Coronary anomalies diagnosed with transesophageal echocardiography: complementary clinical value in adults

Introduction. Coronary arteriography remains a gold standard for the evaluation of coronary anatomy. In the case of anatomical anomalies, understanding of vessel course based upon a coronary angiogram may be difficult. Transesophageal echocardiography is a noninvasive method allowing tomographic visualization of proximal coronary arteries. Experience concerning its usefulness for the assessment of anomalous coronary arteries is limited. Material. Eleven patients with confirmed coronary anomalies studied between 1993-96 were identified in the cohort of those undergoing transesophageal echocardiography. Results. Transesophageal echocardiography revealed potentially serious anomalies (origin of left or right coronary artery from contralateral aortic sinus) in 3 patients and benign in 8. Coronary ostia and proximal course could be delineated in all patients. Anatomical information was consistent between methods, except for a separate origin of the left anterior descending and circumflex artery, where the angiogram missed a very short common left main coronary artery in 2 patients. The relationship between the coronary arteries, aorta and pulmonary trunk was better defined by the echocardiogram. Doppler flow analysis allowed us to exclude anomaly-related flow disturbances. Conclusions. Transesophageal echocardiography can be considered as a noninvasive technique with the potential for anatomical and functional evaluation of anomalous proximal coronary arteries and deserves a routine use whenever such a condition is suspected. This approach may simplify invasive procedures in this patient group.     

Preparing for and understanding transesophageal echocardiography.

The transesophageal approach to cardiac echocardiography has expanded the ability of this (almost) noninvasive method of evaluating and diagnosing certain types of cardiovascular pathology. Its use can be expected to increase as echocardiographers become skilled in endoscopy and new applications are discovered.     

Identification of Chiari's network with transesophageal echocardiography.

A prominent Chiari's network may be difficult to distinguish from pathologic right atrial masses on transthoracic echocardiography. We report a 38-year-old woman who had a cerebrovascular accident. Transthoracic echocardiogram revealed an atrial septal aneurysm and a mobile right atrial mass. This mass was correctly identified as Chiari's network on the basis of the transesophageal echocardiographic findings of a broad base of attachment in the right atrium and filamentous nature of the mass. These findings were confirmed at surgery.     

School-aged children with Turner's syndrome.

Turner's syndrome (TS) is an abnormality of the X chromosome associated with cognitive and psychosocial adjustment problems as well as congenital anomalies. Children with TS are at risk for problems in academic achievement and psychosocial development. Recognition of these risks allows nurses to provide nursing interventions including anticipatory guidance, facilitation of parental interactions with the school, and interventions for management of problems in psychosocial development.     

Hepatobiliary anomalies associated with polysplenia syndrome

The report of a 29-year-old woman with polysplenia syndrome, Crohn's disease, and bilateral cataracts is presented. The patient was noted to have a right-sided stomach and small bowel, Crohn's ileitis, and a left-sided colon. Results of roentgenography of the chest and echocardiography were consistent with a diagnosis of hypoplasia of the inferior vena cava with azygos continuation. The patient underwent laparotomy with cholecystectomy, exploration of the common bile duct, and choledochoscopy for cholelithiasis, choledocholithiasis, and chronic cholecystitis. Laparotomy revealed a liver that had two lobes, each with the morphologic appearance of the left lobe. The gallbladder was centrally located. T-tube cholangiography revealed a quadruplication of the intrahepatic biliary ducts. To our knowledge, this patient is the only known adult with this syndrome in whom cholangiography demonstrated isomerism of the biliary tree. A review of the literature on this subject is given with emphasis on biliary anomalies.     

实时三维经食管超声心动图在二尖瓣成形术中的应用研究

目的 探讨术中实时三维经食管超声心动图(RT-3D TEE)判断二尖瓣病变区域的准确性,以及评价二尖瓣成形术效果的价值.方法 19例因二尖瓣反流(MR)拟接受二尖瓣成形术患者,采集术前、术后RT-3D TEE图像,将术前所见与术中发现进行比较,并在术后即刻评价手术疗效.结果 RT-3DTEE诊断二尖瓣叶病变与术中发现完全相符16例,3例不符合,其中1例术前诊断前叶中间段、后叶中间段脱垂,术中仅发现瓣环扩大,瓣膜黏液退行性变;1例术前诊断后叶后内段脱垂,术中发现后叶中间段及后内段腱索断裂;1例术前提示瓣环扩大,术中发现后叶中间段脱垂.2D TEE诊断二尖瓣病变与术中发现完全相符仅10例,且对二尖瓣脱垂患者难以明确脱垂的确切瓣区和范围.术后即刻观察成形术效果,其中18例RT-3DTEE显示微量至少量二尖瓣反流,1例术后仍为中重度反流,改行二尖瓣置换术,二尖瓣成形术的成功率为94.7%.结论 RT-3D TEE明显提高了二尖瓣反流病因及病变部位定位的诊断准确性,在二尖瓣成形术手术方案制定及疗效的即刻评估方面发挥了非常重要的作用.     

Visualization of coronary artery fistula with transesophageal echocardiography.

Coronary artery fistulas are relatively uncommon and are usually initially suspected on auscultation of a continuous murmur. Long-term complications include congestive heart failure, endocarditis, ischemia, and atrial arrhythmias. The role of echocardiography in visualization and diagnosis of these fistulas is expanding. We report two cases in which transesophageal echocardiography was used to visualize and better define proximal coronary arteries and coronary artery fistulas.     

Complications of transesophageal echocardiography in the ED.

The complication rate of transesophageal echocardiography (TEE) performed in clinical settings outside the emergency department (ED) has been reported to be 1% to 3%. The rate of complications of performing TEE in the ED has not been established. The purpose of this study was to determine the rate of complications associated TEE with carried out on ED patients, and to investigate parameters that might predict complications. A retrospective chart review was carried out on consecutive ED patients undergoing TEE at a major referral center. Complications were abstracted. Parameters to predict complications were assessed, including age, gender, vital signs, pulse oximetry values, serum bicarbonate level, and hematocrit level. A total of 142 patients underwent TEE in the ED during the study period; 88 of these were trauma patients. There were 18 (12.6%) complications: death (1), respiratory insufficiency/failure (7), hypotension (3), emesis (4), agitation (2), and cardiac dysrhythmia (1). None of the tested variables predicted a complication. TEE carried out in the ED has a higher complication rate than has been reported in other clinical settings.     

经食管超声在多发房间隔缺损Amplatzer伞封堵治疗中的应用

目的　探讨多发Ⅱ孔型房间隔缺损 (ASD)经皮导管封堵治疗的可行性及经食管超声 (TEE)在其治疗中的作用和应用价值。方法　 16例经临床及超声心动图等检查确诊ASD患者 ,均行TEE检查并在其引导下采用Amplatzer封堵器经导管封堵。结果　 16例患者均经TEE确诊为房间隔多发缺损 ,其中 2例为 3个孔 ,14例为 2个孔缺损 ,测量大缺损直径 9～ 2 4mm [(17.2± 4.7)mm ] ,小缺损直径 2～ 9mm [(4 .4± 2 .1)mm ] ,缺损之间间隔组织长 2～ 11mm [(4 .5± 3 .1)mm] ,选用封堵器大小为 13～ 3 4mm [(2 4.2± 6.1)mm ] ,所有病例均封堵成功 ,术后 1月经胸超声复查 3例存在少量房间隔残余分流 ,所有病例未发生严重并发症。结论　TEE可以确诊多发ASD ,采用TEE筛选封堵适宜病例并在术中引导监测封堵是理想的影像学方法     

Unruptured noncoronary sinus of Valsalva aneurysm: preoperative characterization by transesophageal echocardiography.

We describe a patient with a large unruptured sinus of Valsalva aneurysm that was discovered incidentally. Transesophageal echocardiography was used to characterize the aneurysm preoperatively, and was helpful intraoperatively in assessment of the degree of native aortic valvular regurgitation after repair. The use of transthoracic echocardiography, contrast echocardiography, Doppler echocardiography, and transesophageal echocardiography are discussed in this condition.     

Pregnancies in women with Turner's syndrome.

Ovarian failure is a typical feature in Turner's syndrome. Therefore, hormone replacement therapy (HRT) is necessary to achieve the development of normal female sexual characteristics and to prevent cardiovascular complications and osteoporosis. Spontaneous puberty occurs in 5-10% of women with Turner's syndrome, and 2-5% of them become pregnant spontaneously. Sexually active young women with Turner's syndrome need contraception. It can be administered as contraceptive pills, which also serve as HRT. Oocyte donation is now a treatment option for infertility of these women. Excellent results have been obtained with 46% of embryo transfers resulting in pregnancy. The pregnancies carry high risks and have to be followed up carefully. The children born following oocyte donation have no additional risks. Risks can be reduced by transferring only one embryo at a time to the uterus, thus avoiding twin pregnancies. Ovarian tissue from young girls with Turner's syndrome could be cryopreserved for infertility treatment in the future, but the optimal age of ovarian biopsy has to be studied, and methods of replantation and maturation of oocytes in vitro have still to be developed. Fertility counselling has become important in the treatment of girls with Turner's syndrome.     

Potential applications for transesophageal echocardiography in hypertrophic cardiomyopathies.

The purpose of the present study was to evaluate the potential advantages of transesophageal echocardiography (TEE) in comparison with transthoracic echocardiography (TTE) in selected patients with hypertrophic cardiomyopathy. Ten patients with previously established or suspected diagnosis of hypertrophic cardiomyopathy were examined by TEE to solve specific clinical questions. TEE was well tolerated by all patients; no arrhythmias were seen during the procedure. The comparison of TTE and TEE showed the following: Advantages of TTE--better assessment of the left ventricle, myocardial thickness measurements available in all regions and sufficient for the diagnosis of hypertrophic cardiomyopathy in nine out of 10 patients; advantages of TEE--precise assessment of mitral valve morphology and regurgitant jets, detailed evaluation of systolic anterior motion, and subaortic membrane (not seen by TTE) recognized in one patient. Clinically, in three patients TEE influenced the management (mitral leaflet perforation, subaortic membrane, and residual mitral regurgitation after valvuloplasty). Thus TEE enables more precise diagnosis in some patients with hypertrophic cardiomyopathy and has the potential to influence their surgical management. However, for medical treatment of hypertrophic cardiomyopathy, TTE is sufficient.     

Feasibility of transesophageal echocardiography with a ten-French monoplane probe.

OBJECTIVES: We examined the feasibility of transesophageal echocardiography (TEE) using a 10F monoplane probe developed for intracardiac ultrasound (AcuNav, Acuson/Siemens, Mountain View, Calif). BACKGROUND: Traditional TEE uses a 10- to 12-mm-diameter probe, and conscious sedation is customary to minimize patient discomfort. Because of its small size (3.2-mm diameter), the 10F monoplane probe can be inserted into the esophagus using only topical anesthesia. This provides the potential for a more easily tolerated examination. METHODS: A total of 20 patients underwent a comprehensive TEE using an adult multiplane probe. Immediately afterward, the 10F monoplane probe was inserted into the esophagus and a targeted examination completed. The 10F monoplane studies were blindly reviewed by 3 observers for the study indication and for 16 diagnostic elements. These were graded against an expert's review of standard TEE. RESULTS: The 10F monoplane probe was well tolerated in all patients. Observers A, B, and C answered the clinical question in 80%, 85%, and 100%, respectively, with the 10F probe. The percentage of clinical elements deemed evaluable was 71%, 78%, and 80%, respectively. Limitations included incomplete visualization of the mitral valve and a systematic underestimation of the severity of valve regurgitation. CONCLUSIONS: The 10F monoplane probe is safe, well-tolerated, and capable of evaluating many clinical questions. Because of its small size, conscious sedation may not be necessary. It may be useful for targeted evaluations, for monitoring invasive procedures, or for intermediate or long-term monitoring in an intensive care department.     

Acoustic characterization of a miniature matrix transducer for pediatric 3D transesophageal echocardiography

This paper presents the design, fabrication and characterization of a miniature PZT-on-CMOS matrix transducer for real-time pediatric 3-dimensional (3D) transesophageal echocardiography (TEE). This 3D TEE probe consists of a 32?×?32 array of PZT elements integrated on top of an Application Specific Integrated Circuit (ASIC). We propose a partitioned transmit/receive array architecture wherein the 8?×?8 transmitter elements, located at the centre of the array, are directly wired out and the remaining receive elements are grouped into 96 sub-arrays of 3?×?3 elements. The echoes received by these sub-groups are locally processed by micro-beamformer circuits in the ASIC that allow pre-steering up to ±37°. The PZT-on-CMOS matrix transducer has been characterized acoustically and has a centre frequency of 5.8 MHz, -6 dB bandwidth of 67%, a transmit efficiency of 6 kPa/V at 30 mm, and a receive dynamic range of 85 dB with minimum and maximum detectable pressures of 5 Pa and 84 kPa respectively. The properties are very suitable for a miniature pediatric real-time 3D TEE probe.     

Ultrasonic myocardial tissue characterization in the operating room: initial results using transesophageal echocardiography.

Ultrasonic tissue characterization provides quantitative assessment of myocardial function and viability. We have previously reported that normal myocardium is characterized by a diastolic-to-systolic cyclic variation of integrated backscatter (IB), whereas ischemic myocardium exhibits blunting of this pattern. To define the applicability of this measurement to characterize the left ventricular myocardium in the operating room, we studied 26 consecutive patients undergoing open heart surgery (12 coronary artery bypass graft, 13 valvular, 1 other) with 5 MHz transesophageal echocardiography. Images of the left ventricle were obtained in the short-axis plane (papillary muscle level) before cardiopulmonary bypass. M-mode acquisition of myocardial IB was attempted from the anterior and inferior segments in each patient. The cyclic variation of IB was measured in at least two consecutive cycles in addition to a qualitative assessment of wall motion. Quantitative measurement of IB was possible in 39/52 (75%) myocardial segments. Cyclic variation of IB averaged 5.7 +/- 1.4 dB (SD) in segments with normal wall motion (n = 25); no difference was noted in the cyclic variation of IB among anterior or inferior walls. Hypokinetic segments demonstrated significant reduction of the cyclic variation (3.8 +/- 1.8 dB; p less than 0.001). Difficulty with obtaining myocardial IB was related to near-field artifact or lateral displacement of the left ventricular wall during systole. Transesophageal echocardiography holds promise for the evaluation of myocardial function and its preservation during cardiac surgery.     

Harmonic imaging for endocardial visualization and myocardial contrast echocardiography during transesophageal echocardiography.

BACKGROUND: Although harmonic imaging (HI) improves endocardial visualization and is necessary for myocardial perfusion imaging, it has yet to be implemented in transesophageal echocardiography. Our goal was to determine whether HI implemented in a prototype transesophageal echocardiography probe improved endocardial visualization and allowed perfusion imaging. METHODS: In 23 patients, fundamental and harmonic images were obtained in the transgastric short-axis (TSAX) and midesophageal 4-chamber views, and reviewed for endocardial visualization by 3 readers blinded to imaging mode. In 14 additional patients, perfusion imaging was performed in the TSAX view during contrast infusion. RESULTS: HI improved overall endocardial visualization, most noticeably in the anterior and lateral segments (P <.004) in the TSAX view, and in the lateral segments (P <.01) in the midesophageal 4-chamber view. The salvage rate was 8.3% in the TSAX view and 12.6% in the midesophageal 4-chamber view. Myocardial perfusion was consistently confirmed in the inferior (86%), posterior (100%), and lateral (79%) segments, but rarely in the septal (21%), anteroseptal (0%), and anterior (14%) segments. CONCLUSION: Use of HI with transesophageal echocardiography improves endorcardial visualization and allows partial assessment of myocardial perfusion.