Contrast echocardiography of the inferior vena cava

M-mode and two-dimensional subcostal contrast echocardiography were used in 67 patients and 10 normal subjects to evaluate the contrast echo effect on the inferior vena cava echogram in relation to the cardiac cycle and respiratory events. No contrast echoes were recorded in the inferior vena cava in normals during normal breathing. Contrast echoes were recorded entering the inferior vena cava in systole in 20 patients with tricuspid regurgitation and in pre-systole in patients with atrial septal defect and left-to-right shunt and in some of the patients with elevated right atrial and ventricular end-diastolic pressure. Forced inspiration increased the contrast echo effect and determined the penetration of microbubbles into the inferior vena cava. This latter feature occurred in all the patients and only in 1 normal subject. The entry of the contrast echoes into the inferior vena cava was attributed to the high right atrial ventricular end-diastolic pressure and to the reversed flow, from the right ventricle to the right atrium and inferior vena cava in tricuspid regurgitation and from the left atrium to the inferior vena cava in atrial septal defect. The contrast echocardiographic diagnosis of tricuspid regurgitation appeared to be most reliable. New encouraging results were obtained by this technique in diagnosing atrial septal defect and left-to-right shunt. The first appearance of the contrast, the time of appearance in relation to the cardiac cycle and the direction of the to and fro motion of contrast echoes were the most important factors considered for a correct diagnosis.     

Atrial septal defect with right to left shunt despite normal pulmonary artery pressure

A 74 year old woman had right to left shunting through an atrial septal defect despite normal right heart pressures. Acute volume expansion temporarily reduced the shunt. Contrast echocardiography and angiography demonstrated that this shunting occurred almost exclusively from the inferior vena cava. At surgery a redundant flap of septum secundum was found that was adjacent to the inferior vena cava orifice, intercepting its blood return like a spinnaker and shunting it into the left atrium.     

Functional and anatomical correlates in atrial septal defect. An echocardiographic analysis.

The results of cross sectional echocardiography, intracardiac contrast echocardiography, and balloon sizing techniques and conventional haemodynamic assessment were correlated in 40 consecutive patients evaluated for an isolated left to right shunt at atrial level. Echo free areas along the septum were identified in 23 of 25 patients with a secundum defect, but not in two with a fenestrated defect, and in the upper atrial septum in three of four patients with a sinus venosus defect. No false positive results occurred in 11 patients with a probe patent foramen ovale. Saline contrast injection into the left atrium showed significant left to right shunting in all patients with atrial septal defect; inferior vena caval injection produced right to left shunting in 15 of 29 patients and a negative contrast effect in eight of 29 patients with an atrial septal defect, although neither correlated quantitatively with defect diameter or magnitude of the left to right shunt. Echocardiographic assessment of defect size as small, moderate, or large showed a highly significant correlation with balloon measurement of defect diameter, although some overlap between the groups was evident. In contrast, the correlation between defect diameter and pulmonary to systemic blood flow ratio was poor, mainly because of highly variable shunting in patients with an anatomically large defect. Cross sectional echocardiography has high sensitivity and specificity in the diagnosis of the non-fenestrated atrial septal defect and provides quantitative information about defect diameter. Contrast studies do not add to the diagnostic value of imaging from the subcostal position. The poor correlation between defect size and the measured shunt suggests that the latter may not be the best criterion for surgical management and that size could be an important factor likely to influence both the long term prognosis and the decision for closure.     

Functional and anatomical correlates in atrial septal defect. An echocardiographic analysis

The results of cross sectional echocardiography, intracardiac contrast echocardiography, and balloon sizing techniques and conventional haemodynamic assessment were correlated in 40 consecutive patients evaluated for an isolated left to right shunt at atrial level. Echo free areas along the septum were identified in 23 of 25 patients with a secundum defect, but not in two with a fenestrated defect, and in the upper atrial septum in three of four patients with a sinus venosus defect. No false positive results occurred in 11 patients with a probe patent foramen ovale. Saline contrast injection into the left atrium showed significant left to right shunting in all patients with atrial septal defect; inferior vena caval injection produced right to left shunting in 15 of 29 patients and a negative contrast effect in eight of 29 patients with an atrial septal defect, although neither correlated quantitatively with defect diameter or magnitude of the left to right shunt. Echocardiographic assessment of defect size as small, moderate, or large showed a highly significant correlation with balloon measurement of defect diameter, although some overlap between the groups was evident. In contrast, the correlation between defect diameter and pulmonary to systemic blood flow ratio was poor, mainly because of highly variable shunting in patients with an anatomically large defect. Cross sectional echocardiography has high sensitivity and specificity in the diagnosis of the non-fenestrated atrial septal defect and provides quantitative information about defect diameter. Contrast studies do not add to the diagnostic value of imaging from the subcostal position. The poor correlation between defect size and the measured shunt suggests that the latter may not be the best criterion for surgical management and that size could be an important factor likely to influence both the long term prognosis and the decision for closure.     

Doppler color-flow imaging assessment of shunt size in atrial septal defect

Two-dimensional echocardiography and pulsed-Doppler studies have not proved to be reliable methods of assessing left-to-right shunt size in atrial septal defect. Doppler color-flow imaging displays the transatrial jet, providing a new dimension with the potential capability of quantifying left-to-right shunt size. Twenty-three patients with atrial septal defect were studied by color-flow imaging and cardiac catheterization. The defect size measured by two-dimensional echocardiography, the maximal color-flow jet width in the atrial septum, and the maximal color-flow jet area in the right atrium were correlated with cardiac catheterization-derived left-to-right shunt size. Correlation coefficients were 0.57 (p less than 0.01), 0.67 (p less than 0.001), and 0.65 (p less than 0.01), respectively. Atrial septal color-flow jet width distinguished patients with less than a 2:1 left-to-right shunt size ratio (eight patients, jet width less than 15 mm in in all) from patients with greater than a 2:1 left-to-right shunt size ratio (15 patients, jet width greater than 15 mm in all). These results indicate that Doppler color-flow imaging can distinguish left-to-right shunt size in atrial septal defect accurately enough to influence decisions with regard to subsequent patient management.     

Right-to-left shunting with normal pulmonary pressure complicating atrial septal defect surgery

We report on a patient in whom a right-to-left shunt with normal pulmonary arterial pressures occurred after surgery of an inferior vena caval sinus venosus-type atrial septal defect. In addition to the inferior vena cava to left atrium anatomic defect, the exceptional occurrence of a post-operative right atrial inflow stenosis contributed to the right-to-left shunting.     

Echocardiographic aspects of persistence of the right valve of the venous sinus

The aim of this work is to demonstrate the possibility to identify persistent right sinus venous valve and to differentiate it from other right sided heart pathology by two dimensional echocardiography. We report the echocardiographic findings observed in three out of 215 paediatric patients we examined for clinically suspected congenital heart disease in 12 months period. The first patient was a 24 hours old newborn with transient pulmonary hypertension; the second one was a 6 months old child with pulmonary atresia, severe right ventricular hypertrophy, atrial septal defect and patent ductus arteriosus; the third patient, aged 6 months, had atrial septal defect and mild pulmonary stenosis. In all three patients a particular linear structure was seen, as a membrane that crossed the right atrium from the orifice of the inferior vena cava towards the atrial septum. This structure was identified as persistent right sinus venosus valve according to its morphology, its position into the right atrium and its connection to the atrial septum. The incidence of this echocardiographic finding was 1.4% in our series. In the first case contrast echocardiography from the inferior vena cava demonstrated the deviation of blood flow caused by the persistent sinus valve, although no intra-atrial pressure gradient was shown at cardiac catheterization. In the second patient who died during the operative procedure for making a systemic-pulmonary anastomosis, post mortem examination showed a membranous structure connecting the orifice of the inferior vena cava to the atrial septum.(ABSTRACT TRUNCATED AT 250 WORDS)     

Atrial septal hematogenous cyst with calcification mimicking myxoma: A rare case

A 61-year-old female presented with right atrial mass during physical examination. Contrast-enhanced left heart echocardiography revealed a mass with the size of 32*23 mm in the right atrium, attached to the atrial septum; there was a certain degree of activity and deformation. MRI showed a mass of about 35*22 mm in the right atrium adjacent to the atrial septum, which was diagnosed with right atrial myxoma. Intraoperative TEE showed that the mass was located in the atrial septum close to the inferior vena cava and spontaneous echo contrast with hyperechoic images within the mass. The lesion was resected under cardiopulmonary bypass. Pathological examination revealed that the filling defect was an atrial septal hematogenous cyst with calcification.     

Non-invasive diagnosis in clinically suspected atrial septal defect of secundum or sinus venosus type. Value of combining chest x-ray,phonocardiography, and M-mode echocardiography.

Twenty-three consecutive patients with clinical (auscultatory and electrocardiographic) signs of uncomplicated atrial septal defect of secundum or sinus venosus type were examined by chest x-ray, phonocardiography, and echocardiography, before right heart catheterisation. Seventeen (74%) had atrial septal defect, two patients (9%) had insignificant pulmonary stenosis, and four subjects (17%) were normal. No false positive diagnosis of atrial septal defect was made by chest x-ray examination, whereas increased vascular markings were incorrectly interpreted as pulmonary congestion in one case. Four patients had x-ray films showing questionable signs of left-to-right shunt. Six of 15 patients with a large left-to-right shunt were correctly selected for surgery based on radiological findings. One false negative but no false positive diagnosis of atrial septal defect was made by phonocardiography. Four cases with and four cases without atrial septal defect were classified as having questionable phonocardiographic signs of atrial septal defect. Echocardiographic distinction between those with atrial septal defect and those without atrial septal defect was correct in all cases; quantitative measurement of left-to-right shunt, however, was unsatisfactory. Combined normal findings by x-ray film and echocardiography appeared adequate in all cases for the exclusion of atrial septal defect (six patients). When the six patients who were correctly identified for surgery from the radiological findings are included, there was a total of 12 patients out of 23 (52%:95% confidence limits 31 to 73%) who were evaluated definitively by the non-invasive tests.     

Identification of atrial septal defects by cross-sectional contrast echocardiography.

Cross-sectional echocardiography, combined with injections of contrast into peripheral arm veins, has been used to study 15 patients with atrial septal defects and 10 patients with an intact interatrial septum. Of 11 patients with ostium secundum or sinus venosus atrial septal defects and left-to-right shunts a defect could be visualised in all, and in eight some degree of transfer of contrast from right atrium to left atrium was seen. In three of four patients with a dominant right-to-left shunt a defect was seen and in all there was free transfer of contrast from right atrium to left atrium. Though there may be variable loss of echoes in the septal image in patients with an intact interatrial septum, in general no fixed defect is seen an there is no transfer of contrast from right atrium to left atrium. This is a potentially valuable technique in the assessment of patients in whom an atrial septal defect is suspected.     

Echography in aneurysm of the interatrial septum

Atrial septal aneurysm can be detected by subcostal echocardiography as a bulge of the intermediate interatrial septum, ballooning toward the right atrium. We retrospectively revised 5412 echo examinations, consecutively performed in our laboratory, and we found 14 cases of atrial septal aneurysm (0.26%), mean age 36 +/- 15 years, 9 males and 5 females. In 7 patients atrial septal aneurysm was wide, including the whole atrial septum; in 5, only cranial two-thirds of the septum were involved and in 2, it regarded only the intermediate septum. No patients referred to arrhythmias, syncope, embolism, endocarditis or transient ischemic neurologic disorders. Cardiac abnormalities or defects were associated to atrial septal aneurysm in 12/14 patients: they consisted of atrial septal defect, mitral valve prolapse, false ventricular tendons or persistent Chiari network. Atrial left-to-right shunt was detected in all 6 cases with atrial communication. Considering each single associated cardiac abnormality, the prevalence of atrial septal aneurysm was 7% in patients with atrial septal defect, 1.7% in those with mitral valve prolapse, 6.6% in persistent Chiari network and 0.9% in false ventricular tendons. In conclusion, echocardiography is the first-choice technique to detect atrial septal aneurysm and other related cardiac defects.     

Budd-Chiari syndrome as a late complication following closure of an atrial septal defect

A case of a Budd-Chiari syndrome in a 19-year-old female patient is reported who had undergone surgical closure of a secundum atrial septal defect 13 years before. 8 months before the development of the Budd-Chiari syndrome she started to take oral contraceptives. The clinical picture of the Budd-Chiari syndrome developed within several days. The inferior vena cava did not fill with contrast dye when an angiography was performed using the right vena iliaca approach. The contrast dye disappeared through collateral veins (vena azygos, vena hemiazygos). After 4 days of treatment with systemic streptokinase she underwent open-heart surgery. The orifice of the inferior vena cava was occluded to a diameter of 6 mm. No thrombi were found. The lesion was corrected with two patches, one in the right atrium and the other in the inferior vena cava. This case report demonstrates that a Budd-Chiari syndrome is a possible late complication after closure of an atrial septal defect which should be treated by surgery.     

Transesophageal contrast echocardiography and color flow mapping: methods of choice for the detection of shunts at the atrial level?

The detection of shunts at the atrial level is important, and a reliable means of diagnosis is required. Precordial contrast echocardiography is usually performed to detect such shunts. To investigate the advantages of transesophageal echocardiographic techniques, we studied 167 consecutive patients with both precordial and transesophageal echocardiography, using two-dimensional imaging with contrast techniques (with and without a Valsalva maneuver) and color flow mapping. A patent foramen ovale was diagnosed in 31 patients, an atrial septal defect in 11 (7 with bidirectional shunts), and a pulmonary arteriovenous fistula in 3 patients. All right-to-left shunts were detected with transesophageal contrast echocardiography. With these results used as the gold standard, the sensitivity of combined precordial techniques was 37% and that of transesophageal color flow mapping 46%. All left-to-right shunts were detected by transesophageal color flow mapping. With these results used as the gold standard, the sensitivities of both precordial color flow mapping and a transesophageal negative right atrial contrast study were 27%. We conclude that transesophageal contrast echocardiography is the echocardiographic method of choice for the detection of a right-to-left shunt at the atrial level, which cannot be excluded by negative results on precordial study or on transesophageal color flow map study. A left-to-right shunt at this level is best detected by transesophageal color flow mapping.     

A rare association recognized before cardiac surgery: persistent left superior vena cava and secundum atrial septal defect

One of the most common congenital anomalies of systemic veins is persistent left superior vena cava. Association of persistent left superior vena cava with other congenital cardiac diseases is common and frequently encountered during diagnostic studies. Contrast echocardiography has an important role in the diagnosis. Owing to the fact that cardiopulmonary by-pass procedure may be problematic in patients with persistent left superior vena cava, this anomaly should be detected before cardiac surgery and required measures should be taken. Our case is an association of persistent left superior vena cava detected in a patient to be operated for secundum atrial septal defect. We report the case owing to its low frequency and to emphasize the importance of detection before cardiac surgery.     

Contrast two-dimensional echocardiography in congenital heart disease: techniques, indications and clinical utility

Saline contrast echocardiography was performed in 889 children from June 1976 through February 1988. One-third of these studies were in postoperative patients. A patent foramen ovale was identified by finding right to left shunting on venous contrast injection in 37% of 127 children studied with a structurally normal heart. The incidence of such shunting was greater at younger ages (55% younger than 1 month versus 22% older than 1 month). In most patients with an atrial or ventricular septal defect, some right to left shunting was demonstrable. The technique was useful in distinguishing different forms of atrial septal defect and identifying muscular ventricular septal defects that were difficult to image directly. The technique was used in the catheterization laboratory to aid in the identification of congenital coronary artery fistulas and was diagnostic in two cases of pulmonary arteriovenous malformation. In patients with situs abnormalities, the technique was useful in identifying the systemic venous connections to the atria. Contrast echocardiography was also used in postoperative evaluations. The technique was useful in identifying patch leaks and residual defects after Senning, Mustard and Fontan operations, and after closure of atrial and ventricular septal defects. Most patients were found to have no superior vena cava obstruction by contrast echocardiography after the Senning or Mustard procedure. Contrast echocardiography continues to be a useful technique in the diagnosis of a wide spectrum of congenital heart disease, as well as in the postoperative evaluation of congenital heart surgery.     

Two dimensional echocardiographic diagnosis of situs.

At present there is no reliable method of recognising atrial isomerism by two dimensional echocardiography. We therefore used two dimensional echocardiography to examine 158 patients including 25 with atrial isomerism and four with situs inversus. Particular attention was paid to the short and long axis subcostal scans of the abdomen. Using the position of the inferior vena cava and the aorta with respect to the spine it was possible to separate those with situs solitus from the others. Two false positives for abnormal situs had exomphalos. In situs solitus the aorta lay to the left of the spine and the inferior vena cava lay to the right. One patient with situs solitus and azygos continuation of the inferior vena cava also had inferior vena cava to right atrial connection. In the four patients with situs inversus the mirror image of the normal pattern was present. In nine patients with right isomerism the inferior vena cava and aorta ran together on one or other side of the spine. The inferior vena cava, anterior to the aorta at the level of the diaphragm, received at least the right hepatic veins (normal or partial anomalous hepatic venous connection). Of the 16 patients with left isomerism, 14 had azygos continuation of the inferior vena cava which was visualised posterior to the aorta in all but two. All patients with left isomerism had total anomalous hepatic venous connection to one or both atria via one or two separate veins. Two dimensional echocardiography therefore provides the means of detecting abnormal atrial situs and of diagnosing right or left isomerism in the great majority of patients, if not all.     

Successful Percutaneous Closure of a Secundum Atrial Septal Defect through Femoral Approach in a Patient with Interrupted Inferior Vena Cava

Percutaneous closure of secundum atrial septal defect (ASD II) is considered the treatment of choice in the majority of cases. Interrupted inferior vena cava with azygos continuation can make delivery of the occluder difficult or not possible. Transjugular, transhepatic approach or surgery can be the alternative. We present the case of a 53-year-old woman with ASD II and interrupted inferior vena cava, and describe successful atrial septal defect closure under transesophageal echocardiography guidance through transfemoral approach using a modification of the standard technique.     

Drainage of the inferior vena cava to the left atrium

Drainage of the inferior vena cava to the left atrium is an extremely unusual congenital heart disease. We describe a 54-year-old woman, in whom the diagnosis was suggested by transthoracic echocardiography, and then confirmed by a transesophageal exam and magnetic resonance imaging, which also revealed an associated secundum atrial septal defect. Surgical management involved reconstruction of the interatrial septum to include the inferior vena cava in the right atrium. The few previously reported cases in the literature are reviewed.     

A simple technique for detecting small defects of the atrial septum

A sensitive technique for detecting small defects of the atrial septum is described. A Valsalva maneuver is used to cause right atrial pressure to exceed left atrial pressure. This reversal of the normal interatrial pressure gradient causes a transient right to left shunt across the defect. The right to left shunt is detected by noting an early appearance deflection in standard indicator-dilution curves performed by injecting indocyanine green dye into the inferior vena cava during the Valsalva maneuver. By means of this technique, 7 of 8 surgically induced defects, from 1 to 12 mm in diameter, were detected. There were no false positive results among 9 control animals with an intact atrial septum. This technique presents a sensitive and simple method for detecting small atrial septal defects. The only equipment required is that used to perform standard indicator-dilution curves.     

Noninvasive pulsed Doppler echocardiographic detection of the direction of shunt flow in patients with atrial septal defect: usefulness of the right parasternal approach

Noninvasive pulsed Doppler echocardiography combined with two-dimensional echocardiography by the right parasternal approach was performed to detect the shunt flow through the defect in 31 patients with suspected secundum atrial septal defect (ASD). A defect of the interatrial septum was seen on the two-dimensional echocardiograms of 30 of 31 patients. In all the 30 patients, Doppler signals of shunt flow could be recorded by placing the sample volume in the center of the defect on the two-dimensional echocardiogram. Neither a defect nor Doppler signal indicating shunt flow were demonstrated in any of 15 normal control subjects. Cardiac catheterization indicated significant shunt flow in all the 31 patients with suspected ASD. Doppler signals obtained from the center of the defect showed left-to-right and/or right-to-left shunt flow patterns. The direction of the shunt flow was mainly left to right, with its peak in late systole and atrial systole in 28 of 30 patients; mainly right-to-left flow was present in the remaining two patients, who had Eisenmenger's syndrome. The direction of flow as predicted by the Doppler signal was confirmed by the coincidence of direction of flow as seen on the contrast two-dimensional echocardiogram. In 22 patients for whom the measurement of the pulmonary-to-systemic flow ratio by oximetry was believed to be reasonably accurate, the ratio was fairly well correlated with Doppler-determined left-to-right shunt flow velocity (r = .71, SEE = 6.7 cm/sec).(ABSTRACT TRUNCATED AT 250 WORDS)