Transesophageal three-dimensional echocardiographic assessment of left ventricular pseudoaneurysm

We report an adult patient with a left ventricular pseudoaneurysm following an acute myocardial infarction in whom three-dimensional (3-D) transesophageal echocardiography (TEE) delineated clearly not only the location but also the size and shape of the rupture site. The size of the rupture site measured by 3-D TEE correlated well with the surgical measurements. Three-dimensional images also showed a localized superior distortion of the lateral aspect of the mitral annulus and left atrial wall produced by the pseudoaneurysm. The resulting severe mitral regurgitation practically disappeared after repair and decompression of the pseudoaneurysm.     

Live three-dimensional transthoracic echocardiographic delineation of ventricular septal rupture following myocardial infarction

We present an elderly patient with ventricular septal rupture following myocardial infarction in whom live three-dimensional transthoracic echocardiography allowed comprehensive noninvasive assessment of the location, shape, and size of the septal defect, which could be clearly visualized en face from both left and right ventricular aspects.     

Postinfarction left ventricular pseudoaneurysm: echocardiographic diagnosis and prolonged survival in three patients

Both echocardiography and radionuclide angiography have been proposed as noninvasive modalities for the diagnosis of left ventricular pseudoaneurysm. In the only three cases seen at our institution over the past five years, this diagnosis was missed with radionuclide blood pool imaging, while two-dimensional echocardiography demonstrated the typical features of a pseudoaneurysm. Our patients were asymptomatic and diagnosis was made incidentally 4 to 6 years after myocardial infarction. Although the patients survived an extended period without surgery, the reported incidence of rupture is high, and prophylactic surgical repair probably is indicated. It is likely that the increased use of noninvasive cardiac imaging techniques will lead to the detection of other cases of unsuspected left ventricular pseudoaneurysm. Two-dimensional echocardiography appears superior to planar radionuclide ventriculography in establishing the diagnosis.     

Long-term survival following cardiac rupture with subsequent development of left ventricular pseudoaneurysm

This report describes a patient who survived rupture of the left ventricular free wall following a myocardial infarction and who then subsequently went on to develop a pseudoaneurysm. The rupture became clinically recognized when the patient developed cardiac tamponade. A large hemopericardium was evacuated by performing a thoracotomy and a pericardiotomy. Although not evident at the time of the initial catheterization, a pseudoaneurysm developed over the ensuing months. The aneurysm was initially recognized by radionuclide angiography and confirmed by left ventricular angiography at a second cardiac catheterization. The aneurysm was successfully resected, and the patient was alive and functioning normally 18 months after rupture and 12 months after aneurysmectomy.     

Real-time three-dimensional echocardiography in diagnosis of right ventricular pseudoaneurysm after pacemaker implantation

Right ventricular rupture is a critical cardiac complication associated with cardiac tamponade and death. Occasionally, the site of rupture may be contained by the parietal pericardium and thrombus, thus forming a pseudoaneurysm. Cases of traumatic pseudoaneurysm of the right ventricle have been reported. However, right ventricular pseudoaneurysm following pacemaker implantation has not been previously reported. This case demonstrates two right ventricular pseudoaneurysms following perforation of the right ventricular wall using real-time three-dimensional echocardiography (3DE) after pacemaker implantation although only one definite pseudoaneurysm was diagnosed by routine two-dimensional echocardiography (2DE). We also found that color Doppler 3DE enhanced visualization of the connections between the right ventricle and the pseudoaneurysm. Color Doppler 3DE allowed us to peel away the myocardial tissue and rotate the image to study the jets from different angles. In summary, real-time 3DE and color Doppler 3DE provided excellent visualization of the right ventricular pseudoaneurysm, flow between the ventricle and the pseudoaneurysm, and additional information to that obtained by 2DE.     

Live/real time three-dimensional echocardiographic demonstration of left ventricular noncompaction and thrombi

We describe two adult patients with left ventricular noncompaction in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) supplemented two-dimensional transthoracic echocardiography in making a definitive diagnosis of clots coexisting with trabeculations in the left ventricle. Mobility of clots and the presence of central echolucencies consistent with clot lysis were best demonstrated by 3DTTE and served to confidently differentiate clots from adjacent trabeculations.     

Missed diagnosis of unruptured,huge left ventricular pseudoaneurysm

We report a case of a huge left ventricular pseudoaneurysm following myocardial infarction. Early after myocardial infarction, the pseudoaneurysm was missed during the cardiac examination. The patient underwent coronary bypass surgery with endoaneurysmorraphy of the pseudoaneurysm, and made a satisfactory recovery.     

Transesophageal three-dimensional echocardiographic demonstration of Ebstein's anomaly

We report three-dimensional transesophageal echocardiographic findings in an adult patient with Ebstein's anomaly. Using the anyplane technique and multiple views, especially the short-axis view of tricuspid valve, three-dimensional transesophageal echocardiography clearly demonstrated the intermittent tethering of all three leaflets of tricuspid valve to the right ventricular walls giving a "bubble-like" appearance. On the other hand, two-dimensional transesophageal echocardiography demonstrated well the tethering of the septal tricuspid leaflet, but tethering of the other two leaflets was not well seen. To our knowledge, these findings have not been demonstrated by three-dimensional transesophageal echocardiography before.     

Comparison of two- and three-dimensional transthoracic echocardiography in the assessment of trabeculations and trabecular mass in left ventricular noncompaction

Twenty-one patients (mean age 47.5 years, 9 females) with left ventricular noncompaction (LVNC) diagnosed by both two-dimensional transthoracic echocardiography (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE) were included in the study. Left ventricular (LV) mass was calculated with epicardial and endocardial border tracings first including the LV trabeculations and then excluding them. LV trabecular mass was then derived as the difference between the two measurements. This was done by 2DTTE using the modified biplane Simpson's method and by live/real time 3DTTE using the Tom Tec imaging system. The number of trabeculations arising from each segment of LV walls as well as the segmental distribution of trabeculations were also assessed by both 2DTTE and 3DTTE. The calculated LV trabecular mass by 3DTTE (mean 11.8 +/- 5.5 g) was significantly greater than 2DTTE (mean 7.3 +/- 4.3 g, P = 0.005). The total number of trabeculations assessed by 3DTTE (mean 11.2 +/- 3.3) was also significantly greater than 2DTTE (mean 3.76 +/- 1.2, P < 0.0001). The values for inter- and intraobserver variability were lower for 3DTTE than 2DTTE. In conclusion, both LV trabecular mass as well as the total number of trabeculations in patients with LVNC were significantly underestimated by 2DTTE as compared to 3DTTE.     

Transesophageal echocardiographic identification of a descending aortic aneurysm rupture into the left lung

This case report describes a patient in whom a descending aortic aneurysm ruptured into the left lung, producing hemoptysis. With transesophageal echocardiography, we were able to define the site and extent of the aneurysm, as well as the two sites of rupture into lung tissue.     

Three Different Coexisting Mechanical Complications of Myocardial Infarction Detected by Transthoracic and Transesophageal Echocardiography

An aneurysm, pseudoaneurysm, and interventricular septal rupture were detected by transthoracic and transesophageal echocardiography (TEE) in a 61-year-old man with anterior myocardial infarction. This case illustrates the value of these techniques in the assessment of mechanical complications associated with myocardial infarction.     

Transesophageal echocardiographic diagnosis of traumatic rupture of the noncoronary cusp of the aortic valve

We report a patient with traumatic aortic valve injury in whom a large defect in the noncoronary cusp of the aortic valve was clearly visualized by multiplane TEE and confirmed at surgery.     

Acute myocardial infarction with ventricular septal rupture

The interventricular septum is one of the three main sites at which the myocardium can rupture. The features of the interventricular septal rupture that occurred in a 72-year-old woman are characteristic of interventricular septal ruptures in general: (1) they occur most commonly in elderly women; (2) the most common site is the midportion of an acute, transmural anteroseptal apical infarct; (3) they are also most common during the patient's first heart attack; (4) the clinical diagnosis of acute myocardial infarct is confirmed by both ECG and by serum enzyme levels; (5) the usual time of the rupture is 3–10 days after the onset of the infarction (it occurred after 3 days in our patient); (6) a new cardiac murmur usually is heard and the patient frequendy goes into shock; (7) the diagnosis can be confirmed by a step-up in pO₂ levels from right atrium to right ventricle; (8) the usual cause is severe old coronary atherosclerosis with a recent thrombotic occlusion as the final precipitating event.     

Intraoperative transesophageal echocardiography of ventricular septal defect

The accuracy and limitations of intraoperative two-dimensional (2-D) and color Doppler flow mapping transesophageal echocardiography (TEE) of ventricular septal defect (VSD), before and after cardiopulmonary bypass, were analyzed in 62 children. Twenty-one patients had an isolated VSD, and 41 had a VSD plus additional cardiac anomalies. Two-dimensional and color Doppler flow mapping TEE were performed with a miniaturized 5-MHz single (transverse) plane transducer in the 51 of 62 patients weighing less than 20 kg. The remaining 11 were monitored using a single plane adult probe (n = 4) and a biplane (transverse plus longitudinal) probe (N = 7). Prebypass TEE provided a correct diagnosis in 57 of 62 cases (92%) and corrected an erroneous preoperative transthoracic echocardiographic diagnosis in three of 62 cases (5%). Single plane TEE diagnosis was erroneous in five patients: four with doubly-committed subarterial VSD and one with multiple small apical muscular defects and pulmonary hypertension. Biplane TEE (transverse longitudinal) provided clear and complete imaging of the right ventricular outflow tract in all seven cases in whom it was used. Postbypass TEE showed absence of a hemodynamically significant residual VSD in 30 of 40 patients (95%) who underwent VSD patch closure, prospectively identified two of 40 with significant residual VSD, and accurately measured the color Doppler jet width of all residual VSDs. We conclude that hemodynamically significant VSDs can be identified immediately after cardiopulmonary bypass based on the width of the residual VSD color Doppler flow map jet. Therefore, 2-D and color Doppler flow mapping TEE provide an accurate diagnosis in most cases of VSD but may miss doubly-committed subarterial and apical muscular VSD unless biplane TEE is used.     

Three-dimensional transesophageal echocardiographic delineation of ventricular septal aneurysm producing right ventricular outflow obstruction in an adult

We report three-dimensional echocardiographic delineation of a congenital aneurysm of the membranous interventricular septum causing right ventricular outflow tract obstruction in an adult patient. To our knowledge, these findings have not been described before.     

Incomplete ventricular septal rupture following blunt chest trauma

Nonpenetrating cardiac trauma should be considered in the diagnosis of electrocardiographic changes after road traffic accidents. Transesophageal echocardiography is the most useful noninvasive technique for the diagnosis of cardiac trauma. This paper reports the case of a patient with traumatic contusion of the ventricular septum following a fall from a 20 m height onto the roof of a car.     

Three-dimensional transesophageal echocardiographic demonstration of anatomical defects in AV septal defect patients presenting for reoperation

We present two- and three-dimensional transesophageal echocardiographic findings of two adult patients who presented for reoperation after previous repair of a partial atrioventricular (AV) septal defect. Both patients had a cleft in the left AV valve with severe regurgitation. One patient had an additional 10 x 5 mm defect connecting the left ventricle to the right atrium through the AV junction. Three-dimensional echocardiography was superior to two-dimensional echocardiography in comprehensively delineating the anatomical defects in the left AV valve and the AV junction.     

Determination of left ventricular mass by real-time three-dimensional echocardiography: in vitro validation

Twenty-one explanted fixed hearts (14 dogs and 7 pigs) were examined to validate newly developed real-time three-dimensional (RT3D) echocardiography for measurement of left ventricular (LV) mass in vitro and to compare its accuracy and variability with those of conventional echocardiographic measurements. There was an excellent correlation and high degree of agreement for the determination of LV mass between RT3D echocardiography and true mass measurement (r = 0.98; standard error of the estimate [SEE] = 7.3 g; absolute difference [AD] = 2.8 g; y = 1.00 x -4.0, interobserver variability; 5.0%). The conventional echocardiographic methods yielded weaker correlations, larger standard errors, and interobserver variability (area-length method: r = 0.90; SEE = 13.3 g; AD = 13.2 g; 13.3 % / truncated ellipsoid method: r = 0.91; SEE = 14.7 g; AD = 10.5 g; 7. 9% / M-mode: r = 0.91; SEE = 16.2 g; AD = 9.4 g; 15.3%). Determination of LV mass by RT3D echocardiography has a high degree of accuracy and is superior to conventional one- and two-dimensional echocardiographic methods.