Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis

The clinical and echocardiographic variables related to left atrial spontaneous echo contrast were prospectively evaluated in a consecutive series of 400 patients undergoing transesophageal echocardiography with a 5-MHz single plane transducer. Left atrial spontaneous echo contrast was found in 75 patients (19%) and was significantly associated with atrial fibrillation, mitral stenosis, absence of mitral regurgitation, increased left atrial dimension and a history of suspected embolism. Seventy-one (95%) of the patients with spontaneous echo contrast had atrial fibrillation or mitral stenosis. Anticoagulant therapy had no significant association with spontaneous echo contrast. Multivariate analysis in 89 patients with mitral stenosis or mitral valve replacement showed that spontaneous echo contrast was the only independent predictor (p = 0.03) of left atrial thrombus or suspected embolism, or both. In 60 patients with atrial fibrillation of nonvalvular origin, spontaneous echo contrast (p = 0.01) and age (p = 0.03) were the only independent predictors of left atrial thrombus or suspected embolism, or both. It is concluded that left atrial spontaneous echo contrast is 1) a common finding in patients undergoing transesophageal echocardiography, 2) associated with conditions favoring stasis of left atrial blood, and 3) a marker of previous thromboembolism in patients with nonvalvular atrial fibrillation and those with mitral stenosis or mitral valve replacement.     

A study of spontaneous echo contrast in patients with rheumatic mitral stenosis and normal sinus rhythm: an Indian perspective.

OBJECTIVE--To study the incidence of spontaneous echo contrast in left atrium of Indian patients with rheumatic mitral stenosis in normal sinus rhythm and to define its relations. SUBJECTS--Transthoracic and multiplane transoesophageal echocardiographic studies were performed in 89 consecutive patients with rheumatic mitral stenosis who were in normal sinus rhythm. RESULTS--Spontaneous echo contrast in the left atrium was seen in 57.3% of patients on multiplane transoesophageal echocardiography and in only 5.6% on transthoracic echocardiography. The mean mitral valve area was 1.07 (SD 0.33) cm2 and 1.32 (0.45) cm2 (P = 0.004), mean left atrial size was 4.27 (0.67) cm and 3.91 (0.5) cm (P = 0.029), mean diastolic pressure gradient was 12.64 (5.69) mm Hg and 10 (5.5) mm Hg (P = 0.049), and absence of mitral regurgitation was seen in 45% and 23% of patients respectively (P = 0.1). Among patients with spontaneous echo contrast, 31% had either left atrial/appendage thrombus or a history of embolism, upsilon 0% in patients without spontaneous echo contrast (P < 0.0001). CONCLUSIONS--There is a high incidence of spontaneous echo contrast in the left atrium in Indian patients with rheumatic mitral stenosis in normal sinus rhythm on multiplane transoesophageal echocardiography. These patients are likely to embolise or form thrombi in the left atrium. The presence of spontaneous echo contrast is also associated with significantly smaller mitral valve area, larger left atrium, and higher mean diastolic mitral pressure gradient.     

Occurrence of dynamic atrial spontaneous contrast in patients with mitral disease]

OBJECTIVE: The aim of this study was to analyze, through transesophageal echocardiography, different factors related to left atrial spontaneous echocardiographic formation. DESIGN: Transthoracic and transesophageal comparative study of left atrial thrombotic phenomena. SETTING: Ambulatory and in hospital patients referred to Gregorio Mara?on General Hospital Echocardiographic Laboratory. PATIENTS: 120 consecutive patients with mitral valve disease or prosthesis were included in this transesophageal echocardiographic prospective study. All patients were divided in two groups, according with left atrial spontaneous contrast. In each patient we measured total left atrial area, rhythm abnormalities, mitral valve area, left atrial cavity thrombus and maximal mitral regurgitation area. MEASUREMENTS AND RESULTS: Transthoracic echocardiography did not detect any patient with left atrial spontaneous contrast, compared to 57.5% diagnosed through the transesophageal technique. Transesophageal echocardiography diagnosed left atrial thrombosis in 19% (n = 23) of patients compared to 1% (n = 2) through the transthoracic technique. In the group with left atrial contrast, 59% of patients had mitral regurgitation less than 600 mm2, 64% were in atrial fibrillation and left atrial total area was 28 +/- 10.8 mm2. CONCLUSIONS: Transesophageal echocardiography is the technique of choice to diagnose, with greater security, left atrial cavity thrombosis, and establish the relationship of echocardiographic variables and left atrial thrombotic phenomena. Among these echocardiographic factors, left atrial dynamic spontaneous echocontrast is fundamental.     

Subaortic stenosis produced by an accessory mitral valve: the role of echocardiography

Subaortic stenosis caused by an accessory mitral valve is an exceedingly rare finding. We report the case of an asymptomatic 14-year-old patient, in whom transthoracic echocardiography revealed an accessory mitral valve in the left ventricular outflow tract, producing mild subaortic stenosis. Except for an aneurysm of the interventricular septum, with no shunt, there were no other anomalies. Transesophageal echocardiography provided details about the morphology and location of the accessory valve. Being asymptomatic and having only a mild gradient, antibiotic prophylaxis for infective endocarditis and follow-up were recommended. After 2 years the patient is asymptomatic, with a similar echocardiographic gradient.     

Fenestrated Aneurysm of the Mitral Valve

Aneurysms of the cardiac valves remain rare. In this report, we describe the first case of a left ventricular to mitral valve aneurysm to left atrial shunt through a fenestrated aneurysm of the mitral valve diagnosed and successfully repaired under the guidance of transesophageal echocardiography. The transesophageal echocardiography provided substantial additional data to the transthoracic echocardiography, and was valuable in planning the surgical approach. Transesophageal echocardiography should be considered when clear-cut transthoracic echocardiographic interpretation cannot be made in patients with mitral regurgitation. (ECHOCARDIOGRAPHY, Volume 8, September 1991)     

Left atrial spontaneous echo contrast in patients with rheumatic mitral valve stenosis in sinus rhythm: relationship to mitral valve and left atrial measurements

We studied 37 consecutive patients with mitral stenosis in sinus rhythm using transthoracic and transesophageal echocardiography to relate the presence of spontaneous echo contrast (SEC) in the left atrium with mitral valve area and left atrial dimensions. We also compared the value of left atrial area by planimetry with that of left atrial dimension by M mode in predicting presence of SEC and monitored the effect of anticoagulation on SEC. Transesophageal echocardiography demonstrated spontaneous echo contrast in 9/37 (24%) patients and thrombus in none. SEC continued to be present despite anticoagulation. Mitral valve orifice area by pressure half time method (P=0.001) and by planimetry (P=0.01), and left atrial area by planimetry (P<0.05) were predictors to presence of SEC. Left atrial dimension by M mode examination failed to predict SEC. Cut off values were mitral valve orifice /=25 cm(2) (agreement 81%). On multivariate analysis mitral valve area was the only independent predictor. SEC persisted despite anticoagulation. This supports the view that more than one mechanism is involved in the development of SEC.     

Visualization of mitral valve aneurysm by transesophageal echocardiography

This article describes the transesophageal echocardiographic findings in a patient with pathologically proven mitral valve aneurysm. This aneurysm probably occurred as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a saccular structure attached to the left atrial side of the anterior mitral leaflet with systolic expansion and diastolic collapse, and its orifice was visualized with excellent resolution. Transesophageal echocardiography is a useful diagnostic tool for evaluation of mitral valve aneurysm.     

Prevalence and clinical significance of left atrial spontaneous echo contrast detected by transesophageal echocardiography

The prevalence and clinical significance of left atrial spontaneous echo contrast (SEC) were studied in patients undergoing transesophageal echocardiography (TEE). The study group included 290 consecutive patients (186 male and 104 female, aged 17-86 years, mean age 56.1 +/- 12.8 years). Left atrial SEC was found in 50 (17.2%) patients, and was significantly associated with atrial fibrillation, mitral stenosis, absence of mitral regurgitation, and left atrial dimension. Atrial fibrillation was recorded in 44 (88%) patients, mitral stenosis or mitral valve replacement in 21 (42%) patients, and left atrial thrombus or previous embolism in 23 (46%) patients with SEC. Univariate analysis showed a significant association between the presence of SEC and atrial fibrillation, mitral stenosis or mitral valve replacement, and left atrial size. Multivariate analysis showed the presence of left atrial SEC and atrial fibrillation to be independent factors for thrombus formation and/or thromboembolism. Since left atrial SEC associated with atrial fibrillation, left atrial enlargement, mitral stenosis, or mitral valve prosthesis was found in 17.2% of patients undergoing TEE, it might be considered a marker of left atrial thrombus or previous thromboembolism.     

Cross-sectional echocardiographic features of ruptured chordae tendineae

Thirty-two patients with mitral regurgitation secondary to rupturedchordae tendineae were studied by cross-sectional echocardiography.Twenty of them subsequently underwent operation. Three signsare described. (1) Non-coaptation of the leaflets (55%). (2)Systolic fluttering echo in the left atrium originating fromthe mitral valve (20%). (3) A previously not described smalldiastolic chaotically moving echo in the short axis sectionof the left ventricle at the level of the papillary muscles(65%). The combined sensitivity of these three signs was 85%.The specificity of the three signs when compared with thoseof 107 patients with mitral regurgitation of different aetiologiesstudied by cross-sectional echocardiography was 99%, 100% and99%, respectively. Six patients were studied after mitral valverepair; restriction of the surgical treated leaflet and reductionof its valve area was seen in all of them, and the disappearanceof the valvar signs of ruptured chordae noted. The persistenceof the small echo sign in the short axis of the left ventricleindicated its chordal origin.     

Right atrial spontaneous contrast: echocardiographic and clinical features

We describe the clinical and echocardiographic findings in eight patients with right atrial spontaneous echo contrast who were identified from 648 consecutive patients undergoing transesophageal echocardiography. Common findings in these patients were right atrial enlargement (8 patients), tricuspid regurgitation (7 patients), atrial fibrillation or flutter (6 patients), elevated right ventricular pressure (5 patients), moderate or severe mitral valve disease (5 patients), and right to left interatrial shunts (3 patients). Right heart catheterization in three patients showed markedly elevated right atrial, right ventricular, and pulmonary artery pressures. Two patients had thromboembolic events — one patient had recurrent pulmonary emboli, and another patient with an atrial septal aneurysm had recurrent transient ischemic attacks. Right atrial echo contrast is an uncommon finding at echocardiography that is associated with severe right heart dysfunction. It may also be associated with paradoxical or pulmonary embolism.     

Visualization of Mitral Valve Tunnel Aneurysm by Transesophageal Echocardiography

We report the echocardiographic findings in a patient with a mitral valve aneurysm, probably occurring as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a tunnel-shaped aneurysm of the atrial side of the anterior mitral leaflet, expanding in systole and collapsing in diastole. Transesophageal echocardiography is a useful diagnostic tool for the evaluation of mitral valve pathology.     

Left atrial spontaneous contrast echoes -- markers of thromboembolic risk in patients with atrial fibrillation

A consecutive series of 80 patients with atrial fibrillationwere studied with both precordial and transoesophageal echocardiography.Left a trial spontaneous contrast echoes were observed in onepatient with precordial echocardiography and in 26 patients(33%) with transoesophageal echocardiography. They were foundmost commonly in patients with rheumatic mitral valve disease(67%) but were observed in 28% of patients with lone atrialfibrillation. Their presence was unrelated to the age, genderand therapy of the patient. Although they were more common inpatients with a large left atrium, they were sometimes observedin a normal sized atrial chamber. They were more common in chronic(40%) than in paroxysmal atrial fibrillation (5.6%). No patienthad severe mitral regurgitation, but contrast echoes were observedin some patients with mild or moderate mitral regurgitation.Of the 26 patients with spontaneous contrast echoes, six (23%)had echoes consistent with left atrial thrombus compared toone of the 54 patients without these echoes (1.9%) (P = 0.006),17 (65%) had suffered a previous thromboembolic event comparedto 17 of the 54 without these echoes (32%) (P = 0.009). Thesedata support the concept that spontaneous contrast echoes inthe left atrium are associated with sluggish blood flow anda thrombogenic environment. Transoesophageal echocardiographymay thus be useful in assessing which patients with atrial fibrillationmight most benefit from anticoagulation. This hypothesis needsto be evaluated further in a prospective study.     

Live 3D TEE demonstrates and guides the management of prosthetic mitral valve obstruction

A 43-year-old woman, with a remote history of rheumatic mitral stenosis and a St. Jude prosthetic mitral valve replacement, presented with shortness of breath and palpitations, shortly after a long flight. On admission, atrial fibrillation with a rapid ventricular response was noted in the setting of a long history of noncompliance with her anticoagulation. Transesophageal echocardiography (TEE) demonstrated multiple laminated thrombi in the left atrial appendage. Live three-dimensional (3D) TEE confirmed this diagnosis and demonstrated an immobile posterior leaflet of the mitral prosthesis, which had direct implications in her management. She successfully underwent surgery for mitral valve replacement, left atrial appendage ligation, and a Maze procedure on the following day. The multiple thrombi within the atrial appendage were confirmed intraoperatively and pannus formation was determined to be the etiology of the leaflet immobility.     

Mitral valve aneurysm: M-mode and two-dimensional echocardiographic features

The following report presents M-mode and two-dimensional echocardiographic findings in a case of mitral valve aneurysm. M-mode echocardiography showed abnormal intravalvular echoes during diastole and a linear echo in the left atrium, with a motion pattern similar to that of the anterior mitral valve leaflet. By allowing visualization of the aneurysmal sac, two-dimensional echocardiography proved to be a more specific diagnostic method.     

Spontaneous echo contrast on transthoracic echocardiography and left atrial thrombus in rheumatic mitral valve disease patients: A clinicopathologic study

The association of spontaneous echo contrast and thrombus in the left atrium in patients with mitral valve disease is controversial. This study was undertaken to determine whether there is an independent association between spontaneous echo contrast on transthoracic echocardiography (TTE) and intraoperative evidence of left atrial thrombus and to evaluate the clinical implications of spontaneous echo contrast in patients with symptomatic rheumatic mitral valve disease. A total of 255 patients who underwent surgery for rheumatic mitral valve disases were preoperatively evaluated by transthoracic two-dimensional and Doppler echocardiography. Spontaneous echo contrast in the left atrium was carefully sought. The left atrium was carefully searched for evidence of thrombus intraoperatively. The association of spontaneous echo contrast and left atrial thrombus was determined by univariate and multivariate analysis. Of the patients studied, 77 (30%) had left atrial thrombus. Left atrial thrombus was found in 47 and 21 % of patients with and without spontaneous echo contrast, respectively (p < 0.001). Spontaneous echo contrast and atrial fibrillation were found to be the only two independent predictors of left atrial thrombus (odds ratio = 2.16; 95% confidence interval 1.15-4.04 p < 0.05, and odds ratio = 6.98; 95% confidence interval 3.45-14.16, p < 0.001, respectively). It was concluded that there is an independent association between spontaneous echo con trast on TTE and left auial thrombus in patients with mitral valve disease requiring surgical correction. These patients are at high risk for left atrial thrombus and should, therefore, be con sidered for long-term anticoagulation.     

Severe mitral stenosis secondary to massive calcification of the mitral annulus with unusual echocardiographic manifestations

In mitral annular calcifications, hemodynamic documentation of a significant diastolic gradient across the mitral valve has been rarely demonstrated, and then only with the associated finding of a small left ventricular cavity with hypertrophic left ventricular wall. We present a patient with severe mitral annular calcification, with a significant diastolic gradient and unusual echocardiographic manifestations which include a densely calcified mitral valve annulus with anterior mitral valve leaflets consistent with what is seen in patients with mitral stenosis. When recordings were made immediately below the mitral valve annulus at the free edge of the mitral valve, its leaflets were seen departing in opposite directions, certainly not suggestive of outflow obstruction of the left atrium. Although in previous studies it has been suggested that mitral stenosis does not exist in the presence of mitral annulus calcification, our present report indicates that significant diastolic gradients can be found in patients with mitral annular calcifications. Because of the predominance of this condition in the elderly population, it is suggested that a more aggressive approach be taken in those patients in whom it is warranted by clinical circumstance.     

M mode and cross-sectional echocardiographic features of flail posterior mitral leaflets

Seventeen patients with accepted M mode echocardiographic criteria for flail mitral leaflet were studied. M mode echocardiograms revealed characteristic disordered mitral valve motion: (1) 16 (94 percent) had chaotic diastolic mitral motion; (2) 14 (82 percent) had systolic mitral flutter; (3) 14 (82 percent) had systolic left atrial echoes; and (4) 12 (71 percent) had systolic mitral valve prolapse. In 8 patients (47 percent) all four findings were present, with three findings present in 16 (35 percent) and two findings present in 13 (18 percent); none had fewer than two findings. Cross-sectional echocardiographic studies in 10 patients revealed a systolic whipping motion of the posterior mitral leaflet into the left atrium in all, abnormal systolic mitral coaptation in all and an abnormal mass of systolic left atrial echoes in 4. None of the first three M mode criteria were observed in 230 patients with uncomplicated “mid systolic click-late systolic murmur” syndrome; cross-sectional echocardiography in 30 of 230 patients revealed normal systolic mitral coaptation and no systolic whipping of the tip of the posterior mitral leaflet into the left atrium.     

Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk

The incidence of left atrial spontaneous echo contrast was evaluated in 52 patients with isolated or predominant mitral valve stenosis (Group 1) and 70 other patients who had undergone mitral valve replacement (Group 2). All patients were studied by conventional transthoracic and transesophageal two-dimensional echocardiography. Spontaneous echo contrast could be visualized within the left atrium in 35 Group 1 patients (67.3%) (including 7 patients with sinus rhythm) and 26 Group 2 patients (37.1%) (all with atrial fibrillation). Patients with spontaneous echo contrast had a significantly larger left atrial diameter and a greater incidence of both left atrial thrombi and a history of arterial embolic episodes than did patients without spontaneous echo contrast. Association between spontaneous echo contrast and left atrial thrombi and a history of arterial embolization (considered individually or in combination) showed a high sensitivity and negative predictive value. It is concluded that spontaneous echo contrast is a helpful finding for identification of an increased thromboembolic risk in patients with mitral stenosis and after mitral valve replacement.     

Commissural fusion as etiology of bioprosthetic mitral stenosis in a patient with rheumatic heart disease

We report commissural fusion as a unique morphologic etiology of early bioprosthetic mitral valve failure in a woman with a history of rheumatic mitral stenosis. She had undergone mitral valve replacement with a 25-mm Edwards Magna Ease bovine pericardial bioprosthesis 3 years earlier and presented with progressive dyspnea. Transesophageal echocardiography revealed severe bioprosthetic stenosis due to commissural fusion. She underwent percutaneous valve-in-valve implantation with a 26-mm Edwards Sapien 3 prosthesis. Marked symptomatic improvement was noted postprocedurally. We speculate that commissural fusion may be a unique pathologic feature of failing bioprosthetic valves in patients with prior rheumatic mitral valve disease.     

Features of patients with severe mitral stenosis with respect to atrial rhythm. Atrial fibrillation in predominant and tight mitral stenosis.

The aim of this study was to assess the features of patients with severe mitral stenosis in relation to atrial rhythm. Six hundred and fifty patients (pts) with severe mitral stenosis (MS) (valve area less than or equal to 1.5 cm2) who underwent percutaneous balloon commissurotomy (n = 600) or surgery (n = 50) were classified into 3 groups according to their atrial rhythm (AR): group A: sinus rhythm (SR) (n = 379), group B: SR with episodes of transient atrial fibrillation (AF) (n = 65), group C: permanent AF (n = 206). Uni- and multivariate analysis of clinical, echocardiographic and hemodynamic parameters with respect to the atrial rhythm was performed. Some parameters were comparable in all 3 groups: sex, pulmonary, right and left atrial pressures, mitral valve area, incidence of associated aortic valve disease. Nine parameters were different: mean age, NYHA class III or IV, previous commissurotomy, previous embolism, cardiac index, mitral regurgitation, tricuspid regurgitation, left atrium diameter, mitral calcification. Multivariate analysis, identified age, left atrial diameter and presence of mitral calcification as independent predictors of atrial fibrillation. Transoesophageal echocardiography was performed in 167 cases. A spontaneous echo contrast was recorded in 106 cases (63.5%) and was significantly correlated with a history of embolism and or left atrial thrombi detected by echocardiography. Atrial fibrillation, size of left atrium, severity of mitral stenosis and cardiac index were found to be independent predictive factors of spontaneous echo contrast.