Misplaced Greenfield filter: diagnosis by transesophageal echocardiography.

A case of accidental placement of a Greenfield filter in the right atrium is described. Transthoracic echocardiography demonstrated the filter but was unable to provide details regarding the exact location of the filter. Transesophageal echocardiography showed the filter to be fixed to the tricuspid anulus. This finding, which was confirmed during surgery, was used to guide the subsequent surgical management.     

Percutaneous placement of the Greenfield vena caval filter

During the period from August 1986 to August 1987, 50 patients underwent percutaneous placement of a Greenfield vena caval filter from the right femoral vein, left femoral vein, or right internal jugular vein at our institution. All 50 patients had a contraindication to anticoagulation therapy or had complications of anticoagulation for deep venous thrombosis or pulmonary emboli. The percutaneous placement was accomplished in the angiographic suite with use of local anesthesia and was well tolerated by all patients. Only three complications related to the percutaneous approach occurred during the short-term follow-up (3 months to 1 year). These complications were deep venous thrombosis of the leg in two patients and misplacement of the filter in one patient. The three patients tolerated these complications well. We conclude that placement of Greenfield vena caval filters can be readily accomplished by means of percutaneous entry. Our experience demonstrated minimal associated morbidity and no mortality.     

Hemodynamic assessment of critically ill patients using echocardiography Doppler

PURPOSE OF REVIEW: The evaluation of hemodynamic status in critically ill patients is a leading recommended indication of transesophageal echocardiography in the intensive care unit. Advantages and diagnostic yield of transesophageal echocardiography in this setting are particularly relevant when considering limitations and questioned prognostic impact of pulmonary artery catheterization. RECENT FINDINGS: Recent clinical studies have been performed to validate and assess the value of transesophageal echocardiography in determining cardiac output, cardiac preload dependence, right ventricular function, and left ventricular filling pressure. In addition, diagnostic capacity and therapeutic impact of transesophageal echocardiography have been widely reported in various intensive care unit settings. SUMMARY: Transesophageal echocardiography appears well suited for the determination of cardiac index and to track its variations after therapeutic interventions. Although repeated measurements of left ventricular end-diastolic dimension allows to accurately track preload variations, a single determination is not reliable to predict fluid responsiveness in intensive care unit patients. Identification of preload dependence in hemodynamically unstable patients currently tends to rely mainly on dynamic parameters that use cardiopulmonary interactions under mechanical ventilation. Transesophageal echocardiography also allows to adequately assess right ventricular function and left ventricular filling pressure using combined Doppler modalities. Adequate education and training of intensivists and anesthesiologists is crucial to further develop the use of transesophageal echocardiography in the intensive care unit setting. Despite the absence of randomized controlled studies documenting transesophageal echocardiography benefits on patient outcome, present evidence and experience strongly recommend a larger use of echocardiography Doppler for a comprehensive functional hemodynamic assessment of critically ill patients with circulatory failure.     

Successful management of infected right iliac pseudoaneurysm caused by penetration of migrated inferior vena cava filter: A case report

BACKGROUNDIndwelling inferior vena cava (IVC) filters might cause various complications, including filter penetration, filter fracture, filter migration, and thrombosis of the IVC. Penetration and migration complications are common, while a caudal migrated double-basket filter with associated infected iliac pseudoaneurysm has seldom been reported.CASE SUMMARYWe report a 64-year-old female admitted for sudden onset of severe right abdominal pain after IVC filter placement for 3 mo. The patient had a history of failed endovascular IVC filter retrieval. Computed tomography showed that the retrieval hook of the filter penetrated the right common iliac artery and vein, leading to right iliac artery pseudoaneurysm accompanied by right ureteral obstruction with ipsilateral hydronephrosis, and bilateral iliac veins were occluded. Emergency open repair was performed to remove the IVC filter, the right iliac pseudoaneurysm, and the compromised segments of the iliac veins and IVC with right common iliac artery reconstruction. Staphylococcus aureus was isolated from the tissue culture. The patient was discharged on postoperative day 12 with anticoagulation therapy and antibiotic therapy after discharge. Six-month follow-up computed tomography revealed that the right common iliac artery was patent, and only mild hydronephrosis was detected.CONCLUSIONAn indwelling IVC filter, even ‘embedded’ within organized thrombus, could still cause life-threatening complications. Open procedures remain the last resort for IVC filters with severe complications.     

Clinical experience with superior vena caval Greenfield filters.

PURPOSE: To evaluate the results of superior vena caval (SVC) Greenfield filters in patients at risk for pulmonary embolism (PE) secondary to upper extremity deep venous thrombosis (UEDVT). METHODS: Over a 46-month period, 26 patients (10 men, mean age 67 years, range 25 to 89) with UEDVT in whom anticoagulation was contraindicated (n = 22) or ineffective in preventing recurrent PE or extension of the thrombus (n = 4) were treated with placement of SVC Greenfield filters. RESULTS: One SVC filter was misplaced into the innominate vein but left in place; this vein remains patent after 2 months without evidence of filter migration. Follow-up ranged from 10 days to 46 months (mean 7.8 months). Fifteen (58%) patients died inhospital of causes unrelated to the SVC filter or recurrent thromboembolism (mean time to death 36 days). Of the 11 survivors, follow-up ranged from 1 to 38 months (mean 22). Sequential chest roentgenograms in 9 (82%) patients revealed no filter migration or displacement. No evidence of PE was found in any of the survivors over the course of follow-up. CONCLUSIONS: Insertion of SVC Greenfield filters is a safe and feasible therapy to prevent recurrent thromboembolism in patients with UEDVT who are refractory to or inappropriate for anticoagulation therapy.     

Coronary artery fistula: diagnosis by biplane transesophageal echocardiography.

A 56-year-old man underwent coronary angiography during evaluation of severe mitral regurgitation. A right coronary artery fistula was incidentally discovered but its site of termination was uncertain. Transthoracic echocardiography also did not reveal the location of its drainage. The correct diagnosis of a right coronary artery to left atrial fistula was made using biplane transesophageal echocardiography. This case demonstrates the utility of biplane transesophageal echocardiography in the diagnosis of the origin and termination of congenital coronary artery anomalies.     

Precise evaluation of a complex coronary arteriovenous fistula: the utility of transesophageal color Doppler

The transesophageal color flow Doppler appearance of coronary artery fistulas have not been described previously. We present a patient with a fistulous connection between the right coronary artery and the right atrium with an additional connection to the coronary sinus. The fistulous connection to the coronary sinus, confirmed at operation, was only diagnosed with transesophageal color flow Doppler and missed on both transthoracic echocardiography and cardiac catheterization. In addition, intraoperative transesophageal echocardiography was extremely useful in confirming closure of both these fistulas, thus confirming a successful operative result.     

Posttraumatic phlegmasia cerulea dolens: an indication for the Greenfield filter

Phlegmasia cerulea dolens (PCD) can be a threat to both life and limb and therefore must receive prompt treatment. In most clinical settings, anticoagulant therapy is standard treatment for PCD. Iliofemoral thrombectomy has been recommended as surgical treatment of massive thrombosis where venous gangrene may occur. In the severely traumatized patient, however, massive venous occlusion presents difficulties in management in a complex clinical setting. We have described a 52-year-old white man who had a posterior fracture dislocation of the right hip, with a pulseless, cyanotic, swollen right leg. A Greenfield filter was placed via the internal jugular vein approach, followed by leg and thigh fasciotomy and iliofemoral thrombectomy. Femoral arteriotomy revealed good inflow, and arterial thrombectomy yielded very little thrombus. He subsequently required an above-knee amputation for venous gangrene. In cases of PCD, iliofemoral thrombectomy should be considered early when the threat of venous gangrene exists. We propose internal jugular vein placement of a Greenfield filter before venous thrombectomy. The Greenfield filter has proven to be a safe and effective prophylaxis for thromboembolism should a clot migrate or detach during thrombectomy. Additionally, placement of the filter in the early post-traumatic period would safeguard against pulmonary emboli during a period in which anti-coagulant therapy would be contraindicated.     

Recurrent pulmonary embolism originating from right atrial myxoma.

The use of transesophageal echocardiography is a useful adjunct to transthoracic echocardiography in the diagnosis and management of right atrial tumors in patients who are thought to have idiopathic recurrent pulmonary embolism, especially with suboptimal transthoracic echocardiography studies. We describe a 30-year-old woman with a history of recurrent pulmonary embolism who was admitted for investigation of pleuritic chest pain in whom transesophageal echocardiography played a critical role in the diagnosis and management.     

The Role of Transesophageal Echocardiography in the Diagnosis and Treatment of Right Atrial Thrombi

Twenty patients with right atrial thrombi were identified through the use of transthoracic and transesophageal echocardiography. Transesophageal echocardiography identified right atrial thrombi in all 20 cases. Transthoracic echocardiography showed definite thrombi in only 6 (30%) cases and suggested thrombus in another 2 (10%) patients. Thus transthoracic echocardiography results were false-negative for right atrial thrombus in 60% of cases. All 3 thrombi found within the right atrial appendage and 2 of 3 thrombi on pacemaker wires were missed by transthoracic echocardiography. There was no significant difference in the mean size between those thrombi seen (1.37 ± 0.6 cm) and those missed (1.5 ± 0.9 cm) by transthoracic echocardiography. Transesophageal echocardiography also significantly affected treatment. Anticoagulation was initiated or amplified in 13 patients. In 8 of these 13, thrombi were seen only by transesophageal echocardiography. Surgery was performed to remove thrombi in 7 cases, and in 3 (43%) cases it was because of thrombi seen only by transesophageal echocardiography. This study suggests that transesophageal echocardiography should be performed whenever right atrial thrombi are suspected. Transesophageal echocardiography has a significant effect on the diagnosis and management of patients with right atrial thrombi. (J Am Soc Echocardiogr 1999;12:64-9.)     

多平面经食管三维超声心动图定量评价右心室收缩功能准确性的临床研究

应用多平面经食管三维超声心动图技术（3DE）对10例心脏病患者的右室射血分数进行了分析，并与二维超声心动图（2DE）及放射性核素心室造影（RNA）所测值进行了对比，结果显示；2DE所测右室射血分数（RVEF）与放射性核素心室造影所测结果仅呈轻度相关（r为0．77），3DE所测RVEF与核素心室造影结果呈中度相关且相关性明显优于2DE方法（P＜0．05）。但2DE、3DE所测RVEF均明显高于放射性核素心室造影的结果（RVEF分别为0．56，0．52和0.49，P＜0.05）。     

经食管超声心动图对心房颤动时右心耳血流动力学的研究

目的　应用经食管超声心动图(TEE)技术观察慢性心房颤动(房颤)时右心耳结构、功能和血流流速曲线的改变。方法　选取 26例房颤患者和 13例窦性心律患者,采用TEE充分清楚显示右心耳图像并采集血流流速曲线和其他相应指标。结果　与对照组相比,房颤组右心房射血分数 (RAEF)和右心耳射血分数(RAAEF)均显著降低(P<0. 05~0. 01);房颤时右心耳血流流速曲线峰值排空、充盈流速和流速积分均显著下降(P<0. 05~0. 01)。右心耳峰值排空、充盈流速与右室射血分数 (RVEF)、RAAEF、RAEF、右心房最大面积(Smax RA)等指标具有显著的相关性。结论　TEE可以安全、准确地评价右心耳血流动力学情况;房颤时右心耳血流流速曲线是反映右心房、右心耳功能的良好指标。     

经食管右心系统三维超声心动成像

探讨经食管右心系统三维成像技术的应用,选择并确定对临床有诊断意义的三维超声心动图图像。方法当食管探头分别插入到食管３０ｃｍ、３５ｃｍ、４０ｃｍ处,图像分别显示心房二腔和右房、三尖瓣和右室以及右房、三尖瓣、右室和右室流出道结构时,分别采集并进行三维重建。     

Massive tricuspid regurgitation due to pacemaker-lead puncture of the tricuspid valve: successful diagnosis by 3-dimensional echocardiography

An 83-year-old woman presented to our echocardiographic center with symptoms of right heart failure. A dual-chamber DDDR pacemaker had been implanted 9 years earlier. Two-dimensional echocardiography revealed right atrial and ventricular enlargement and massive tricuspid regurgitation with immobilization of the anterior leaflet of the tricuspid valve. Three-dimensional transesophageal echocardiography showed that the pacemaker lead had punctured the leaflet. These echocardiographic findings were confirmed during surgery. The pacemaker lead was transected and removed, and pericardial patch closure of the leaflet hole and tricuspid annuloplasty were performed. The mechanism of regurgitation was elucidated by real-time three-dimensional echocardiography, and surgical repair was straightforward.     

Transesophageal echocardiographic evaluation of right atrial mass lesions

Transesophageal echocardiography with color flow Doppler studies was performed on 10 consecutive patients who had right atrial masses identified by transthoracic echocardiography. In one patient with right atrial myxoma, transesophageal study identified the tumor by its attachment to the atrial septum and ruled out the transthoracic finding of possible additional tumor mass in the right ventricle. In two instances the mass in the atria were deemed to be thrombi because of lack of attachment to the atrial septum, atrial fibrillation, and enlarged right atrial chambers. In all patients, the thrombi appeared larger by transesophageal study and was associated in one instance with atrial septal defect. The atrial septal defect was not identified by the transthoracic study and probably accounted for stroke of the patient through paradoxical emboli. In six patients, because of superior quality images rendered by transesophageal imaging, the right atrial mass lesions were deemed to be anatomic variants, which included prominent eustachian valves, remnants of Chiari network, and thickened atrial septum. We concluded that transesophageal echocardiography is superior to transthoracic imaging in elucidating the cause and significance of right atrial mass lesions and that it helps in guiding appropriate therapy.     

经胸二维和多平面经食管三维超声心动图测量慢性肺心病右室收缩功能的对比研究

目的探讨慢性肺心病右室收缩功能的测量新方法。方法对３２例慢性肺心病患者进行经胸二维和多平面经食管超声心动图检查,分别采用双平面Ｓｉｍｐｓｏｎ法和自制的三维超声心动图软件系统测量右室射血分数（ＲＶＥＦ）,并与放射性核素心室造影测量的ＲＶＥＦ对比。结果经胸二维超声心动图与放射性核素心室造影的ＲＶＥＦ呈中度相关（ｒ＝０．０８,Ｐ＜０．０１,ＳＥＥ＝０．０７）,但前者显著高估了后者的测值（Ｐ＜０．０５）。而多平面经食管三维超声心动图与放射性核素心室造影的测值高度相关（ｒ＝０．９１,Ｐ＜０．００１,ＳＥＥ＝０．０５）,且组间均数无显著性差异（Ｐ＞０．０５）。结论多平面经食管三维超声心动图为定量评价右室收缩功能提供了相对无创和相当可靠的新途径。     

Asymptomatic dissection of the ascending aorta: diagnosis by transesophageal echocardiography

A young man with marfanoid habitus underwent transesophageal echocardiography to evaluate an aortic root abnormality visualized on transthoracic echocardiography. Transesophageal echo demonstrated a type A aortic dissection traversing across the right sinus of Valsalva but not involving the aortic valve, right coronary artery, or pericardial sac. The aorta was not dilated. This is apparently the first reported case of an asymptomatic and uncomplicated aortic dissection localized to the sinus of Valsalva.     

Right upper lobe pulmonary edema after mitral valve replacement caused by paravalvular leakage recognized by bedside transesophageal echocardiography

OBJECTIVE: To describe an unusual case of right upper lobe pulmonary edema caused by acute paravalvular leakage that was identified by the use of bedside transesophageal echocardiography. DESIGN: Case report. SETTING: University-affiliated hospital. PATIENT: A 59-yr-old male patient underwent prosthetic mitral valve replacement (St. Jude valve) for severe mitral regurgitation and developed sudden onset of dyspnea and change in consciousness with blood pressure decreased to 70/30 mm Hg. Elevation of central venous pressure and images of transthoracic echocardiography led to the diagnosis of cardiac tamponade. CONCLUSION: Acute paravalvular leakage after mitral valvular replacement should be considered as one of the differential diagnoses for unilateral pulmonary edema. Physical findings of a holosystolic murmur and findings from bedside transesophageal echocardiography can confirm the diagnosis, avoiding delay in management.     

Spontaneous drainage of paravalvular abscess diagnosed by transesophageal echocardiography

Paravalvular abscesses, which occur in up to 30% of cases of native valve endocarditis, are being detected with increasing frequency with the use of transesophageal echocardiography. Abscesses of the mitral aortic intervalvular fibrosa have been described but only in association with native or prosthetic aortic valve endocarditis. We describe a patient with native mitral valve endocarditis complicated by an abscess in the fibrosa. A 51-year-old diabetic man presented with Staphylococcus aureus mitral valve endocarditis. A transesophageal echocardiographic study done 8 days after admission revealed two large masses at the base of the anterior mitral leaflet with extension into the fibrosa consistent with a paravalvular abscess that was not detected by precordial echocardiography. A repeat transesophageal echocardiographic study done 20 days after admission showed spontaneous drainage of the abscess and a subsequent fistula between the left atrium and left ventricle. This case highlights the important role that transesophageal echocardiography has in suspected and known cases of endocarditis. Its major advantage of delineating posterior cardiac structures allowed accurate diagnosis and serial evaluation of this previously unreported complication of endocarditis.     

经食道心脏超声检测冠状动脉结构及血流速度60例报告

经食道心脏超声对60例患者检测冠状动脉。二维超声冠状动脉显像率为左冠状动脉主干95%,左前降支50%,左旋支37%和右冠状动脉82%。本组左冠状动脉近段直径显著大于右冠状动脉。冠状动脉记录到舒张期多普勒血流频谱者依次为91%、40%、27%和33%,少数冠脉亦可显示收缩期血流频谱。检测的冠状动脉血流速度峰值范围为0.20~0.72m/s。经食道心脏超声为冠状动脉近段解剖学和功能学的非创伤性诊断措施之一,具有潜在的临床实用价值。