Two dimensional echocardiographic diagnosis of aortic dissection

The usefulness of two dimensional echocardiography in establishing the diagnosis of aortic dissection was evaluated. Forty-two patients were referred for study; 15 had a dissection and 27 did not. Two dimensional echocardiography detected the intimai flap in 12 of 15 patients with a dissection; the three false negative studies were in patients with a localized dissection. There was one false positive study in the 27 patients who did not have a dissection.     

Two dimensional echocardiographic recognition of the descending thoracic aorta.

Two dimensional echocardiography was used to identify the descending thoracic aorta in 106 subjects. In 12 of these subjects, contrast injection techniques were used to identify this structure as it descended posteriorly adjacent to the atrioventricular groove. The course of the descending thoracic aorta was mapped using both the long axis and transverse axis views. The normal descending thoracic aorta (26 subjects) measured 10 +/- 1.4 mm/m2 during diastole. Unusual M mode echocardiographic patterns of the descending aorta may be confused with other disease states; they are clarified with the two dimensional study. The size and appearance of the descending aorta in different types of cardiovascular disease, including aortic aneurysm, in 80 patients are described. It is anticipated that two dimensional echocardiography will prove to be a useful method of studying patients with aortic disease.     

Two dimensional echocardiographic detection of intraatrial masses

With two dimensional echocardiography, a left atrial mass was detected in 19 patients. Of these, 10 patients with rheumatic mitral stenosis had a left atrial thrombus. The distinctive two dimensional echocardiographic features of left atrial thrombus included a mass of irregular nonmobile laminated echoes within an enlarged atrial cavity, usually with a broad base of attachment to the posterior left atrial wall. Seven patients had a left atrial myxoma. Usually, the myxoma appeared as a mottled ovoid, sharply demarcated mobile mass attached to the interatrial septum. One patient had a right atrial angiosarcoma that appeared as a nonmobile mass extending from the inferior vena caval-right atrial junction into the right atrial cavity. One patient had a left atrial leiomyosarcoma producing a highly mobile mass attached to the lateral wall of the left atrium. M mode echocardiography detected six of the seven myxomas, one thrombus and neither of the other tumors. Thus, two dimensional echocardiography appears to be the technique of choice in the detection, localization and differentiation of intraatrial masses.     

Two dimensional echocardiographic assessment of patients with bioprosthetic valves.

The clinical utility of two dimensional echocardiography in assessing bioprosthetic and left ventricular function was studied in 40 consecutive patients 1 week to 60 months after valve replacement surgery. These patients were referred to obtain normal baseline studies as well as to evaluate complications:suspected endocarditis, embolic phenomena and congestive heart failure of unknown cause. Independent M mode echocardiograms were also obtained in each patient. Confirmation of ultrasonic studies was by cardiac catheterization with angiography, surgery and pathologic study in 10 patients; cardiac catheterization with angiography alone in 7 patients; surgery and pathologic study in 3 patients; autopsy in 3 patients; blood cultures to confirm or exclude endocarditis in 10 patients; and confirmation on clinical grounds in 7 patients. Technically adequate two dimensional studies were recorded in 39 of 40 subjects. Two dimensional echocardiography accurately assessed 15 of 16 patients with an abnormal bioprosthetic valve and a normal left ventricle (1 of 16 patients had a false positive two dimensional echocardiogram); 8 of 8 patients suspected to have prosthetic valve or left ventricular dysfunction but who were normal; 7 of 7 patients with a normal prosthesis and an abnormal left ventricle; the one patient with an abnormal valve and left ventricle; and 7 of 7 clinically normal patients who were referred for baseline studies. In summary, the two-dimensional echocardiogram demonstrated a 97 percent diagnostic accuracy rate which was significantly greater than the 67 percent (P less than 0.001) for M mode echocardiography in the same group of patients. It is concluded that two dimensional echocardiography has excellent diagnostic accuracy in assessing bioprosthetic and left ventricular function and is superior to M mode echocardiography in evaluating patients after such valve replacement.     

Two dimensional echocardiographic characteristics of double outlet right ventricle.

The reliability was evaluated of two dimensional echocardiography in distinguishing double outlet right ventricle from other anomalies of the great arteries. Accordingly, a combined retrospective and prospective study was conducted in 13 children with double outlet right ventricle, 12 with tetralogy of Fallot, 13 with complete d-transposition of the great arteries, 5 with congenitally corrected I-transposition and 2 with truncus arteriosus. Echographic findings using a standard long axis view in all subjects with double outlet right ventricle included (1) inability to identify a great artery arising from the left ventricle, and (2) lack of continuity between the anterior mitral leaflet and any semilunar valve. In the short axis view constant findings were (1) simultaneous imaging of both great arteries in an anterior location with the ventricular septum identified posteriorly on sweeping into the left ventricle, and (2) lack of a clockwise wraparound of the aorta by the right ventricular outflow tract. Imaging revealed that the great arteries were side by side in seven patients d-malposed in three and l-malposed in two. A modified left precordial tomographic view demonstrated both great arteries arising from the right ventricle in four of nine patients not treated surgically. In four patients with surgically repaired double outlet right ventricle, the left ventricular outflow tract had a tunnel-like configuration in the long axis view. These findings were diagnostic of double outlet right ventricle in all patients and accurately differentiated the malformation from other anomalies of the great arteries.     

Ventricular septal defects. Two dimensional echocardiographic and morphological correlations.

To evaluate the ability of two dimensional echocardiography to identify and classify ventricular septal defects, 280 infants and children with clinically significant ventricular septal defects were studied. Multiple precordial and subcostal echocardiographic planes were scanned in each patient in an attempt to identify the defects. Defects visualised were classified on the basis of the structures which formed their margins. Subsequent correlation of this information with angiographic (280 patients), surgical (130 patients), and pathological (31 patients) data confirmed that defects in the following sites produced a specific two dimensional echocardiographic pattern. (a) Perimembranous inlet, (b) perimembranous outlet, (c) muscular inlet, (d) single trabecular, (e) muscular outlet, and (f) doubly committed subarterial. A defect was identified and correctly classified in 252 patients. Individual defects were identified with varying degrees of accuracy. All subarterial (24 patients) defects were correctly identified and classified, as were muscular defects of the inlet (18 patients) and outlet (six patients) septa. Of the 185 perimembranous defects, 182 were identified. Only 23 of the 43 single trabecular defects were identified. Small multiple ("Swiss cheese") defects (four patients) were not identified. We conclude that two dimensional echocardiography provides a reliable non-invasive method of identifying and classifying the following ventricular septal defects: (a) perimembranous defects, (b) doubly committed subarterial defects, and (c) muscular defects of the inlet and outlet septa. In our experience it fails consistently to visualise defects in the trabecular septum.     

Two dimensional and Doppler echocardiographic evaluation of double chambered right ventricle.

Two-dimensional and Doppler echocardiographic findings in 20 patients with double chambered right ventricle are described. All patients had the diagnosis established by cardiac catheterisation and confirmed at operation. Echocardiographic evaluation was done prior to surgical correction. Anomalous muscle bands in right ventricular cavity were detected in 16 patients. Doppler flow velocities in the right ventricular cavity suggested infundibular obstruction to blood flow at a low level in all 17 patients studied by Doppler echocardiography. Ventricular septal defects (11 patients), pulmonary stenosis (3 patients), and aortic regurgitation (3 patients) were detected accurately before operation by echocardiographic examination. Failure to detect the anomalous muscles in right ventricular cavity may occur in adult patients with poor anterior resolution and in those with severe right ventricular outflow obstruction and myocardial hypertrophy. Two dimensional echocardiography with Doppler flow analysis is useful in the evaluation and differential diagnosis of right ventricular outflow obstructions prior to invasive studies and surgical intervention.     

Two dimensional echocardiographic quantification of infarct size alteration by pharmacologic agents.

In 27 closed chest dogs left ventricular wall motion abnormalities assessed quantitatively with two dimensional echocardiography were used as a measure of myocardial infarct size, and the change in extent of segmental wall motion abnormalities due to drug intervention early after infarction was evaluated. The extent of wall motion abnormalities was measured with echocardiography before and at 20 and 40 minutes and 5 1/2 hours after coronary occlusion. Three subgroups of dogs received, respectively, an infusion of nitroglycerin, phenylephrine or saline solution. Infarct size was measured with technetium pyrophosphate scintigraphy of the excised left ventricle. The infarct size correlated well with the extent of wall motion abnormalities before death. Wall motion was initially similar among the three groups but was significantly improved after treatment with nitroglycerin (P less than 0.025), remained stable with continued saline infusion and worsened significantly (P less than 0.05) after treatment with phenylephrine. Two dimensional echocardiography can be used to quantify experimental canine myocardial infarction and assess the effect of nitroglycerin.     

Two dimensional echocardiographic evaluation of patients with mitral insufficiency

One hundred forty patients with clinical mitral insufficiency were studied with two dimensional echocardiography. Cardiac catheterization was performed in 51 patients; all had mitral insufficiency. Thirty-three patients were surgically treated. An etiologic diagnosis was made in 133 patients. Mitral valve prolapse (41 patients) was the most common cause of mitral insufficiency; the amount of valve insufficiency did not correlate with the leaflet involved or the severity of the prolapse. Patients with rheumatic disease either had combined mitral stenosis and insufficiency (27 patients) or pure mitral insufficiency (10 patients). Echocardiographic measurement of the mitral valve area separated patients with combined lesions from those with pure insufficiency. Fourteen patients had ruptured chordae tendineae; surgical findings were confirmatory in each patient who had valve replacement. Nineteen patients had left ventricular dysfunction; angiographie findings were confirmatory in each patient who underwent cardiac catheterization. Two dimensional echocardiographic findings reliably differentiated mitral insufficiency secondary to valve disease from that secondary to ventricular or papillary muscle dysfunction. Other causes of mitral insufficiency included mitral anular calcification (11 patients), idiopathic hypertrophic subaortic stenosis (5 patients), cleft anterior mitral leaflet (5 patients) and atrial myxoma (1 patient).     

Two dimensional echocardiographic demonstration of an unusual complication of aortic infective endocarditis

The two dimensional echocardiographic findings of aortic root abscess have been described. The echocardiographic findings in a patient with aortic valve endocarditis complicated by abscess formation, tear in the intima of the ascending aorta, and rupture of abscess cavity into the right ventricle are reported.     

Two dimensional echocardiographic evaluation of mustard operation for d-transposition of the great arteries

Two dimensional sector scan echocardiography was used to evaluate the morphologic characteristics of the surgically revised atria in 17 patients with d-transposition of the great arteries who had undergone the Mustard operation. Echocardiographic imaging of the atria was obtained from various planar projections. Dimensional measurements of various segments of the systemic and pulmonary venous atria were obtained in each patient. Correlative hemodynamic, angiographic, postmortem and echocardiographic data showed that seven patients (Group I) had no structural abnormalities of the atria. These 7 patients served as controls for 10 other patients with structural abnormalities of the surgically created atria. One patient (Group II) showed stenosis of the junction of the superior vena cava and systemic venous atrium compared with findings in the control group. Three patients (Group III) had significantly reduced echocardiographic dimensions of the junction of the anterior and posterior segments of the pulmonary venous atrium. Six patients (Group IV) had increased echocardiographic dimensions of all components of the pulmonary venous atrium due to tricuspid regurgitation. These data show that qualitative and quantitative two dimensional sector echocardiography can reliably detect structural abnormalities of the surgically revised atria after the Mustard operation.     

Two dimensional echocardiographic visualization of ventricular septal rupture after acute anterior myocardial infarction

In three consecutive cases of ventricular septal rupture after acute anterior myocardial infarction, wide angle two dimensional echocardiography readily visualized the septal defect, permitting the defect to be localized and its size estimated. In addition, negative contrast echoventriculography identified a left to right shunt at the ventricular level. The echocardiographic findings were corroborated by cardiac catheterization data in all patients, by perioperative examination in two and by postmortem findings in one patient. Postoperative echocardiographic studies afforded demonstration of the patch closing the defect.In patients with acute myocardial infarction associated with the sudden appearance of a systolic murmur, two dimensional echocardiography should be performed promptly in order to guide the diagnosis and management of these critically ill patients. In some patients with severe cardiogenic shock, in whom a favorable prognosis depends on rapid treatment, two dimensional echocardiography may allow the patient to be taken to surgery immediately without further study.     

Two dimensional echocardiographic assessment of communications between ascending aorta and pulmonary trunk or individual pulmonary arteries.

The value of two dimensional echocardiography in identifying communications between the ascending aorta and pulmonary trunk or individual pulmonary arteries was assessed in 24 children, all of whom had either angiocardiographic and surgical or angiocardiographic confirmation alone. Fourteen cases had truncus arteriosus, four aortopulmonary window, four anomalous origin of the left pulmonary artery from the ascending aorta, and two anomalous origin of the right pulmonary artery from the ascending aorta. It was possible to identify reliably each individual abnormality with a combination of suprasternal, precordial, and subcostal cuts. Problems only arose in differentiating truncus arteriosus from pulmonary atresia and ventricular septal defect when the main pulmonary artery and infundibular region of the right ventricle were extremely hypoplastic.     

An unusual case of mitral valve aneurysm: Two dimensional echocardiographic and cineangiocardiographic features

A patient is described in whom an aneurysm of the posterior mitral leaflet caused severe mitral incompetence and cardiac failure. The aneurysm was seen as an additional echo-free space within the left atrium in the real time two dimensional echocardiogram. Both echocardiographic and cineangiocardiographic appearances were misinterpreted initially because the aneurysmal leaflet did not move into the left ventricle during diastole. This feature was explained during the successful surgical repair of the valve by the observation that the aneurysm was adherent to the left atrial wall.     

Balloon atrial septostomy under two dimensional echocardiographic control.

Two dimensional echocardiography has been used to guide balloon atrial septostomy in five cases of transposition of the great arteries. A single lumen balloon catheter was used. The catheter can be accurately located within the left atrium before inflation of the balloon, thus avoiding some of the traumatic accidents possible during septostomy. The balloon can be observed creating the atrial defect and the approximate size of the resulting defect noted. It can also be seen if the foramen ovale is only being stretched and not torn. The use of the two dimensional echocardiogram during septostomy should significantly contribute to the speed, efficiency, and safety of the procedure.     

Two dimensional echocardiographic categorisation of the univentricular heart. Ventricular morphology, type, and mode of atrioventricular connection.

Most univentricular hearts have two chambers in their ventricular mass, only one of which possesses an atrioventricular connection. Categorisation into univentricular heart of right, left, or indeterminate type, using two dimensional echocardiography has been successfully achieved in 122 out of 132 patients to whom this technique has been applied. Thus, right ventricular rudimentary chambers in 84 univentricular hearts of left ventricular type were shown to be anterosuperior and either to the right or left. In contrast, left ventricular rudimentary chambers in 25 univentricular hearts of right ventricular type were posteroinferior and to the right, left, or directly posterior. Thirteen univentricular hearts of indeterminate morphology were characterised by absence of rudimentary chamber on angiography and echocardiography. The trabecular pattern of both main and rudimentary chambers were separately identified in some of the patients with univentricular hearts of right and left ventricular type and two dimensional echocardiography also illustrated the mode of atrioventricular connection, either via two atrioventricular valves, a common valve, or a valve straddling or overriding the trabecular septum. Finally it was also possible to distinguish absent atrioventricular connection from an imperforate valve in 10 patients.     

Statistical comparison of M mode and two dimensional echocardiographic diagnosis of flail mitral leaflets

Forty-five patients who had surgical therapy for pure mitral insufficiency were evaluated prospectively with both M mode and two dimensional echocardiography; 26 patients (Group I) had a flail mitral valve leaflet, and 19 patients (Group II) had intact chordae tendineae. The M mode echocardiographic criteria of a flail valve (systolic left atrial echoes, systolic mitral valve flutter, diastolic mitral flutter and chaotic paradoxic diastolic posterior leaflet motion) were compared statistically with the two dimensional echocardiographic criterion (loss of systolic leaflet coaptation). The presence of one M mode echocardiographic finding had a sensitivity of 60 percent, a specificity of 53 percent, a predictive accuracy of 63 percent and a predictive value of 50 percent. The sensitivity (96 percent), specificity (84 percent), predictive accuracy (89 percent) and predictive value (94 percent) of the two dimensional echocardiogram were statistically superior to those of the M mode study (p < 0.05 or better for each criterion). Thus, two dimensional echocardiography is distinctly superior to M mode echocardiography in the diagnosis of flail mitral valve leaflets.     

Cardiac echinococcosis--a rare echocardiographic diagnosis.

A 30 year old female admitted for evaluation of left chest pain was suspected to have multiple cardiac hydatid cysts. The diagnosis was established by cross sectional echocardiography and computed tomography, supported by enzyme linked immunosorbent assay (ELISA) for echinococcosis. Medical therapy altered the echopattern of the cysts but failed to reduce cystic masses. Surgery was advocated but refused by the patient.     

Two-dimensional echocardiographic diagnosis of aorticopulmonary window.

Two-dimensional echocardiography was performed in two cases of distal type aorticopulmonary window. The defect of the aorticopulmonary septum could be visualised in both cases in transverse section of the great arteries using our method. We make it a rule to study three different levels of section: plane 1, where the echo of the semilunar valve of the posterior great artery is well seen; plane 2, where the echo of the semilunar valve of the anterior great artery is clearly observed; and plane 3, where neither semilunar valve is seen. The aorticopulmonary septal defects were recognised at the level of plane 2 to plane 3 in our two cases. Two-dimensional contrast echocardiography was performed in one of the cases. The contrast entered the ascending aorta from the main pulmonary artery through the aorticopulmonary septal defect in early systole. Postoperatively, no defects were detected in the aorticopulmonary septum in either case using the same approach, and no passage of contrast into the ascending aorta from the pulmonary artery was noted in the case where contrast was injected. Accurate diagnosis of this anomaly can be made by visualisation of the defect utilising two-dimensional echocardiography. Typing of this anomaly, proximal, distal, or combined may be possible with our new approach.