经胸房间隔缺损堵闭术对房室瓣反流的影响

目的探讨经胸房间隔缺损封堵术对房室瓣反流的影响。方法回顾性分析2002年1月至2011年3月在南方医科大学珠江医院经胸微创房间隔缺损堵闭术患者的临床资料,其中资料完全者43例,40例在食道超声、2例在经胸超声辅助下行房间隔缺损堵闭术。患者术前、术后1个月及6个月经超声心动图检查,观察心脏各指标的变化和房室瓣反流程度。结果41例手术成功,手术成功率95．3％（41／43）;1例术中改为右侧开胸小切口体外循环下房间隔缺损修补术,1例术中并发心搏骤停。1例术后并发肾功能衰竭：12例术后即时有少量残余漏,1个月后超声复查消失。术后超声随访显示：右心室、右心房直径较前缩小,左心室直径较前增大,肺动脉瓣血流速度明显降低,差异有统计学意义（P〈0．05）;室间隔厚度、二尖瓣血流速度、主动脉瓣血流速度无明显改变,差异无统计学意义（P〉0．05）。房间隔缺损堵闭术后1个月、6个月,二尖瓣瓣膜反流程度较术前加重,差异有统计学意义（平均秩次：2．01VS．2．17vs1．77,x2=10．78,P=0．04）;而三尖瓣的瓣膜反流程度术前与术后1个月、6个月比较,差异无统计学意义（平均秩次：1．88vs2．11US．2．01,X2=4．23,P=0．134）。结论房间隔缺损封堵术后,可引起二尖瓣反流程度的加重,但对三尖瓣的反流程度近期影响不明显;二尖瓣中度以上或三尖瓣重度反流的患者或不适宜行单纯房间缺损封堵术。     

Partial atrioventricular septal defect assessed by real-time three-dimensional echocardiography: a case report

A 48-year-old woman was admitted with a heart murmur and increased difficulty in breathing. Two-dimensional echocardiography revealed a defect in the lower part of the atrial septum [(primum atrial septal defect (ASD)] and a pouch at the interventricular septum. Color Doppler echocardiography detected grade 3/4 mitral regurgitation. Real-time three-dimensional echocardiography (RT-3DE) revealed a cleft in the anterior leaflet of the mitral valve toward the tricuspid valve, and the ASD located near the atrioventricular valves with 14mm in minor axis. Color Doppler three-dimensional echocardiography disclosed left-to-right ASD shunt toward the atrial posterior wall. No shunt through the pouch at the membranous part, left ventricular outflow obstruction, or partial anomalous pulmonary venous connection was observed. RT-3DE is quite useful to describe complicated congenital heart disease.     

Use of echocardiography in mitral regurgitation for the assessment of its mechanism and etiology for the morphological analysis of the mitral valve

Echocardiographic assessment of mitral regurgitation allows the diagnosis of its mechanism and cause which are major determinants in the feasibility of mitral valve repair. This assessment is based on a systematic analysis of the different structures of the mitral valve apparatus: mitral annulus (enlargement, calcification), mitral valve morphology (thickening, calcification, floppy valve, vegetations, perforation), mitral valve motion (restriction, identification of the prolapsed leaflets and scallops in patients with mitral valve prolapse or flail leaflets), subvalvular apparatus (ruptured chordae, thickening), papillary muscles, and left ventricular wall. This analysis can diagnose the mechanism of mitral regurgitation according to the Carpentier classification, and can clarify its cause: degenerative lesions (prolapse or flail leaflet with or without ruptured chordae), rheumatic lesions (thickened valves with restricted motion), endocarditis (vegetations, perforation, ruptured chordae), ischemic mitral regurgitation (restricted valve motion with inferior or posterior left ventricular wall asynergy), or functional mitral regurgitation (annular dilatation, displacement of papillary muscles with restricted leaflet motion). Transthoracic echocardiography with harmonic imaging usually allows a comprehensive assessment of functional anatomy of mitral regurgitation. Transesophageal echocardiography is indicated if transthoracic echocardiography is inadequate. It is also indicated just before surgery and as an intraoperative procedure. Real time 3D echocardiography should probably complete the evaluation of mitral regurgitation in the near future.     

Transthoracic real-time three-dimensional echocardiography using a fan-like scanning approach for data acquisition: methods, strengths, problems, and initial clinical experience

Three-dimensional echocardiography is an emerging clinical method to assess cardiovascular disorders. The feasibility of using a linear mode scanning (parallel slicing) for transthoracic data acquisition has been demonstrated. In this study, we evaluated the feasibility of real-time transthoracic three-dimensional imaging of the heart using a fan-like scanning mode of echocardiographic data acquisition. We used a computer-driven motor to sequentially angulate transthoracic transducers over a fan-like arc up to 90 degrees. With careful ECG and respiratory gating, we acquired basic two-dimensional data set via parasternal and subcostal windows and performed dynamic three-dimensional reconstructions. The problems encountered included the need to repeat data acquisition sequences because of transducer movement or inappropriate gain and gray scale settings. From 15 scanning sequences in four patients, we were able to use ten sets of data. These yielded good quality three-dimensional studies projecting normal valves, a stenotic mitral valve, and an atrial septal defect, in a number of novel views. The valves could be visualized from above and from below as well as in other orientations, and the detailed anatomy appraised. Spatial relationships of the atrial septal defect with inferior and superior vena cava, coronary sinus, or tricuspid annulus could be uniquely displayed through views from the right side of the heart. This technique provided adequate new imaging planes not available from two-dimensional echocardiography. This experience demonstrates for the first time that transthoracic three-dimensional echocardiography using a fan-like scanning mode of data acquisition is feasible, and that it provides adequate visualization of intracardiac structures in unique projections.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of transthoracic and transesophageal assessment of prosthetic valve dysfunction

Transesophageal echocardiography has added another dimension to the assessment of prosthetic valve dysfunction with high-resolution images that allow for more detailed structural evaluation of tissue and mechanical valves. This study is a retrospective analysis of 140 prosthetic valves (90 tissue, 50 mechanical) in the mitral (89), aortic (45), and tricuspid (6) position in 116 patients studied by transthoracic and transesophageal echocardiography techniques. Transesophageal echocardiography was consistently better than the transthoracic technique in the evaluation of structural abnormalities of tissue valves in the mitral and aortic positions with respect to leaflet thickening, prolapse, flail, and vegetations. With transesophageal echocardiography, five tissue mitral valves had flail leaflets that were not identified by the transthoracic technique. Transesophageal echocardiography was better than transthoracic in the detection, quantification, and localization of prosthetic mitral regurgitation. Physiological mitral regurgitation was detected in 31 valves by transesophageal echocardiography compared to seven by transthoracic technique. By transesophageal echocardiography, mitral regurgitation was paravalvular in 24% compared with 4% by transthoracic technique. Left atrial spontaneous contrast was seen in 42% of the patients with a mitral prosthesis detected only by transesophageal echocardiography. Six patients had left atrial or left atrial appendage thrombus and in five patients they were detected only by transesophageal echocardiography. We conclude that transesophageal echocardiography should be a complimentary test to transthoracic studies in patients with suspected prosthetic valve dysfunction or for the follow-up of older tissue valves.     

A new anatomical approach to congenital valve diseases by three-dimensional echocardiography]

Congenital valvular heart disease in childhood is often complex. Conventional echocardiography provides two-dimensional views which require mental reconstruction for three-dimensional assessment. This problem may be solved by the use of three-dimensional (3D) echocardiography which obtains images of valves comparable to those seen at surgery. This was confirmed by 4 cases of congenital valvular heart disease studied by 3D echocardiography: stenotic bicuspid aortic valve disease, parachute mitral valve and two cases of mitral regurgitation in patients with atrioventricular canal. The 3D views of the aortic valve showed the commissural opening after percutaneous balloon valvuloplasty of the bicuspid valve. The surface of the aortic orifice and the surface of the two mitral leaflets were measured from 3D reconstructions. The longitudinal 3D view analysed the extension of the single obstructive mitral papillary muscle of the parachute malformation. The 3D ventricular views allowed assessment of the extension of the cleft and the surface of the three mitral leaflets of the 2 cases of atrioventricular canal. In one of these cases, the results of surgical valvuloplasty were evaluated after 3D reconstruction of the valve. 3D echocardiography is not only a diagnostic tool for congenital heart disease but also a very useful complementary investigation for accurate evaluation of congenital valvular lesions to optimise possible valve repair.     

Live/Real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.     

Live/real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.     

Three-Dimensional Echocardiographic Evaluation of Aortic and Mitral Valve Stenosis

Dynamic volume rendered three-dimensional echocardiography allows the spatial recognition of anatomy and function of the aortic and mitral valves with acceptable image quality. The aortic valve can be best visualized in a view from the ascending aorta down to the valve level, thus allowing an overview of the aortic aspect of the valve in a surgeon's perspective in ∼ 80% of patients. Planimetric measurement of the aortic valve area was possible in 88% of patients, and there is no systematic overestimation or underestimation of aortic valve area compared with two-dimensional echocardiography and catheterization. The entire valvular circumference of the mitral valve can be assessed from both a left atrial and a left ventricular perspective. Advantages of the three-dimensional transesophageal echocardiography mitral valve area determination compared with transthoracic two-dimensional planimetry and Doppler-derived pressure half-time method are present in patients with severely calcified mitral valves and in those with combined aortic regurgitation.     

Tricuspid cleft or tetracuspid valve? Usefulness of three-dimensional echocardiogram in the assessment of isolated tricuspid regurgitation in pediatrics

Tricuspid regurgitation (TR) in children may be secondary to congenital anomalies of the tricuspid valve complex which is composed by annulus, leaflets, commissures, chordae tendineae, and papillary muscles. The most common congenital cause is Ebstein's anomaly; however, there are less frequent causes such as abnormal number of tricuspid leaflets, tricuspid cleft, leaflet prolapse, double orifice tricuspid valve, and congenital tricuspid valve dysplasia. Identifying the precise cause is important to plan an appropriate repair surgery. In this article, the case of a 4-year-old patient with a tetracuspid valve with significant tricuspid regurgitation is presented and the morphological analysis was made by two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography. The morphological differences between a tetracuspid valve and a cleft of the anterior leaflet tricuspid valve are exposed. 3D echocardiographic evaluation of the tricuspid valve allowed a better understanding of the tricuspid valve anatomy, which includes evaluation of the tricuspid annulus, leaflets, commissures, and subvalvular apparatus. Recognizing the accurate cause of isolated tricuspid regurgitation allows better planning of the surgical technique.     

Isolated tricuspid valve regurgitation resulting from severe annular dilatation: case report.

A rare case of isolated tricuspid regurgitation (TR) in a 65-year-old man is presented. Echocardiography revealed enlargement of the right atrium, dilatation of the tricuspid valve annulus without thickening or prolapse of the leaflets, and an intact atrial septum. No downward displacement of the tricuspid septal leaflet was observed by echocardiography. Mild mitral regurgitation and severe TR were detected on color flow Doppler studies. Cardiac catheterization indicated elevated right atrial pressure, with a pronounced V-wave. No left-to-right shunt was detected at the right atrium. At surgery, severe annular dilatation of the tricuspid valve (without organically diseased or deformed tricuspid leaflets) was observed, and tricuspid annuloplasty with a prosthetic ring performed. Postoperative echocardiography and right ventriculography showed trivial TR.     

Morphological Assessment of the Tricuspid Apparatus and Grading Regurgitation Severity in Patients With Functional Tricuspid Regurgitation: Thinking Outside the Box

Current guidelines recommend transthoracic echocardiography to assess patients with functional tricuspid regurgitation (FTR) because it provides information regarding the presence of structural abnormalities of the tricuspid valve (TV), allows measurement of tricuspid annulus diameter, and evaluates severity of FTR by integrating data obtained from 2D and Doppler echocardiography. Critical components of the noninvasive evaluation include information regarding TV anatomy, tricuspid regurgitation severity, right ventricular size and systolic function, and associated findings such as estimated pulmonary artery pressure. However, most of the parameters included in the current recommendations to assess FTR are derived from the experience and knowledge developed about the mitral valve and have been transferred from the left to the right side of the heart without accounting for differences in anatomy of the tricuspid and mitral apparatus or for differences in hemodynamic environment in which the TV operates compared to its left counterpart.     

Left ventricular noncompaction and mid-caviter narrowing associated with Ebstein's anomaly: three-dimensional transthoracic echocardiographic image

An 50 year-old asymptomatic female was admitted to preoperative cardiovascular evaluation for noncardiac surgery. Two-dimensional transthoracic echocardiography demonstrated that left ventricular dimensions and ejection fraction were normal. The mitral valve was normal both in morphology and function. The attached margin of septal and anterior leaflet of the tricuspid valve was apically displaced. But right ventricle and right atrium dimensions were normal, and Doppler interrogation showed a slight tricuspid regurgitation. Two and three-dimensional transthoracic echocardiography showed prominent numerous trabeculations in the left ventricular apex. Colour flow Doppler studies confirmed the presence of blood flow within the trabeculations. Multi-plane three-dimensional transthoracic echocardiography showed a muscular band leading to left ventricular mid-caviter narrowing. Pulse wave Doppler echocardiography demonstrated that no intraventricular gradient existed. Ventricular noncompaction associated with Ebstein's malformation has been reported. But left ventricular noncompaction and mid-caviter narrowing associated with Ebstein's anomaly have not been reported so far.     

Original Article--Predictors of Persistent Functional Tricuspid Regurgitation After Transcatheter Closure of Atrial Septal Defect and its Relationship to Tricuspid Valve Remodeling

ObjectivesThe aim of this study is assessment of persistent functional tricuspid regurgitation in patients with atrial septal defect before and after successful device closure and its relationship to tricuspid valve remodeling.MethodsThe current study was conducted on 60 patients referred to Tanta University Hospital Cardiology Department with the provisional diagnosis of atrial septal defect secundum type for transcatheter closure from December 2017 to December 2019. All patients were subjected to history taking, clinical examination, 12 lead electrocardiography, plain chest X-ray, full two dimension transthoracic echocardiography (for assessment of tricuspid regurgitation severity) before and at 3, 6 months after transcatheter closure.ResultsTricuspid regurgitation was decreased significantly after atrial septal defect closure due to remodeling in the right side. Age, estimated systolic pulmonary artery pressure, right atrium end systolic area, right ventricular end diastolic area, tricuspid valve tenting area and height, tricuspid septal leaflet angle and tricuspid annular diameter were predictors of persistent tricuspid regurgitation after 3 and 6 months of closure. Only estimated systolic pulmonary artery pressure, tricuspid septal leaflet angle and tricuspid annular diameter were independent predictors of persistent tricuspid regurgitation after 3, and 6 months of closure.ConclusionTricuspid regurgitation significantly improved after transcatheter atrial septal defect closure despite its significance at baseline due to remodeling in right side and tricuspid valve.     

Two dimensional echocardiography and the tricuspid valve. Leaflet definition and prolapse.

The tricuspid valve was studied in 143 subjects using two dimensional echocardiography. The groups studied were 40 normal subjects, 31 patients with mitral valve prolapse, 22 with clinically probable tricuspid valve prolapse, 20 with congestive cardiac failure, and 30 with miscellaneous cardiac conditions but no features of right heart disease. Using multiple views it was possible to record all three leaflets in 74.8% of cases and anterior and septal leaflets in 95%. Prolapse of the tricuspid valve was recognised in 13 patients: six (19.5%) of the group with mitral valve prolapse and seven (6%) of the remaining patients. Prolapse of all three leaflets was shown in one patient, anterior and septal prolapse in six patients, anterior and posterior in three patients, septal leaflet prolapse alone in two patients, and anterior alone in one patient. Two dimensional echocardiography allows definition of individual tricuspid leaflets and prolapse of any or all leaflets can be diagnosed. Tricuspid valve prolapse is commonly associated with prolapse of mitral valve leaflets but isolated cases are recognised.     

Live/Real Time Three-Dimensional Transthoracic Echocardiographic Findings in an Adult with Complete Atrioventricular Septal Defect

Live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional transthoracic echocardiography in an adult patient with complete atrioventricular (AV) septal defect by (1) making a confident diagnosis of Rastelli type A defect, (2) providing en face view of all the five leaflets of the common AV valve, (3) diagnosing left ventricle to right atrial shunt, and (4) permitting more accurate quantitative assessment of regurgitant lesions. (Echocardiography 2010;27:87-90)     

Echocardiography of operated heart. Assessment of results of mitral valvuloplasty

AIM: To assess results of surgery and to elaborate criteria of noninvasive diagnosis of cardiac function in patients with rheumatic mitral disease after reconstructive interventions on mitral valve. MATERIAL: Patients (n=192, mean age 41.2+/-1.2 years) with pure mitral stenosis (76%) and combined mitral valve disease with prevalent stenosis (24%), and 32 practically healthy people (n=32, mean age 36.6+/-3.5 years, control group). METHODS: Comprised transthoracic mono and two-dimensional echocardiography and doppler echocardiography. Results of intracardiac flow study were compared with data of invasive methods of investigation--intraoperative flowmetry and manometry, cardiac catheterization and intraoperative transesophageal echocardiography. RESULTS AND CONCLUSIONS: The following criteria of hemodynamically effective valvuloplasty were established: lowering of mean mitral valve pressure gradient by 54-65%; absence of regurgitation or lowering of mitral valve regurgitation fraction to < or =6% of total stroke volume. Significant increase of left ventricular stroke volume (by 22-27%), increase of mitral valve area (by 164-222%), decrease of left atrial diameter (mean decrease 17%) were also noted.     

Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: incremental value over the two-dimensional technique

Twenty-nine patients with different tricuspid valve (TV) pathologies were studied by both two-dimensional transthoracic (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE). A major contribution of 3DTTE over 2DTTE was the en face visualization of all three leaflets of the TV in all patients. This allowed accurate assessment of TV orifice area in patients with TV stenosis and carcinoid disease. Loss of TV leaflet tissue, defects in TV leaflets and size of TV systolic non-coaptation could also be delineated and resulted in identifying the mechanism of tricuspid regurgitation (TR) in patients with Ebstein's anomaly and rheumatic heart disease. Prolapse of TV leaflets could also be well visualized and enabled us to develop a schema for systematic assessment of individual segment prolapse which could help in surgical planning. The exact sites of chordae rupture in patients with flail TV as well as right ventricular papillary muscle rupture could be well seen by 3DTTE. 3DTTE also permitted sectioning of various TV masses for more specific diagnosis of their nature. In addition, color Doppler 3DTTE provided an estimate of quantitative evaluation of TR severity, since the exact shape and size of the vena contracta could be accurately assessed. In conclusion, our preliminary experience with 3DTTE has demonstrated substantial incremental value over 2DTTE in the assessment of various TV pathologies.     

Clinical uses of two dimensional echocardiography

The added advantages of two dimensional over M mode echocardiography in the diagnosis of cardiac disorders occurring in adults are reviewed. In patients with coronary artery disease, left ventricular aneurysm, wall motion abnormalities and ventricular dysfunction can be reliably evaluated with two dimensional echocardiography. Preliminary studies have demonstrated that two dimensional echocardiography is useful for assessing regional cardiac dilatation and prognosis after acute myocardial infarction, detecting left main coronary stenosis and predicting operability in patients with ventricular aneurysm. Determination of mitral valve area by two dimensional echocardiography in patients with mitral stenosis has shown good correlation with measurements of mitral valve area and size performed at the time of operation or calculated from cardiac catheterization data. The cause of mitral regurgitation can be more reliably elucidated by the differentiation of valvular and myocardial pathologic conditions. In addition, precise anatomic cardiac detail can be obtained in the localization of left and right ventricular and aortic outflow obstruction. Tricuspid valve disorders are particularly apparent because all three leaflets of the tricuspid valve can be visualized in real time studies and the detection of tricuspid regurgitation can be readily accomplished. Two dimensional echocardiography appears to be more reliable than M mode echocardiography in the detection of complications occurring as a result of bacterial endocarditis. Bioprosthetic valve function and localization and site of pericardial effusions as well as aortic aneurysms can be determined with two dimensional echocardiography. Two dimensional echocardiography can provide an accurate appreciation of the size, shape, mobility and origin of an intracardiac mass. With the use of contrast echocardiography, right to left shunting or the negative contrast effect can be demonstrated in patients with an atrial septal defect. Thus, the precision, accuracy and sensitivity of two dimensional echocardiography affords the clinician a valuable noninvasive instrument in the detection of cardiac disease.