Benigno Soto

Color Doppler assessment of mitral regurgitation with orthogonal planes.

We evaluated 147 patients with adequate color Doppler and angiographic studies for mitral regurgitation. Sixty-five patients had no mitral regurgitation by both color Doppler and angiography and 82 patients had mitral regurgitation by both techniques. Thus the sensitivity and specificity of color Doppler for the detection of mitral regurgitation was 100%. Three two-dimensional echocardiographic planes (parasternal long and short axis, apical four-chamber view) were used to analyze variables of the mitral regurgitant jet signals in the left atrium. The best correlation with angiography was obtained when the regurgitant jet area (RJA) (maximum or average from three planes) expressed as a percentage of the left atrial area (LAA) obtained in the same plane as the maximum regurgitant area was considered. The maximum RJA/LAA was under 20% in 34 of 36 patients with angiographic grade I mitral regurgitation, between 20% and 40% in 17 of 18 patients with grade II mitral regurgitation, and over 40% in 26 of 28 patients with severe mitral regurgitation. Maximum RJA/LAA also correlated with angiographic regurgitant fractions (r = .78) obtained in 21 of 40 patients in normal sinus rhythm and with no evidence of associated aortic regurgitation. Other variables of the regurgitant jet such as maximal linear and transverse dimensions, maximal area, or maximal area expressed as a percentage of the LAA in one or two planes correlated less well with angiography. Color Doppler is a useful noninvasive technique that is not only highly sensitive and specific in the identification of mitral regurgitation but also provides accurate estimation of its severity.

Evaluation of aortic insufficiency by Doppler color flow mapping

The color Doppler echocardiographic studies and aortic angiograms of all patients who had these procedures performed within 2 weeks of each other between October 1984 and August 1985 were reviewed to determine whether any parameters of the regurgitant jet visualized by color Doppler study predicted the severity of aortic insufficiency as assessed by angiographic grading. Patients with an aortic valve prosthesis were excluded. Twenty-nine patients had aortic insufficiency and had adequate color Doppler studies for analysis. The mean time between color Doppler examination and angiography was 2.3 days (range 0 to 12). The maximal length and area of the regurgitant jet were poorly predictive of the angiographic grade of aortic insufficiency. The short-axis area of the regurgitant jet from the parasternal short-axis view at the level of the high left ventricular outflow tract relative to the short-axis area of the left ventricular outflow tract at the same location best predicted angiographic grade, correctly classifying 23 of 24 patients. However, the jet could be seen from this view in only 24 of the 29 patients. The height of the regurgitant jet relative to left ventricular outflow tract height measured from the parasternal long-axis view just beneath the aortic valve correctly classified 23 of the 29 patients. Mitral stenosis or valve prosthesis, which was present in 10 patients, did not interfere with the diagnosis or quantitation of aortic insufficiency by these methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Repair in Anatomically Corrected Malposition of the Great Arteries

Anatomically corrected malposition of the great arteries is a congenital cardiac malformation in which the atria and ventricles are in concordant relation, as are the ventricles and great arteries, but the aorta is to the left of the pulmonary artery (1-position). The reported cases and our two patients have had situs solitus of viscera and atria. The aortic and pulmonary circulations are in series. We report successful surgical repair in 2 patients with associated large ventricular septal defects and pulmonary stenosis. In one the defect was posterior and in relation to the pulmonary artery which slightly overrode it. In the other the defect was anterior and the aorta overrode it. The developmental basis of these two examples of the same entity is probably different. An appropriate terminology and categorization that is useful surgically is presented.

Axial cineangiography in congenital heart disease. Section II. Specific lesions.

The value of axial cineangiography in several forms of congenital heart disease serves as an illustrated supplement to Section I. These techniques visualize defects in the entire ventricular and atrial septum. In persistent atrioventricular (A-V) canal, it is possible to visualize all parts of both septa, status of the A-V valves (two valves versus a common A-V valve), and if a common A-V valve, its degree of override. In tetralogy of Fallot, the bifurcation of the pulmonary trunk, entire ventricular septum and coronary arteries are vividly shown. The presence of true and confluent pulmonary arteries versus systemic or bronchial arteries in pseudotruncus is clearcut. In double outlet right ventricle or in transpositions with or without double outlet right ventricle, the mitral valve-semilunar valve relationships, the left ventricular outflow tract, subpulmonary region and a straddling tricuspid valve are well demonstrated. In asymmetric septal hypertrophy, biventricular angiography may be circumvented.

Surgical treatment of straddling tricuspid valves.

Six patients whose cardiac malformations included a large ventricular septal defect (VSD) in the inlet portion of the septum and straddling tricuspid valve underwent corrective intracardiac operations. In four patients, both the tricuspid valve annulus and its tensor apparatus occupied part of each ventricle. In one, only the annulus overrode the ventricular septum and in one the annulus was normally positioned, but a portion of the tensor apparatus crossed through the VSD from its origin in the left ventricle. This last patient had related mitral valve incompetence. One patient had an isolated VSD and one had isolated, multiple VSDs and a previously banded pulmonary artery. Associated malformations in the other four included tetralogy of Fallot, double outlet right ventricle, transposition of the great arteries with severe tricuspid incompetence, and corrected transposition. Hypoplasia of the sinus portion of the right ventricle was present to some degree in four patients. Preoperatively the diagnosis was definitively established by axial cineangiocardiograms in three and suspected in one.The straddling tricuspid valve was preserved in the repair in five patients, but tricuspid valve replacement was used in the patient with severe tricuspid incompetence. In one case, intraoperative electrophysiologic mapping studies were performed and showed abnormal conduction pathways.Five patients survived the hospital period. Postoperative cardiac catheterization studies were performed in four, one of whom died 16 months postoperatively from chronic congestive heart failure. The remaining four survivors have had a good clinical result.

Left Ventricular Size and Function and Heart Size in the Year Following Myocardial Infarction

Interrelationships among left ventricular (LV) size, LV function, and heart size were investigated in 49 patients studied 2-12 months after myocardial infarction. LV end-diastolic volume (EDV) and ejection fraction (EF) were determined by biplane ventriculography. Heart size was estimated from chest films by the cardiothoracic ratio (CTR) and cardiac volume (CV) methods. Ventricular function (i.e., EF) was related to chamber size (i.e., EDV), but the correlation coefficient was not high (r = 0.74); thus, chamber size was not an accurate predictor of EF. Because of the close linear relation that exists between LV end-systolic volume and EDV (r = 0.98), a hyperbola describes the relation between EF and EDV. In general, EF was depressed (<0.50) when EDV exceeded 70 ml/m2, was <0.35 when EDV exceeded upper normal limits (110 ml/m2), and was <0.25 with chamber size >150 ml/m2. Thus relatively small chamber size (<150 ml/m2) was associated with a wide range in ventricular function, while large chamber size was associated with severe dysfunction (EF < 0.30). By either heart size method, cardiomegaly (CTR > 0.50 or CV > 540 ml/m2) was not found consistently until EDV exceeded 150 ml/m2. Hence normal heart size was often associated with moderate EF depression (0.49-0.30), while cardiomegaly was often associated with severe dysfunction. Clinical heart failure (CHF) was usually accompanied by EF < 0.30, but chamber size ranged from 101 to 331 ml/m2. Primarily because of this variation in chamber size, both normal heart size and cardiomegaly were at times associated with CHF.The poor correlations of EF with CTR (r = −0.43) and CV (r = −0.52) preclude use of the heart size indices as accurate predictors of LV function. When the data were analyzed according to the presence or absence of cardiomegaly, the following generalizations could be made regardless of the heart size method used. Cardiomegaly was a reasonable indicator of postinfarction LV function, being associated with depressed function and often with CHF. However normal heart size was associated with either normal LV function, or commonly, with depressed function, often not clinically apparent.

Two-dimensional and color doppler assessment of ventricular septal defect of congenital origin

Two-dimensional echocardiography and color Doppler examinations were performed in 53 patients with 58 ventricular septal defects (VSD) proven surgically or anatomically. All patients also had angiocardiograms. Two-dimensional echocardiography/color Doppler examination detected all VSDs and correctly categorized the site and extension of VSDs in 50 of 58 (86%). All 40 perimembranous VSDs were diagnosed in the left ventricular outflow tract short-axis plane as an area of discontinuity adjacent to septal tricuspid valve leaflet attachment. Fourteen of 16 VSDs with inlet extension showed initial color flow signals along the septal tricuspid leaflet and along the ventricular septum. Of 23 perimembranous VSDs with outlet extension, 19 had flow signals moving directly toward the right ventricular outflow tract. One perimembranous VSD with trabecular extension showed flow signals directed anterolaterally toward the right ventricular free wall. Eleven of 13 muscular VSDs were similarly categorized correctly by color Doppler as inlet, outlet and trabecular. All 5 doubly committed VSDs were correctly diagnosed as an area of discontinuity adjacent to the pulmonary valve in the short-axis view with flow signals directly moving through VSD into right ventricular outflow and pulmonary artery. Angiography correctly detected all VSDs and correctly classified their site and extension in 45 of 58 (77.5%). It misclassified 8 of 40 perimembranous, 3 of 13 muscular and 2 of 5 doubly committed VSDs. Color Doppler compares favorably with angiocardiography in the detection and localization of VSDs.

Live Three-Dimensional Transthoracic Echocardiographic Delineation of Patent Ductus Arteriosus

We report an adult patient with a patent ductus arteriosus in whom live three‐dimensional transthoracic echocardiography provided comprehensive assessment of the morphology and pathophysiology of the lesion. (ECHOCARDIOGRAPHY, Volume 21, July 2004)

Angiographic study of univentricular heart of right ventricular type.

An angiographic analysis of 10 cases of univentricular heart of the right ventricular type is reported. This congenital malformation is characterized by a large chamber with right ventricular morphology that receives both atrioventricular valves, and a second, smaller chamber, a trabecular pouch, with left ventricular morphology. These chambers are separated by a posterior septum but are connected by an inlet septal defect. The angiographic studies were done using the angled angiographic techniques in three patients and the standard frontal and lateral angiographic views in seven cases. The atrial situs in seven patients was solitus, in one inversus, and in two it was ambiguus with left isomerism. In seven patients the usually large right ventricular chamber received two atrioventricular valves and in four patients, one atrioventricular valve was straddling. Three patients had atresia of one atrioventricular valve. The trabecular pouch was small in seven patients but relatively large in three. In six patients the trabecular pouch was located posterior and to the left of the right ventricular chamber and in four anterior and to the right. Double outlet right ventricle was present in all cases. The aorta arose anteriorly to the pulmonary artery in nine patients and posteriorly in one. An autopsy was performed in one case and its correlation with the angiographic findings was remarkable. The angiographic demonstration of the anatomicaly details of this entity and its associated anomalies was facilitated by angled angiography.

Surgical Treatment of Double-Outlet Left Ventricle Report of Four Cases

Four patients with double-outlet left ventricle and ventricular septal defect have been successfully corrected surgically. Three of the patients had pulmonary stenosis, and one did not. Three patients had d-position of the great arteries, and one patient had l-position with the aorta anterior and to the left. Surgical correction was accomplished by repairing the ventricular septal defect, closing the connection between left ventricle and pulmonary artery, and creating a conduit between right ventricle and pulmonary artery. The preferred conduit is a composite valved one.