Thoracic Aortic Aneurysm Presenting as Pulmonary Vein Stenosis

We present the case of a 66-year-old woman presenting with pulmonary vein stenosis with a large descending thoracic aortic aneurysm. Pulmonary vein stenosis is a rare condition and can be caused by extrinsic compression, as well as by inflammatory diseases, congenital anomalies and related surgical repair, tuberculosis, and pulmonary veno-occlusive disease. With obstruction to pulmonary vein flow, the velocity increases and becomes continuous. The finding of turbulent antegrade flow in the left atrium through the use of transthoracic color flow Doppler and pulsed-Doppler warrants further investigation to evaluate known causes of pulmonary vein stenosis. We believe this is the first reported case of a patient with an aortic aneurysm causing pulmonary vein stenosis.     

Two-Dimensional Echocardiographic Detection of Asymptomatic Pulmonary Thromboembolism

Asymptomatic pulmonary thromboembolism is a well-known clinical entity. In this case, a routine two-dimensional echocardiogram detected a thrombus in the right atrium. During the examination, it was seen to move into the right ventricle and across the pulmonic valve into the pulmonary artery. The patient remained completely asymptomatic. To my knowledge, this is the first case describing two-dimensional echocardiographic demonstration of asymptomatic pulmonary thromboembolism.     

Pulmonary valve papillary fibroelastoma

We present a case of a 70-year-old woman with exertional shortness of breath. A transthoracic echocardiogram showed a large mass on the ventricular side of the pulmonary valve. The anatomy of the mass was additionally investigated with a transesophageal echocardiogram, which delineated the anatomical details of the structure. The mass was surgically excised, and histopathology confirmed a cardiac papillary fibroelastoma.     

Primary Angiosarcoma of the Pulmonary Trunk Mimicking Pulmonary Thromboembolism

We present a case of primary angiosarcoma of the pulmonary trunk that was initially misdiagnosed as a subacute massive pulmonary thromboembolism in a 26‐year‐old woman. This is an extremely rare disease that is usually indistinguishable from acute or chronic thromboembolic disease of the pulmonary arteries because the clinical and radiologic findings of pulmonary artery angiosarcoma are similar to those of pulmonary thromboembolism. Although the incidence of pulmonary artery angiosarcoma is very low, our case demonstrates that this disease entity should be included in the differential diagnosis of pulmonary thromboembolism, especially in patients who do not respond to anticoagulant therapy or present with no identifiable source of thromboembolic events. (ECHOCARDIOGRAPHY 2010;27:E23‐E26)     

Pulmonary atresia and suprasternal echocardiography

A 54-year-old housewife with pulmonary atresia and ventricular septal defect developed increasing cyanosis, dyspnea, weakness, and myocardial ischemia. Initial cardiac catheterizations with angiography, including subtraction techniques, did not definitely indicate main pulmonary artery or right or left pulmonary arteries that would make her amenable to currently available surgical correction. Single-crystal suprasternal notch echocardiography indicated the presence of a small but definite right pulmonary artery. She subsequently underwent first-stage surgical correction after angiography and selective catheterization of aortopulmonary shunt vessels, which also revealed the presence of small proximal pulmonary arteries.     

Echocardiographic and Doppler Findings in Primary Sarcoma of the Pulmonary Artery

Primary sarcoma of the pulmonary artery is a rare heart tumor. In the reported case, the clinical findings were nonspecific, and were characterized by progressive dyspnea, fever, and a systolic murmur in the pulmonary area. Echocardiographic examination showed an echogenic mass partially obstructing the pulmonary artery trunk, dilation of the right cardiac chambers, and a pressure overload pattern. Doppler and color Doppler demonstrated a high-velocity systolic flow jet in the pulmonary artery due to obstruction of the vessel by the tumor, as well as severe high-velocity tricuspid regurgitation. The patient died suddenly soon thereafter. The autopsy confirmed almost total occlusion of the pulmonary artery by a neoplastic mass. Histopathological diagnosis was primary vascular leiomyosarcoma of the pulmonary artery. In addition, a large tumor embolus had occluded the right pulmonary artery. Doppler echocardiography proved useful in noninvasively recognizing the sarcoma of the pulmonary artery, and explaining the clinical picture and hemodynamic derangements produced by this tumor. This could, in other patients, allow an early diagnosis and timely surgical intervention.     

Isolated pulmonary valve prolapse: a sign of pulmonary hypertension

Isolated pulmonary valve prolapse may be a sign of pulmonary hypertension. Three patients with pulmonary hypertension as a result of left ventricular failure, chronic obstructive pulmonary disease, and primary pulmonary hypertension, respectively, are described in the case reports. It is likely that the morphological change of the pulmonary valve is due to exaggeration of the normal convexity of the elastic pulmonary leaflets as a result of a high pulmonary artery diastolic pressure. This two-dimensional echocardiographic sign may prove to be a useful qualitative hallmark for pulmonary hypertension. Present methods to detect pulmonary hypertension by two-dimensional echocardiography rely on remote findings of right heart abnormalities or changes in systolic time intervals. Pulmonic valve prolapse is the first direct sign of pulmonary hypertension found on two-dimensional echocardiography.     

Idiopathic Pulmonary Artery Aneurysm

Pulmonary artery aneurysm (PAA) is an uncommon lesion, which may be associated with different etiologies including congenital cardiovascular diseases, systemic vasculitis, connective tissue diseases, infections, and trauma. Idiopathic PAA is sporadically diagnosed by exclusion of concomitant major pathology. We report a case of a 56-year-old female with an idiopathic pulmonary artery dilatation identified fortuitously by echocardiography and confirmed by contrast-enhanced computed tomography. Neither significant pulmonary valve dysfunction nor pulmonary hypertension and other cardiac abnormalities which might contribute to the PAA development were found. Here, we describe echocardiographic and computed tomography findings and review the literature on PAA management.     

The Role of Echocardiography Doppler in Pulmonary Embolism

The purpose of this review is to make a critical analysis of selected literature about the role of echo-Doppler in suspected or proved venous thromboembolism and to address some issues about the potential use of echo-Doppler in specific situations in patients with pulmonary embolism (PE). Echo-Doppler is of great value in patients with suspected PE because many conditions that may be clinically mistaken for PE will be diagnosed. Echo-Doppler should not be used alone to rule out the diagnosis of PE because the ability of the technique in proving the diagnosis of PE in a nonselected population is limited. Echo-Doppler may be of value for diagnosis in selected subgroups of PE patients, mostly in scenarios like the emergency department or intensive care unit. Echo-Doppler is valuable in the hemodynamic assessment of patients with PE, making possible a strategy for risk stratification of in-hospital death in relation to the degree of right ventricle dysfunction at the time of diagnosis of acute PE. Echo-Doppler is useful for serial assessment of patients with established diagnosis of chronic thromboembolic pulmonary hypertension. Echo-Doppler may be useful in follow-up of patients after a diagnosis of acute PE to enable early identification of patients with persistent pulmonary hypertension / right ventricle dysfunction.     

Pedunculated Pulmonary Artery Sarcoma Suggested by Transthoracic Echocardiography

Pulmonary artery sarcoma (PAS) is an extremely rare malignancy. It is usually found after it grows large enough to occupy almost the entire lumen of the pulmonary artery and causes serious clinical symptoms. Thus, it is usually difficult to distinguish PAS from pulmonary thromboembolism based on imaging examinations. Few case reports had shown the attachment of PAS to pulmonary artery, a key characteristic for diagnosis, and differential diagnosis of PAS. In this case, we found a PAS, which did not cause local obstruction and some tumor emboli, which obstructed the branches of the pulmonary arteries and caused pulmonary hypertension and clinical symptoms. Transthoracic echocardiography (TTE) revealed a part of the tumor attached to the intima of the main pulmonary artery with a peduncle and had obvious mobility, which was suggestive of PAS and differentiated it from the pulmonary thromboembolism. To our knowledge, this is the first case report of a pedunculated PAS suggested by TTE. Combined with pulmonary artery computed tomography angiography, the diagnosis of PAS is strongly suggested before the operation. This case indicates that TTE could reveal the attachment and mobility of PAS in the main pulmonary and may provide useful information for the diagnosis and differential diagnosis of PAS, especially a pedunculated PAS.     

Isolated Supravalvular Pulmonary Stenosis: A Rare Echocardiographic Finding

Isolated supravalvular pulmonary stenosis is a rare finding, usually evidenced in the pediatric age. Here, we report a case of a 76‐year‐old patient with isolated, severely obstructive, pulmonary supravalvular stenosis. The peculiarity of the present case is the paucity of symptoms and lack of changes in right heart sections, despite of the importance of stenosis. The report confirms the utility of transthoracic two‐ and three‐dimensional echocardiography and transesophageal echocardiography in the detection and quantification of this rare anomaly.     

Fatal Migratory Pulmonary Thromboembolism Following Successful Pericardiocentesis

Echocardiography‐guided pericardiocentesis is relatively safe with minimal risk in experienced hands. However, complications can occur because of the procedure. This report describes a unique case of an 84‐year‐old man with unanticipated fatal pulmonary thromboembolism following a successful pericardiocentesis. (Echocardiography 2010;27:E125‐E127)     

Pulmonary artery diastolic pressure: a simultaneous Doppler echocardiography and catheterization study

Pulmonary hypertension is an important determinant of the clinical presentation of and surgical approach to patients with heart disease. To confirm the utility of continuous wave Doppler echocardiography in assessing the pulmonary artery diastolic pressure in patients with pulmonary regurgitation, 51 patients representing the wide hemodynamic spectrum of pulmonary artery pressure underwent simultaneous determination of pulmonary artery diastolic pressure by continuous wave Doppler echocardiography and cardiac catheterization. Pulmonary artery diastolic pressure was estimated from the Doppler recordings by the end-diastolic pressure gradient obtained by the modified Bernoulli equation plus the estimated right atrial pressure. A correlation was observed (r = 0.935, SEE = 7.4 mmHg) between Doppler and catheterization pulmonary artery diastolic pressure. In addition, comparison between the mean diastolic pressure gradient across the pulmonary valve by Doppler and pulmonary artery diastolic pressure at catheterization yielded a high correlation (r = 0.947, SEE = 5.1 mmHg). These data demonstrate that continuous wave Doppler echocardiography is a useful noninvasive technique for evaluating the pulmonary artery diastolic pressure in patients with pulmonary regurgitation.     

Multiplane Transesophageal Echocardiographic Detection and Differential Diagnosis of Isolated Right Pulmonary Artery Agenesis

We present a case report of isolated right pulmonary artery agenesis detected by multiplane trans-esophageal echocardiography (TEE). A special emphasis is placed on its important role in the differential diagnosis and hemodynamic and functional evaluation of patients with unilateral pulmonary oligemia on chest radiograph. We also present a case report of pulmonary embolism with complete obstruction of the right pulmonary artery for better understanding and for comparison of TEE images in patients with pulmonary artery agenesis.     

Color Doppler Transesophageal Echocardiography in Detection of Massive Pulmonary Embolism

In this article, the potential value of color Doppler in improving diagnostic accuracy of transesophageal echocardiography (TEE) in patients with incomplete obstruction of large pulmonary vessels is illustrated, We present an unusual case of massive pulmonary embolism that was unequivocally detected by color Doppler TEE both before and after pulmonary angiography, which failed to demonstrate filling defects in the pulmonary artery.     

Absent Pulmonary Valve: Echocardiographic Features

Congenital absence of the pulmonary valve, a rare anomaly, is characterized by absent or rudimentary pulmonary valve, often with annular stenosis, and aneurysmal dilatation of the pulmonary arteries. This defect is most commonly an accompaniment of tetralogy of Fallot but occasionally occurs alone. Four patients with this abnormality were examined by two-dimensional echocardiography at the Mayo Clinic. Doppler echocardiography provided hemodynamic assessment of the magnitude of outflow obstruction and valve regurgitation. The two-dimensional echocardio-graphic and Doppler features of absent or rudimentary pulmonary valve provided diagnostic information sufficient to proceed directly to surgical correction.     

Noninvasive Estimation of Pulmonary Vascular Resistance in Pulmonary Hypertension

Background: Determination of pulmonary vascular resistance (PVR) in patients with suspected or known pulmonary hypertension (PH) requires right heart catheterization. Our purpose was to use Doppler echocardiography to estimate PVR in patients with PH. Methods: Patient population consisted of 52 patients (53 ± 12 years; 35 females) who underwent Doppler echocardiography and right heart catheterization within 24 hours of each other. The ratio of peak tricuspid regurgitation velocity (TRV) and right ventricular outflow time-velocity integral (VTI_RVOT) was measured via transthoracic echocardiography and correlated to invasively determined PVR. A linear regression equation was generated to determine PVR by echocardiography based upon the TRV/VTI_RVOT ratio. PVR by echocardiography was compared to invasive PVR using Bland-Altman analysis. Results: Significant correlation was demonstrated between TRV/VTI_RVOT and PVR by catheterization (r = 0.73; P < 0.001). However, Bland-Altman analysis showed that agreement between PVR determined by echocardiography and invasive PVR was poor (bias = 0; standard deviation = 4.3 Wood units). In a subset of patients with invasive PVR < 8 Wood units (26 patients), correlation between TRV/VTI_RVOT and invasive PVR was strong (r = 0.94; P < 0.001). In these patients, agreement between PVR by echocardiography and invasive PVR was satisfactory (bias = 0; standard deviation = 0.5 Wood units). There was no correlation between TRV/VTI_RVOT and invasive PVR in patients with PVR > 8 Wood units (n = 26; r = 0.17). Conclusion: While TRV/VTI_RVOT correlates significantly with PVR, using it to estimate PVR in a PH patient population cannot be recommended.     

Transthoracic Echocardiographic Assessment of Spindle Cell Sarcoma of the Pulmonary Artery in a Child

In this report, we present a case of spindle cell sarcoma of the pulmonary artery diagnosed by transthoracic echocardiography. To the best of our knowledge, this case is the youngest reported case of pulmonary artery sarcoma (PAS) to date. PAS is frequently confused for pulmonary embolism; in this case, echocardiographic findings allowed for differentiation between pulmonary embolism and solid tumor.     

Massive main pulmonary artery embolism diagnosed with two-dimensional Doppler echocardiography.

This report describes the usefulness of echocardiography in the differential diagnosis of acute cardiovascular events. In a 66-year-old patient with known aortic stenosis and mitral valve prosthesis, who suddenly deteriorated with severe dyspnea, a thrombus within the pulmonary artery could be detected with 2-D echo. Pulsed-wave Doppler disclosed the resulting flow-velocity disturbances.     

Silent Pulmonary Embolism of a Large Right Atrial Thrombus

We report the case of a patient who was admitted to the hospital with acute pulmonary embolism 2 weeks after a complicated pelvis fracture. Echocardiography revealed a large, long, and mobile thrombus in the right atrium. The patient was scheduled to undergo urgent surgical thrombectomy. Preoperative echocardiography did not detect any thrombi in the right heart and pulmonary artery. The obvious embolism of this large thrombus in the pulmonary circulation was silent as the patient remained asymptomatic and hemodynamically stable. We discuss the contribution of echocardiography to the appropriate therapeutic management of right atrial thrombi and particularly to the cancellation of urgent operative thrombectomy.