A case report of intramyocardial dissecting hematoma:a challenging diagnosis

<正>Intramyocardial dissecting hematoma (IDH) is an uncommon complication of myocardial infarction that can potentially lead to cardiac rupture.^[1]Two distinguishable types of cardiac rupture have been identified:a simple tear,which is the most common case and is characterized by a lineal or tortuous tear along the myocardial wall,and complex hemorrhagic dissection.IDH is generally classified as complex hemorrhagic dissection,in which blood infiltrates into the myocardial wall.     

Two- and three-dimensional echocardiographic unroofed coronary sinus.

We present the 2-dimensional findings and 3-dimensional reconstruction of images from an 18-year-old patient with unroofed coronary sinus, persistent left superior vena cava, a common atrium with levoisomerism, ventricular septal defect, and double-outlet right ventricle. The left superior vena cava showed continuity with the floor of the coronary sinus. Diagnosis of the constellation of anomalies established by transesophageal reconstruction clarified the continuity of the coronary sinus with left superior vena cava and atrial wall.     

Differential diagnosis of hemotamponade in myocardial infarction and aortic dissecting aneurysm

Clinical picture was analysed for 29 patients with myocardial infarction and 12 patients with dissecting aortic aneurysm who had died of cardiac hemotamponade. Similar symptoms of these conditions did not allow to establish pathognomonic clinical criteria. To prevent diagnostic mistakes, it is recommended to use early device examinations.     

Intracardiac rhabdomyosarcoma: transesophageal echocardiographic findings and diagnosis.

Transesophageal echocardiography (TEE) was performed on a 41-year-old woman who presented with a cerebrovascular accident. TEE confirmed the presence of a morphologically bizarre biatrial tumor with precarious, vigorous motion throughout the cardiac cycle. Surgical intervention was decided on, and the patient underwent cardiac surgery for tumor excision 16 hours after TEE. Intraoperative frozen section diagnosis was spindle cell sarcoma, and subsequent immunohistochemical analysis showed the tumor to be a rhabdomyosarcoma. The data are presented here, and the role of TEE to establish a preoperative diagnosis of intracardiac tumor is discussed.     

Two- and three-dimensional prenatal sonographic diagnosis of hepatic cysts

We describe the 2-dimensional and 3-dimensional multiplanar sonographic diagnosis and characterization of isolated hepatic cysts in 2 fetuses. Two-dimensional imaging of a fetus at 36 weeks' gestation revealed 2 right upper quadrant cystic masses anterior to the gallbladder, demonstrating no peristalsis or blood flow. Postnatal sonographic examination confirmed 2 simple hepatic cysts. Two- and three-dimensional sonograms suggested 2 hepatic cysts in a 23-week-old fetus that resolved by 33 weeks' gestation. In reporting 2 unusual cases of prenatally diagnosed fetal hepatic cysts, we also demonstrate the diagnostic use of 3-dimensional multiplanar imaging.     

Left atrial hematoma complicating inferior myocardial infarction.

Intramyocardial dissecting hematoma after myocardial infarction is a rare condition. Previous reports have documented that these hematomas form almost exclusively in the myocardium adjacent to the culprit coronary lesion. We report a case of coexistent intramyocardial dissecting hematoma and ventricular rupture that arose as a consequence of a distal right coronary artery occlusion. Unusually, there was a very long dissection plane, which crossed the atrioventricular groove, with the hematoma manifesting on the opposite side of the heart (left atrium) to the infarcted myocardium (inferior wall).     

Cor triatriatum dexter: transesophageal echocardiographic diagnosis and 3-dimensional reconstruction.

Cor triatriatum dexter is an unusual cardiac abnormality with division between the sinus and primitive atrial portions of the right atrium. Three-dimensional echocardiography is a novel technique that defines this entity.     

Intramyocardial dissecting hematoma in anterior wall ST elevation myocardial infarction: impact on left ventricular remodeling and prognosis

Intramyocardial dissecting hematoma is an uncommon complication of myocardial infarction potentially leading to cardiac rupture. The aim of the present study was to investigate coronary reperfusion results, left ventricular (LV) function recovery and remodeling and clinical outcomes in patients with anterior STEMI complicated by intramyocardial hematoma. We prospectively studied 87 patients (mean age 59?±?10 years; 88% male) with anterior STEMI (42 with intramyocardial hematoma) in order to evaluate coronary reperfusion results, LV remodeling (≥15% increase in end-systolic volume) and clinical outcomes (cardiac death, non-fatal reinfarction, and hospitalization for congestive heart failure) at 24 months. Thrombolysis in myocardial infarction (TIMI) flow score and myocardial blush grade (MBG) were assessed both pre- and post-percutaneous coronary intervention (PCI) and speckle-tracking echocardiography was performed post PCI and at 6-month follow-up. Patients with hematoma had lower post-PCI TIMI score and MBG, higher heart rate, worse LV ejection fraction and longitudinal or rotational function than their counterparts. LV remodeling occurred in 33 (78.6%) patients with hematoma and 11 (24.4%) patients without (p?<?0.001). Independent predictors of LV remodeling were heart rate (p?=?0.018), MBG (p?=?0.036) and presence of hematoma (p?<?0.001). Hematoma (log-rank test, χ²?=?9.849; p?=?0.002) and LV remodeling (log-rank test, χ²?=?13.770; p?<?0.001) were associated to a higher rate of adverse events. Cox analysis identified LV remodeling as the only independent predictor of adverse events (hazard ratio?=?3.912; 95% confidence interval, 1.429–10.714; p?=?0.008). Intramyocardial dissecting hematoma complicating anterior STEMI is an independent determinant of LV remodeling and is associated to poor prognosis.     

Early pericarditis after acute myocardial infarction: a clinical echocardiographic study

Clinical and echocardiographic data were evaluated in 46 patients after acute myocardial infarction (AMI). M-mode echocardiogram was performed 24 and 72 h and 5 days after AMI. Early acute pericarditis (EAP) was clinically recognized in 19 (41%) patients. Pericardial effusion (PE) was detected in 29 (63%) patients. In 23 (50%) patients both anterior and posterior PE was observed, while in six (13%) patients PE was only posterior. An echocardiographic pattern consistent with localized fibrinous pericarditis was detected in 11 (24%) patients. Eighteen (95%) of 19 patients with EAP had PE, and only 11 (40%) of the patients without EAP had PE (p less than .001). We conclude that PE is observed frequently after AMI and that the echocardiographic study can help in the diagnosis of EAP after AMI.     

Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction.

We sought to investigate the relation between left ventricular (LV) and right ventricular (RV) function assessed with the Doppler-derived myocardial performance index (MPI), to assess serial changes, and to investigate the prognostic value of biventricular assessment of cardiac function after a first myocardial infarction (MI). To do so, serial Doppler echocardiography was performed in 77 consecutive patients with a first MI. Right ventricular MPI correlated significantly with LV MPI (r = 0.51, P <.0001). In patients with echocardiographic signs of RV MI, the RV MPI was significantly higher (0.59 +/- 0.18 versus 0.44 +/- 0.19, P =.001), whereas no difference in LV MPI was seen (0.55 +/- 0.19 versus 0.56 +/- 0.13, P = not significant). Right ventricular MPI showed a rapid normalization during follow-up, whereas LV MPI did not decrease. During follow-up, 23 patients died of cardiac causes or were readmitted because of worsening heart failure. Multivariate Cox analysis indicated LV MPI (relative risk 4.9 [95% CI 1.8-13.5], P =.002) and RV MPI (relative risk 3.8 [1.3-17.0], P =.01) to be predictors of cardiac events. Thus the RV MPI is frequently abnormal after a first MI but normalizes rapidly on follow-up, and biventricular assessment of cardiac function may improve the prognostic accuracy compared with LV assessment alone.     

三维经食道超声心动图、二维经食道超声心动图、DSA测量左心耳开口与成功植入左心耳封堵器型号大小的相关性研究

目的:探讨三维经食道超声心动图成像（Three-dimensiona transesophageal echocardiography imaging,3D-TEE）、二维经食道超声心动图成像（2D-TEE）、DSA测量左心耳开口与成功植入左心耳封堵器型号大小的相关性。方法：回顾性纳入我院2019-01-03至2020-01-25非瓣膜性房颤择期行左心耳封堵术患者180例,术前分别采用2D-TEE和3D-TEE评估左心耳开口最大直径,术中进行左心耳造影测量左心耳开口最大直径。比较三种影像学方法测量的左心耳开口最大直径和最终植入的封堵器型号大小的相关性。结果：3D-TEE、2D-TEE、DSA测量左心耳开口与成功植入左心耳封堵器型号大小的相关性研究：共180例患者选入本研究,平均年龄68.25±9.15岁,男性112例（112/180,62.2%）,女性68例（68/180,37.8%）,CHA2DS2-VASc评分3.56±1.76,左房前后径46.00±6.31mm。180例患者均成功植入Watchman左心耳封堵器,最终植入的平均封堵器大小为28.1±3.2 mm。术前3D-TEE测量的左心耳开口最大直径为24.67±2.67mm,显著高于2D-TEE测量的左心耳开口最大直径（20.95±2.91mm）（P<0.001）和DSA测量的左心耳开口最大直径（23.91±2.79mm）（P <0.001）。3D-TEE测量的左心耳开口最大直径与最终植入封堵器大小呈正相关且具有极强相关性（r=0.862,P<0.001）,2D-TEE和DSA测量的左心耳开口最大直径与最终植入封堵器大小呈正相关（r=0.614,0.656,P<0.001）。结论3D-TEE通过三维容积成像测量的左心耳开口最大直径显著高于2D-TEE和DSA测量的最大径,且其与成功植入的封堵器大小的相关性最强。 关键词：三维经食道超声心动图成像　左心耳封堵术     

Accuracy of three-dimensional volume measurement using biplane transesophageal echocardiographic probe: in vitro experiment.

Two phased-array scanning methods can be used for volumetric transesophageal echocardiographic imaging: (1) pull-back "breadloaf" reconstruction, and (2) rotation "fan-like" reconstruction. The purpose of this study was to (1) test accuracy and precision of pull-back versus rotational geometries for three-dimensional volume determination, and (2) test accuracy of the resulting surface/volume rendered images. The endoscope shaft was inserted into a tube with the handle connected to a stepper device. Seventeen balloons (61 to 471 ml) were put into a water bath consecutively. Two scans were performed: (1) pull-back: the probe was withdraw in 1 mm steps to obtain parallel "breadloaf" slices, and (2) rotational: the probe was rotated in increments of 1.8 degrees, 3.6 degrees, or 5.4 degrees to obtain "fan-like" slices. Each image was digitized for computer analysis. The data were interpolated into 128 x 128 x 128 voxels for three-dimensional reconstruction. Volume measurement was done using a stereometric random marking method. Volumes obtained from the reconstructed images were compared with the true volume (weight) by linear regression analysis. Excellent correlation between measured and actual volumes was obtained from rotation scans as follows: for 1.8 degrees steps (r = 0.9987, SEE = 6.5 ml), for 3.6 degrees steps (r = 0.9959, SEE = 11.5 ml), and for 5.4 degrees steps (r = 0.9943, SEE = 13.5 ml). The pull-back scans showed r = 0.9990, SEE = 5.8 ml. Three-dimensional surface/volume rendered images of the balloons indicate that 1.8 degrees rotation scans are almost as good as 1 mm pull-back scans. We conclude that volume measurements from rotation scans in vivo will not be hindered by scan geometry or software interpolation.     

基于经食管三维超声的3D打印模型评价左心耳解剖

目的 探讨经食管三维超声心动图（3D-TEE）作为左心耳（LAA）三维（3D）打印数据源的可行性及超声3D打印模型的准确性,并评价3D打印模型对特殊解剖形态LAA封堵手术的指导价值。方法 回顾性分析18例因心房颤动接受LAA封堵术的患者资料,包括LAA的3D-TEE和CT容积图像数据。对3D-TEE数据进行后处理,并使用弹性材料制作LAA的3D打印模型。采用3D打印模型评价LAA解剖分型与分叶分型,测量LAA开口的最大径、最小径及深度,并与3D-TEE及CT容积图像结果进行对比。在封堵困难的特殊形态LAA模型上进行封堵器释放试验。结果 对18例患者均成功进行超声数据后处理并获取LAA 3D打印模型。应用3D打印模型与CT容积图像对LAA进行解剖分型及分叶分型的一致性均较高,Kappa值分别为0.92和0.83。且3D打印模型对LAA开口最大径、最小径及深度的测量值与3D-TEE测量值差异均无统计学意义（P均>0.05）。18例中2例为特殊形态LAA,均通过3D打印模型进行封堵伞释放模拟出术中封堵过程。结论 基于3D-TEE的LAA 3D打印技术具有较高的可行性及准确性,有助于指导特殊形态LAA的个性化封堵。     

Use of contrast echocardiography in the diagnosis of subacute myocardial rupture after myocardial infarction.

Myocardial rupture is an uncommon and catastrophic complication after acute myocardial infarction. It can present in an acute form or in a subacute form, with slower hemorrhage and thrombus formation at the site of rupture. These patients can survive several hours or days before the diagnosis is confirmed and the myocardial ruptured repaired. Two-dimensional Doppler echocardiography is very useful in the diagnosis of this complication, but the number of false-positive diagnoses is high, even in the presence of a large amount of pericardial effusion. In these patients, administration of a contrast agent can be useful to demonstrate active bleeding into the pericardium. We report a case of subacute myocardial rupture for which contrast echocardiography was useful in demonstrating the presence of persistent hemorrhage into the pericardium. To reduce the number of false-positive diagnoses, contrast echocardiography should be considered in patients with possible subacute myocardial rupture.     

Contrast enhanced echocardiographic follow-up of cardiac remodeling and function after myocardial infarction in rats

Echocardiography is a reliable and commonly used method to examine cardiac diseases. Recent employment of modern technologies provides new opportunities to study left ventricular (LV) remodeling after myocardial infarction (MI) also in small rodents. LV volumes as most important prognostic parameters can be estimated by noncontrast enhanced echocardiography in rats from M-mode or single cross sections only. In this study, contrast enhanced echocardiography and volume measurements by the biplane method of discs (Simpson's rule) were applied in rats to monitor remodeling and function after MI. MI was induced in female Sprague-Dawley rats (n = 26 for MI, and n = 16 for sham). LV remodeling and heart function were serially studied by contrast enhanced echocardiography for 12 to 16 wk. At the end of the observation periods hemodynamic data were additionally measured by left and right heart catheterization. LV end systolic volume (LVESV) measured by biplane method of discs correlated best with LV developed pressure as indicator for severely impaired heart function. Interestingly, LV end systolic area (LVESA) from native short axis view correlated well with LVESV (R(2) = 0.93) and was the second best predictor for depressed heart function. Moreover, left atrial size was a powerful indicator of severely impaired heart function whereas ejection fraction or fractional area change were primarily related to infarct size. In conclusion, contrast enhanced echocardiography in rats is feasible and an economical method to study time-dependent LV remodeling and deterioration of contractile function after MI.     

经食管超声心动图诊断降主动脉壁内血肿1例

患者男,65岁,既往高血压病史13年,18天前无明显诱因出现胸部剧痛半小时,以心前区为主,呈持续性,伴后背放射痛,大汗淋漓,外院予硝酸甘油静脉点滴、阿司匹林口服等药物治疗后胸痛仍无缓解.入院查体:心脏未见明显异常.心电图:窦性心律,V1～～V2 ST段上移0.2mV,V5～V9ST段上移0.05～0.10 mV,V5～V9T波倒置,左心室肥厚.经胸超声心动图:降主动脉内膜不光滑,增厚,呈不均质低回声,未见确切破口,未探及血流信号.     

Clinical, laboratory, and transesophageal echocardiographic correlates of interatrial septal thickness: a population-based transesophageal echocardiographic study.

BACKGROUND: The determinants of interatrial septal (IAS) thickening ("lipomatous hypertrophy"), a common echocardiographic finding in the elderly, are poorly defined. The objective of this study was to determine the clinical, laboratory, and transesophageal echocardiographic correlates of IAS thickening in the general population. METHODS: The thickness of the IAS was measured by transesophageal echocardiography in 384 patients (median age: 66 years; range: 51-101 years; 53% men) participating in a population-based study (Stroke Prevention: Assessment of Risk in a Community). The associations between atherosclerosis risk factors, clinical cardiovascular disease, aortic atherosclerotic plaques, and IAS thickness were examined. RESULTS: Age and body surface area (BSA) were significantly associated with IAS thickness (median: 6 mm; range: 2-17 mm). IAS thickness increased by 12.6% per 10 years of age (95% confidence interval: 9.0-16.4%) adjusting for sex and BSA, and increased by 7.0% per 0.1 m 2 BSA (confidence interval: 5.0-9.2%) adjusting for age and sex. Overall, age, sex, and BSA accounted for 22.5% of the variability in IAS thickness. Current smoking (20.4% increase in IAS thickness in current smokers) and hypertension treatment (8.5% increase in treated patients) were associated with increased IAS thickness, adjusting for age, sex, and BSA ( P < .05), but these two risk factor variables jointly explained only an additional 2.3% of the variability in IAS thickness beyond the variability explained by age, sex, and BSA. Clinical coronary artery and cerebrovascular disease, atrial arrhythmias, and aortic atherosclerotic plaques were not associated with IAS thickness, adjusting for age, sex, and BSA ( P > .3). CONCLUSIONS: IAS thickening is an age-associated process. Atherosclerosis risk factors are weakly associated with IAS thickening, whereas atherosclerotic vascular disease is not.