malignant and benign lesions. This report demonstrates that not only transthoracic echocardiography but also the other different forms of echocardiography such as transesophageal echocardiography, as well as contrast and intracardiac echocardiography, are useful tools in the diagnostic workup of cardiac masses.     

Multichamber gunshot wounds of the heart. The utility of transesophageal echocardiography.

A patient had a gunshot wound to the heart involving three cardiac chambers. Conventional echocardiography failed to identify the intracardiac injuries. The utility of transesophageal echocardiography in a patient with cardiac trauma is described.     

Contribution of complementary examinations in the diagnosis and treatment of emboligenic cardiopathies. Retrospective study apropos of 46 cases

The aim of this prospective study was to assess the value of complementary investigations in the diagnosis and follow-up of embolic heart disease. Forty-six patients having presented a systemic embolism cardiac origin underwent a standard work up which included clinical examination, ECG, chest X-ray and 2D echocardiography. Other investigations were carried out in some patients: CT cardiac scan (11 cases), gamma scintigraphy with Indium III labelled platelets (6 cases) and angiocardiography (12 cases). The diagnosis of an embolic cardiac lesion was made after the standard investigations in 82% of cases. The remaining 18% of cases hall had echocardiographic abnormalities and enable the diagnosis of clinically imapparent conditions: mitral valve prolapse, aneurysm of the interatrial septum, valvular calcification and cardiomyopathy. A potentially embolic mass was visualised in 18 patients; 6 valvular vegetations, 12 left atrial or ventricular thrombi. The other specialised radionuclide, angiographic and CT investigations only confirmed the echocardiographic diagnosis of intravavitary thrombosis. These results were confirmed surgically in 19% of cases. This study shows that complementary investigations especially echocardiography, allow diagnosis of latent embolic cardiac lesions, some of which may benefit from surgical treatment. In addition, potentially embolic intracardiac masses may be visualised, so confirming the origin of systemic emboli. When surgery is not indicated, echocardiography is a good method of following up the results of medical treatment in some of these masses.     

Cardiac echinococcal cyst: diagnosis by two-dimensional echocardiography

A case of an intracardiac echinococcal cyst is presented. The diagnosis was made by two-dimensional echocardiography, which clearly identified a large multiseptated cystic structure in the right ventricular outflow tract. The findings were verified at surgery. It is suggested that two-dimensional echocardiography may be the procedure of choice in the diagnosis of cardiac echinococcal disease.     

Diaphragmatic hernia mimicking an atrial mass: a two-dimensional echocardiographic pitfall

Two-dimensional echocardiography has become the diagnostic method of choice for identifying intracardiac masses. However, adjacent extracardiac structures may closely mimic intracardiac masses on the two-dimensional echocardiogram. Five cases of a previously unrecognized phenomenon in which a diaphragmatic hernia mimicked an intraatrial mass are reported. Techniques to identify a diaphragmatic hernia properly on two-dimensional echocardiographic examination and distinguish it from intracardiac masses are discussed.     

Platypnoea-orthodeoxia syndrome

PLATYPNOEA: orthodeoxia is a rare syndrome of postural hypoxaemia accompanied by breathlessness. The predominant symptom, dyspnoea induced by upright posture, can be debilitating and difficult to discern without thorough evaluation of the patient's pattern of dyspnoea. The precise cause of the syndrome is unclear but patients develop right to left intracardiac shunting in the presence of normal right sided cardiac pressures. Initially, patients should have confirmation of orthostatic desaturation by erect and supine pulse oximetry. However, definitive diagnosis of an orthostatic intracardiac shunt is most readily established by echocardiography. The use of echocontrast with postural manoeuvres may facilitate the diagnosis. The treatment of choice is surgical closure of the intracardiac (usually interatrial) communication, which may result in dramatic symptomatic and haemodynamic improvement. Three cases (a 27 year old man and two women aged 63 and 72 years) are described that exemplify the presentation of this syndrome, and reflect the varied management strategies and outcomes of this condition.     

Primary lymphoma of the right atrium: a case report]

Primary cardiac tumor is an extremely rare disease and is associated with a high mortality. The cases described in the literature are recently increased thanks to the employment of the new diagnostic methodologies (computed tomography, nuclear magnetic resonance, transesophageal echocardiography). Particularly the primitive lymphoma, non-HIV correlated, is very rare (< 1.5% of all cardiac tumors), but it is treatable when appropriately diagnosed. We report a case of 52-year-old patient who presented with an infiltrative mass in the right atrium. The examination of the tissue obtained by transvenous intracardiac biopsy with transesophageal echocardiography guidance revealed high grade non-Hodgkin's lymphoma of B-cell lineage. The patient achieved complete tumor remission after treatment with standard chemotherapy. This case demonstrates that early diagnosis might contribute to a better prognosis for patients with malignant lymphoma of the heart.     

Pathophysiologic mechanisms of cardiac tamponade and pulsus alternans shown by echocardiography

A pericardial effusion is easily recognized by echocardiography, but the diagnosis of cardiac tamponade by echocardiography is controversial. Recently, several reports have indicated that right ventricular (RV) or right atrial (RA) diastolic collapse represent highly specific and sensitive signs of a hemodynamically significant pericardial effusion. This report evaluates the pathophysiologic significance of these findings in 3 patients. One patient had classic clinical and hemodynamic features of tamponade without typical echocardiographic features; 1 had typical echocardiographic features of tamponade without the characteristic clinical or hemodynamic features; and 1 had all the findings characteristic of tamponade, including mechanical and electrical alternans. The first patient had increased right-sided cardiac pressures and RV hypertrophy, which prevented RV or RA collapse. The second patient had low right-sided intracardiac pressures, which allowed RV and RA diastolic compression to occur during early and mid-diastole. In the third patient, severe holodiastolic impairment of right-sided filling, and presumed decreased pulmonary venous and pericardial compliance, in the setting of tamponade produced a beat-to-beat alternation of RV and left ventricular filling with associated electrical and mechanical alternans. RV or RA collapse during diastole occurs when intrapericardial pressure equals or exceeds intracardiac pressure. Increases in wall stiffness of chamber pressures may prevent diastolic collapse in the setting of tamponade. Conversely, extremely low intracardiac pressures may allow diastolic collapse to occur in the absence of overt cardiac tamponade. The extent and timing of the RA or RV collapse, rather than its mere occurrence, are important in the diagnosis of cardiac tamponade by echocardiography.     

Prediction of Intracardiac Pressures and Assessment of Ventricular Function with Doppler Echocardiography

Doppler echocardiography has had a profound influence on the clinical practice of cardiology. With the use of the modified Bernoulli equation, Doppler echocardiography provides a noninvasive technique for calculating intracardiac pressures. Compared to invasive measurements, the Doppler estimates of intracardiac pressures are accurate and reproducible. By the evaluation of intracardiac blood flow, Doppler echocardiography provides a technique for the evaluation of ventricular performance that is independent of ventricular geometry. This application of the Doppler technique is in its infancy and much investigative work is needed to correlate the invasive and noninvasive measurements of ventricular function and to determine the effect of factors such as heart rate, loading conditions, and cardiac drugs on the Doppler indexes of function. In the future, it is very likely that Doppler color flow mapping techniques will provide additional information on ventricular emptying and filling patterns that will be important in the noninvasive assessment of cardiac function.     

Intracardiac Echocardiography in Structural Heart Disease Interventions

Intracardiac echocardiography has historically been used to guide a limited number of transcatheter cardiac interventions. However, the tremendous advances in structural heart disease interventions in the last decade led to a growing interest in intracardiac echocardiography as a potential alternative to transesophageal echocardiography that mitigates the need for endotracheal intubation. Nonetheless, the scarcity of data, the imperfection of the current probes, and the limited experience among operators prevented a wider adoption of this technology. This review summarizes the contemporary relevant evidence and provides the structural interventionalist with an illustrative guide on the use of intracardiac echocardiography to guide various structural heart interventions.