Albert D. Pacifico

Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve.

We evaluated the potential usefulness of three‐dimensional (3D) transesophageal echocardiography (TEE) in assessing individual scallop/segment prolapse in 36 adult patients with mitral valve prolapse (MVP) undergoing surgical correction. Intraoperative 3D TEE correctly identified the location of scallop/segment prolapse in 34 of 36 patients (94%). However, in 6 of these patients 3D TEE images revealed more scallops or segments with prolapse than the surgeon noted intraoperatively. Prolapse of these areas was less prominent and this could possibly explain the lack of correlation with the surgical findings in these patients. In another 2 patients areas of prolapse seen by the surgeon were missed by 3D TEE because some of those scallops/segments could not be well imaged due to image “drop out” and artifacts. Thus, perfect correlation between 3D TEE and surgery was noted in 28 of 36 (78%) patients. Noncoaptation of the MV was also identified in 2 patients. The prolapsed area of posterior (n = 28 observations) and anterior (n = 9 observations) MV leaflets ranged from 1 cm2 to 9 cm2 (mean 3.50 cm2± 2.14) and 1.20 cm2 to 5.99 cm2 (mean 3.21 cm2± 1.33), respectively. Interobserver and intraobserver agreement for location and area of MVP was excellent (r = 0.97 and r = 0.99, respectively; all P values are <0.0001). In conclusion, 3D TEE is useful in identifying the location of MVP. It may also be potentially useful in assessing the extent of individual scallop/segment prolapse and identifying sites of MV noncoaptation. This information could aid the surgeon in deciding the extent of MV resection. (ECHOCARDIOGRAPHY, Volume 20, February 2003)

Incremental Value of Three‐Dimensional Echocardiography Over Transesophageal Multiplane Two‐Dimensional Echocardiography in Qualitative and Quantitative Assessment of Cardiac Masses and Defects

In the present study, we compared three‐dimensionally (3‐D) reconstructed images with multiplane two‐dimensional (2‐D) transesophageal echocardiographic (TEE) images in 17 patients with various cardiac masses and defects. To overcome the problem of making measurements from 3‐D reconstructed images, we carefully “dissected” the 3‐D dataset using paraplane and anyplane 2‐D sections, which were then used to obtain the maximum sizes of the cardiac masses and defects. Of the 15 vegetations and 9 abscesses detected by 3‐D TEE in 7 patients, only 8 (53%) vegetations and 4 (44%) abscesses were detected by multiplane 2‐D TEE (P < 0.02). Also, the exact anatomical location, shape, geometry, and extent of various cardiac masses and defects were more clearly delineated by 3‐D than 2‐D TEE. The maximum dimensions of cardiac masses and defects were larger by 3‐D than by 2‐D TEE in 17 (89%) of the 19 lesions available for comparison (P < 0.002). In addition, 3‐D TEE correlated more closely than 2‐D TEE when compared to surgical measurements in three patients in whom they were available. Thus, it would appear that in several instances, the exact size of the cardiac lesion could only be assessed by analysis of the 3‐D volumetric dataset. Out preliminary study has demonstrated the superiority of transesophageal 3‐D reconstruction over multiplane 2‐D TEE in both qualitative and quantitative assessment of various cardiac mass lesions and pathological defects.

Three‐Dimensional Transesophageal Echocardiographic Demonstration of Anatomical Defects in AV Septal Defect Patients Presenting for Reoperation

We present two‐ and three‐dimensional transesophageal echocardiographic findings of two adult patients who presented for reoperation after previous repair of a partial atrioventricular (AV) septal defect. Both patients had a cleft in the left AV valve with severe regurgitation. One patient had an additional 10 × 5 mm defect connecting the left ventricle to the right atrium through the AV junction. Three‐dimensional echocardiography was superior to two‐dimensional echocardiography in comprehensively delineating the anatomical defects in the left AV valve and the AV junction. (ECHOCARDIOGRAPHY, Volume 20, January 2003)

Usefulness of Live/Real Time Three‐Dimensional Transthoracic Echocardiography in the Characterization of Ventricular Septal Defects in Adults

In this report, we present 12 patients (range 14–76 years, mean 40 ± 22.7 years) who underwent surgical repair of a ventricular septal defect (VSD). Location, size, and surrounding anatomy of the VSD were assessed prior to intervention in all patients with live/real time three‐dimensional transthoracic echocardiography (3DTTE). In 9 patients, measurements of maximum dimension, circumference, and area by 3DTTE correlated well with the same measurements from intraoperative three‐dimensional transesophageal echocardiographic (3DTEE) reconstruction. 3DTTE measurement of maximum dimension of VSDs also agreed well with maximum dimension by surgery in 10 patients. Live/real time 3DTTE accurately defined VSD location, size, and surrounding anatomy in all patients studied by us. VSD characterization by live 3DTTE agreed well with surgery descriptions and 3DTEE measurements.

Intraventricular Tunnel Repair of Double Outlet Right Ventricle

Double outlet right ventricle (DORV) may be divided into subsets according to the position and commitment of the ventricular septal defect (VSD) to the great arteries. In DORV with subaortic VSD, an intraventricular tunnel repair is the recommended operation. The current hospital mortality is 5% with an actuarial survival of 83% at 15 years. DORV with doubly committed VSD should also be repaired with an intraventricular tunnel, and the surgical results are similar to those for DORV and subaortic VSD. In DORV with subpulmonary VSD, an intraventricular tunnel repair is advisable when the distance from the tricuspid to the pulmonary valve exceeds the distance from tricuspid to aortic valve. Otherwise, a spiral intraventicular tunnel or an arterial switch procedure should be considered. In DORV with doubly committed VSD, the results of surgical treatment have been less good, and alternative forms of surgical treatment require further evaluation. The surgical treatment of DORV with pulmonary stenosis and the surgical details of the intraventricular tunnel repair are discussed.

Transesophageal Three-Dimensional Echo Assessment of Sinus Venosus Atrial Septal Defect

The incremental value of three‐dimensional echocardiography over transesophageal multiplane two‐dimensional imaging in the assessment of sinus venosus atrial septal defect is demonstrated in the present study.

Transesophageal Echocardiographic Findings of a Dehisced Duran Mitral Annuloplasty Ring

We describe multiplane transesophageal echocardiographic findings in a patient with severe mitral regurgitation secondary to dehiscence of a Duran ring.

Surgical Treatment of Double Inlet Ventricle (“Single Ventricle”)

The surgical techniques described are the result of an evolution over a number of years in the performance of the septation operation and the modified Fontan-Kreutzer repair for patients with double inlet ventricles. Those with associated pulmonary stenosis are best palliated by a classical Blalock-Taussig or Goretex shunt if an operation is required during the first few years of life and later, between two and four years of age, definitive repair by the modified Fontan-Kreutzer operation is advised. Although controversial, we prefer the use of a large nonvalved right atrial-pulmonary artery connection. Ventricular septation remains the best definitive surgical option when pulmonary stenosis is absent or mild. It is contraindicated by severe pulmonary vascular disease and also by less than moderate ventricular enlargement. The need for concomitant AV valve replacement and the use of an extracardiac conduit are associated with increased hospital mortality in our experience. Infants identified during the first year of life who do not have pulmonary stenosis are a difficult subset to manage. If the VSD and subaortic area is large and unobstructed, pulmonary artery banding early in life will control pulmonary vascular resistance and from this standpoint, permit these patients to become ultimately suited to a modified Fontan-Kreutzer repair. Unfortunately, ventricular hypertrophy usually results from pulmonary artery banding and has been associated with higher hospital mortality at the time of definitive repair. When pulmonary artery banding is undertaken for this subset, debanding and definitive repair seems best advised at about two years of age. Pulmonary artery banding is well known to accelerate the development of subaortic stenosis by spontaneous progressive restriction of the VSD. This results in small ventricular cavity size and increased ventricular hypertrophy, which are incremental risk factors for increased hospital mortality by either definitive procedure. When the VSD or subaortic area is narrow and the patient is identified during the first year of life, isolated pulmonary artery banding is inappropriate. The surgical options for these patients include Eberts two-stage management program consisting of the initial placement of a loose partial septation patch with concomitant pulmonary artery banding, and later debanding and complete septation. Alternatively, a trial of primary complete septation may be warranted, or the use of a procedure consisting of division of the main pulmonary artery with distal closure and anastomosis of the proximal portion to the side of the ascending aorta, coupled with a systemic-pulmonary artery shunt.

Transesophageal Echocardiographic Findings in Primary Leiomyoma of Inferior Vena Cava

We describe for the first time the usefulness of transesophageal echocardiography for the identification of a primary leiomyoma of the inferior vena cava, which originated near its junction with the right atrium. A portion of the tumor was initially visualized in the right atrium during a transthoracic echocardiographic study, but its attachment in the inferior vena cava was evident only by transesophageal echocardiography using the transgastric approach. (ECHOCARDIOGRAPHY, Volume 10, November 1993)