Two-dimensional echocardiography of intracardiac masses: Echo pattern-histopathology correlation

Two-dimensional echo patterns (EP) of 21 pathologically confirmed intra-cardiac masses (10 tumors, 6 thrombi and 5 vegetations) were correlated with histopathology. Three types of echo patterns were defined. Five tumors and 3 thrombi demonstrated a fine, speckled and uniform appearance (type AEP) and none had any hemorrhages or calcification on pathological examination. Three left atrial masses showed large and discrete echolucent areas (type B EP) and histopathological correlation revealed large hemorrhages in the tumors and a large area of clot lysis in the thrombus. Three tumors, 2 thrombi and 5 vegetations revealed either localized areas of bright echoes or appeared uniformly bright (type C EP) and on pathological examination, all had calcification and/or fibrosis. Two-dimensional echo patterns are useful in delineating some of the structural components of intracardiac masses.     

二次谐波技术在胰腺肿块诊断中的应用

目的 探讨二次谐波技术对胰腺肿块的诊断价值。方法 对47例患者和30例正常胰腺者比较基波与谐波条件下二维及彩色血流特点。结果 谐波条件下不同类型胰腺肿块的二维特征性更加清晰，正常胰腺和肿块周围及内部的血流可得到不同显示。结论 谐波技术对受气体干扰明显、位置较深的胰腺肿块的超声检出和鉴别诊断有重要临床意义。     

Mode vibrations of a matrix transducer for three-dimensional second harmonic transesophageal echocardiography

Transesophageal echocardiography (TEE) uses the esophagus as an imaging window to the heart. This enables cardiac imaging without interference from the ribs or lungs and allows for higher frequency ultrasound to be used compared with transthoracic echocardiography (TTE). TEE facilitates the successful imaging of obese or elderly patients, where TTE may be unable to produce images of satisfactory quality. Recently, three-dimensional (3-D) TEE has been introduced, which greatly improves the image quality and diagnostic value of TEE by adding an extra dimension. Further improvement could be achieved by optimizing 3-D TEE for harmonic imaging. This article describes the optimal geometry and element configuration for a matrix probe for 3-D second harmonic TEE. The array concept features separated transmit and receive subarrays. The element geometry was studied using finite element modeling and a transmit subarray prototype was examined both acoustically and with laser interferometry. The transmit subarray is suitable for its role, with a 3 MHz resonance frequency, a 40%-50% -3 dB bandwidth and crosstalk levels <-27 dB. The proposed concept for the receive subarray has a 5.6 MHz center frequency and a 50% -3 dB bandwidth.     

Novel uses of intracardiac echocardiography with a phased-array imaging catheter.

A newer phased-array ultrasound imaging catheter (AcuNav, Siemens, Moutainview, Calif) provides comprehensive anatomic and physiologic data during cardiac interventions. The role of this catheter in percutaneous closure procedures, transseptal ablative procedures, and valvular interventions has been reported. We describe an expanded role of intracardiac echocardiography using AcuNav imaging catheter (Siemens) in 2 clinical situations.     

Optical delineation of human malignant melanoma using second harmonic imaging of collagen

Skin cancer incidence has increased exponentially over the last three decades. In 2008 skin cancer caused 2280 deaths in the UK, with 2067 due to malignant melanoma. Early diagnosis can prevent mortality, however, conventional treatment requires multiple procedures and increasing treatment times. Second harmonic generation (SHG) imaging could offer diagnosis and demarcation of melanoma borders non-invasively at presentation thereby short-cutting the excision biopsy stage. To test the efficacy and accuracy of SHG imaging of collagen in skin and to delineate the borders of skin cancers, unstained human melanoma biopsy sections were imaged using SHG microscopy. Comparisons with sister sections, stained with H&E or Melan-A were made for correlation of invasion borders. Fresh ex vivo normal human and rat skin was imaged through its whole thickness using SHG to demonstrate this technique is transferable to in vivo tissues. SHG imaging demonstrated detailed collagen distribution in normal skin, with total absence of SHG signal (fibrillar collagen) within the melanoma-invaded tissue. The presence or absence of signal changes dramatically at the borders of the melanoma, accurately demarcating the edges that strongly correlated with H&E and Melan-A defined borders (p<0.002). SHG imaging of ex vivo human and rat skin demonstrated collagen architecture could be imaged through the full thickness of the skin. We propose that SHG imaging could be used for diagnosis and accurate demarcation of melanoma borders on presentation and therefore potentially reduce mortality rates.     

Detection of intracardiac masses in patients with coronary artery disease using cardiac magnetic resonance imaging: a comparison with transthoracic echocardiography

We sought to evaluate the diagnostic accuracy of contrast-enhanced cardiac magnetic resonance (CMR) imaging for the detection of intracardiac masses and thrombus formation in patients with history of coronary artery disease (CAD) in comparison to transthoracic echocardiography (TTE) under clinical routine conditions. 171 patients with history of CAD (89 male, aged 34–89 years, median 63 ± 11) underwent TTE and CMR during routine clinical examinations. TTE and CMR were independently analysed regarding the presence of intracardiac thrombus formation, masses and related size, dimensions, shape and signal characteristics. TTE depicted intracavitary thrombus formation in 40/171 patients (23.4 %) and intracardiac mass in 12/171 patients (7.0 %). All masses revealed in TTE were correctly detected on CMR and confirmed by histology. However, CMR showed 15 additional thrombi and 3 additional intracardiac masses (p = 0.001) that were not seen in TTE. Patients with poor systolic function (LVEF <30 %) had misleading results when referred to TTE (19 vs. 27 thrombi detected, p < 0.01). The detection of intracardiac masses or thrombi was not significantly different in patient with LVEF >30 %, whereas CMR was superior when the LVEF was <30 %. Routine TTE in patients with CAD leads to lower detection rates of intracardiac masses and thrombus formation in patients with severely impaired EF. Consequently we are missing a significant amount of clinically relevant diagnosis when only assessing patients with TTE. In patients with CAD and severely impaired LVEF, CMR should be considered as first line imaging tool to detect or rule out intracardiac masses and thrombi.     

二次谐波声学造影诊断先天性肝动脉—门静脉瘘的初步探讨

目的：探讨经静脉二次谐波声学造影诊断先天性肝动脉－门静脉瘘的可行性。方法：对4例彩色多普勒超声检查提示为先天性肝动脉－门静脉瘘患者,行经静脉二次谐波声学造影检查,并与X线血管造影对照。结果：造影剂经左前臂浅静脉注射后13－15s（平均14s)肝动脉显影,见门脉左、右支周围及其远侧有多个短条状强回声带,宽0．22－0．41cm。几乎与肝动脉显影的同时,门静脉左、右支内亦充满造影剂密集点状强回声,呈“脉冲”样反向流动。超声造影与X线血管造影结果相符。结论：经静脉二次谐波声学造影是诊断先天性肝动脉－门静脉瘘简便、准确的方法。     

间歇二次谐波成像声学造影鉴别肝肿瘤的初步研究

目的 探讨间歇二次谐波成像声学造影在肝肿瘤鉴别诊断中的作用。方法 １１例肝肿瘤患者行间歇二次谐波声学造影,其中原发性肝癌４例,转移性肝癌１例,局灶性脂肪肝１例,肝血管瘤５例。声学造影剂经左前臂静脉注射。结果 造影后,４例原发性肝癌和１例肝转移癌瘤组织回声增强,肿瘤内的异常增生血管清楚显示,呈“蜘蛛网”样形态。１例局灶性脂肪肝显示出正常走行的肝动脉和门静脉。５例肝血管瘤呈均匀增强回声,与正常肝组织回     

Characterization of fibrillar collagen isoforms in infarcted mouse hearts using second harmonic generation imaging

We utilized collagen specific second harmonic generation (SHG) signatures coupled with correlative immunofluorescence imaging techniques to characterize collagen structural isoforms (type I and type III) in a murine model of myocardial infarction (MI). Tissue samples were imaged over a four week period using SHG, transmitted light microscopy and immunofluorescence imaging using fluorescently-labeled collagen antibodies. The post-mortem cardiac tissue imaging using SHG demonstrated a progressive increase in collagen deposition in the left ventricle (LV) post-MI. We were able to monitor structural morphology and LV remodeling parameters in terms of extent of LV dilation, stiffness and fiber dimensions in the infarcted myocardium.     

Feasibility of intracardiac echocardiography imaging from the left superior pulmonary vein for left atrial appendage occlusion

Intracardiac echocardiography (ICE) is considered an alternative imaging modality for left atrium appendage occlusion (LAAO) to avoid general anesthesia. However, the quality of ICE images obtained from right atrium can be suboptimal compared with transesophageal echocardiography (TEE) imaging. Although placing an ICE probe into left atrium can improve imaging quality, there are limited data regarding procedure outcomes of ICE-guided LAAO versus TEE-guided LAAO. One hundred forty four patients who underwent LAAO with Amplatzer Cardiac Plug, Amulet, or Watchman device were enrolled from two referral institutes. TEE-guided LAAO was performed under general anesthesia or deep sedation (n?=?103), and ICE-guided LAAO was conducted under local anesthesia (n?=?41). An ICE probe was placed into left superior pulmonary vein (LSPV) via transseptal approach. The procedure success and complication rates of the ICE-guided LAAO were comparable with the TEE-guided LAAO (100 vs. 97.1%, p?=?1.0; 2.4 vs. 6.8%, p?=?0.734, respectively). The procedure time and total radiation dose were significantly lower in ICE-guided group compared with TEE-guided group (58.0 [55.0, 61.0] min vs. 80.0 [58.0, 95.0] min, p?<?0.001; 456.0 [359.0, 604.0] mGy vs. 625.0 [439.0, 1502.5] mGy, p?<?0.001, respectively). In multivariate analysis, younger age, the last time period of procedure, and local anesthesia were independent factors affecting shorter procedure time. ICE imaging from the LSPV provided optimal views for LAAO procedure with a significant reduction of total procedure time through performing under local anesthesia. This approach can be very useful for LAAO procedure especially in patients who are ineligible for general anesthesia.     

经颅多普勒发泡试验、经胸超声心动图右心造影及颈胸联合超声造影诊断卵圆孔未闭右向左分流

目的 对比观察经颅多普勒（TCD）发泡试验、经胸超声心动图（TTE）右心造影及颈胸联合超声造影诊断卵圆孔未闭（PFO）右向左分流（RLS）的价值。方法 对39例PFO-RLS患者先后行TCD发泡试验、TTE右心造影、颈胸联合超声造影和经食管超声心动图（TEE）检查,以TEE为金标准,观察前三者诊断PFO-RLS的能力。结果 TTE右心造影和颈胸联合超声造影诊断PFO-RLS的特异度均为100%,TTE右心造影的敏感度（53.49%）及准确率（54.85%）均低于TCD发泡试验（敏感度93.02%,准确率95.35%）和颈胸联合超声造影（敏感度90.69%,准确率95.23%）（P均<0.05）;TCD发泡试验与颈胸联合超声造影的诊断敏感度、准确率及检出不同分流量PFO-RLS能力差异均无统计学意义（P均>0.05）,且诊断一致性极高（Kappa=0.852）。TCD发泡试验和颈胸联合超声造影检出少量PFO-RLS的能力均高于TTE右心造影（P均<0.05）,与后二者诊断结果的一致性分别为中等和一般（Kappa=0.429、0.311）。结论 TCD发泡试验诊断PFO-RLS敏感度和准确率较高,但难以判断RLS位置;TTE右心造影诊断PFO-RLS特异度极高,但敏感度和准确率欠佳,尤其对少量PFO-RLS;颈胸联合超声造影有较高诊断特异度、敏感度和准确率,可检出少量PFO-RLS,并有助于判断RLS位置。     

Determinants of myocardial hypoperfusion analyzed for the interventricular septum using power Doppler harmonic imaging with contrast echocardiography in humans: a methodologic approach for clinical practice.

BACKGROUND: To evaluate determinants of myocardial hypoperfusion using power Doppler harmonic imaging (PDHI) with myocardial contrast echocardiography (MCE) in clinical practice, a retrospective clinical study was performed comparing echocardiographic and angiographic data. Angiographic data of patients with a normal coronary angiogram (non-CAD) and symptomatic patients with low flow conditions caused by a stenosis of the left anterior descending coronary artery (LAD) or occlusion, or TIMI-II-flow in the LAD were compared with the PDHI data. METHODS AND RESULTS: In 32 patients, MCE was performed with a System Five Performance ultrasound system (GE Vingmed Ultrasound, Horten, Norway). Myocardial perfusion was semiquantitatively analyzed with the EchoPac 6.2b.134 software, bolus injection with Optison (0.35 mL with 5 mL saline flush), and continuous infusion with Levovist (400 mg/mL(-1); 3.5-5 mL/min(-1)) were performed (8 non-CAD patients, 8 CAD patients, respectively). After bolus injection, Doppler intensity (DI) kinetics showed a significant decrease of maximum DI wash-in rate (eg, apical septum [AS]: 4.9 +/- 3.3 vs 2.4 +/- 1.9 dB/s(-1)), of peak maximum DI (eg, AS: 25.3 +/- 6.3 vs 16.4 +/- 5.7 dB), and of DI determined 10 and 20 seconds after peak maximum DI (eg, AS: 22.1 +/- 4.9 vs 10.8 +/- 4.6 dB; AS: 20.4 +/- 5.3 vs 8.0 +/- 3.8 dB, respectively) using a trigger interval once every 3 cardiac cycles when normal perfused areas were compared with hypoperfused areas. During infusion coronary transit time (3.3 +/- 0.9 vs 7.0 +/- 3.6 seconds), maximum DI wash-in rate (eg, AS: 3.2 +/- 1.3 vs 1.3 +/- 0.8 dB/s(-1)) and DI-maximum plateau (eg, AS: 28.6 +/- 4.7 vs 18.3 +/- 6.4 dB) significantly decreased, respectively. CONCLUSION: Regional myocardial hypoperfusion at rest can be detected by using PDHI with MCE in clinical practice, according to a standardized methodologic protocol.     

微泡声学造影剂气体构成对二次谐波显像的作用

目的探讨二次谐波成像条件下改变微泡造影剂的气体构成是否能够增强经静脉注射后的心肌显像效果。方法对１０条开胸犬经静脉注射含有不同气体的声振右旋糖酐白蛋白微泡造影剂ＲＡ（空气,ｒｏｏｍａｉｒ）、ＳＦ６（六氟化硫,ｓｕｌｆｕｒｈｅｘａｆｌｕｏｒｉｄｅ）、ＦＸ系列（含有氟碳气体Ｃ３Ｆ８、Ｃ４Ｆ１０、Ｃ５Ｆ１２）。二次谐波显像条件下取左心室短轴切面观,观察心肌造影效果。结果含有氟碳气体的微泡造影剂经静脉注射后二次谐波显像下产生强烈的心肌显影,心肌声学密度分别为（１４．７２±２．７）ｄＢ（ＦＸ３３０）、（１４．３±２．４ｄＢ）（ＦＸ４３０）、（１３．７８±２．２４）ｄＢ（ＦＸ５３０）;氟硫气体仅存在轻微的心肌显像［（６．２４±１．５８）ｄＢ］,但心腔显影强烈［（２９．４８±６．０２）ｄＢ］,空气造影剂经静脉注射后几乎不产生心肌显影［（２．５３±０．７８）ｄＢ］,心腔内造影剂亦较弱［（１１．３±４．９６）ｄＢ］。结论不同气体构成的微泡声学造影剂二次谐波显像效果差异显著。氟碳气体声振右旋糖酐白蛋白是较好的经静脉声学造影剂。     

Comparison of transthoracic and transesophageal echocardiography in the diagnosis of intracardiac tumors in adults

To compare transthoracic and transesophageal echocardiography in the diagnosis of intracardiac tumors, 17 patients (8 men and 9 women, aged 19 years to 67 years) whose intracardiac tumors were detected by echocardiography were studied in a 4-year period. Of these, 14 patients underwent cardiac surgery and 13 were proved to have tumors. There were 4 false-positive and 2 false-negative diagnoses by transthoracic echocardiography, but only one false-positive and no false-negative diagnosis by transesophageal echocardiography. The stalk of a myxoma was detected clearly in 5 of 11 patients by transthoracic echocardiography, whereas in 10 of 11 it was detected by transesophageal echocardiography. The detailed morphologic characteristics of the tumor, such as contour of the tumor, and the presence of cysts and calcification in the tumor, were seen more clearly with transesophageal echocardiography than with transthoracic echocardiography. © 1994 John Wiley & Sons, Inc.     

Evaluation of tissue harmonic imaging for the diagnosis of focal liver lesions

This was a prospective study to evaluate tissue harmonic imaging (THI) for the diagnosis of focal liver lesions. A total of 15 reviewers read 100 randomly arranged liver images, a fundamental grey-scale image (FGI) and a THI (transmitted: 2 MHz, received: 4 MHz) of each of 50 patients (29 with liver cirrhosis, 42 with focal lesions) taken from the same section. The mean value of overall accuracy for detecting lesions (presence or absence) was significantly higher with THI (82.3%) than with FGI (79.6%) (t = 1. 96, p< 0.05). When only the 29 cirrhosis patients were analyzed, the difference was more significant (t = 2.48, p < 0.02). The correct count rate of the number of focal lesions was higher with THI (78. 0%) than with FGI (67.0%) (t = 3.61, p< 0.005) in 23 cirrhosis patients with focal lesions. The correct diagnosis of HCC was achieved at a higher rate with THI (42.5%) than with FGI (36.8%). THI was statistically effective for detecting focal lesions, particularly in cirrhotic livers.     

In vivo structural imaging of the cornea by polarization-resolved second harmonic microscopy

The transparency and mechanical strength of the cornea are related to the highly organized three-dimensional distribution of collagen fibrils. It is of great interest to develop specific and contrasted in vivo imaging tools to probe these collagenous structures, which is not available yet. Second Harmonic Generation (SHG) microscopy is a unique tool to reveal fibrillar collagen within unstained tissues, but backward SHG images of cornea fail to reveal any spatial features due to the nanometric diameter of stromal collagen fibrils. To overcome this limitation, we performed polarization-resolved SHG imaging, which is highly sensitive to the sub-micrometer distribution of anisotropic structures. Using advanced data processing, we successfully retrieved the orientation of the collagenous fibrils at each depth of human corneas, even in backward SHG homogenous images. Quantitative information was also obtained about the submicrometer heterogeneities of the fibrillar collagen distribution by measuring the SHG anisotropy. All these results were consistent with numerical simulation of the polarization-resolved SHG response of cornea. Finally, we performed in vivo SHG imaging of rat corneas and achieved structural imaging of corneal stroma without any labeling. Epi-detected polarization-resolved SHG imaging should extend to other organs and become a new diagnosis tool for collagen remodeling.     

Right-to-left shunt across a patent foramen ovale caused by cardiac tamponade: diagnosis by transesophageal echocardiography

Cardiac tamponade can manifest as profound hypoxemia from intracardiac shunting across a patent foramen ovale. As a consequence, pulmonary embolus can be erroneously diagnosed. As demonstrated in the case described herein, transesophageal echocardiography can be useful in determining the correct diagnosis, especially if transthoracic echocardiography is technically limited. In our patient, the findings on transesophageal echocardiography also helped determine the appropriate treatment. The relative inaccessibility of the pericardial effusion to needle drainage prompted open surgical drainage.     

经食管与经胸超声心动图造影诊断卵圆孔未闭及右向左分流

目的 对比经食管超声心动图造影（cTEE）与经胸超声心动图造影（cTTE）诊断卵圆孔未闭（PFO）及右向左分流（RLS）的价值。方法 回顾性分析117例因偏头痛或隐源性卒中就诊的患者,均依次接受TTE、cTTE、TEE及cTEE检查;比较cTTE与cTEE诊断PFO的敏感度、特异度及对RLS分级的差异,观察二者诊断价值。结果 TEE联合cTEE共检出89例（76.07%,89/117）PFO;TTE、cTTE、TEE及cTEE分别检出18例（20.22%,18/89）、80例（89.89%,80/89）、75例（84.27%,75/89）及88例（98.88%,88/89）。cTTE存在9例（10.11%,9/89）假阴性、7例（25.00%,7/28）假阳性;cTEE存在1例（1.12%,1/89）假阴性,无假阳性病例。cTEE诊断PFO的敏感度（98.88%）及特异度（100%）均高于cTTE（89.89%、75.00%;χ²=6.125、5.143,P=0.008、0.016）;cTEE的PFO-RLS分级结果总体低于cTTE（Z=-3.464,P=0.001）。结论 cTEE诊断PFO的敏感度及特异度均高于cTTE,而其PFO-RLS分级总体低于cTTE。     

经静脉二次谐波超声造影对正常兔肝造影分期的声学定量分析

目的　利用声学定量技术对正常兔肝的超声造影分期进行探讨。方法　对 10只健康大白兔进行二次谐波超声造影 ,观察经耳缘静脉注射造影剂时 ,门静脉主干血流阻断前后 ,肝组织声学定量 (AD)曲线形态及测值变化 ;及经耳缘静脉和经肠系膜静脉注射造影剂时 ,肝组织AD曲线形态及测值变化。结果　经耳缘静脉注射造影剂 ,正常兔肝组织AD曲线形态呈单峰形 ,近似直角三角形 ,可分为上升段、高峰段和下降段 ,峰值密度(PI)值为 (18.4± 1.7)dB。上升段为肝动脉期 ,高峰段和下降段均为门静脉期 ;门静脉主干血流阻断后 ,肝组织AD曲线形态与阻断前基本相似 ,但峰值略减低 ,其PI值平均减低 2dB。经耳缘静脉注射造影剂后 10～ 15s再经肠系膜静脉注射造影剂 ,肝组织AD曲线呈“驼峰征” ,第二个峰高于第一个峰。结论　正常兔肝声学造影肝动脉期短暂 ,门静脉期长。肝组织回声增强主要由于肝动脉来源造影剂所致 ,门静脉来源造影剂增强幅度低 ,仅起次要作用