Benjamin F. Byrd

Two-dimensional echocardiography in the diagnosis of carcinoid heart disease

Tricuspid valve disease accounts for significant morbidity and mortality in the carcinoid syndrome, but M-mode echocardiography is often insensitive in completely defining the tricuspid valve. We performed two-dimensional echocardiography (2DE) in seven patients with proven carcinoid syndrome. There were five males and two females whose ages ranged from 53 to 79 years. The carcinoid syndrome had been present by symptoms for 12 to 84 months and by 5-HIAA levels for 6 to 84 months prior to 2DE. Short, thickened, immobile tricuspid valve leaflets, fixed in a partially open position, were visualized in two patients and confirmed in one patient at surgery. Tricuspid regurgitation was demonstrated angiographically in one and by contrast 2DE in the other. A third patient had clinical evidence of tricuspid stenosis with a doming tricuspid valve on 2DE. The motion of the tricuspid value viewed in real time was clearly distinct in these two situations. Four patients had both normal M-mode and 2DE studies despite the fact that clinical and biochemical evidence of carcinoid disease had been present for equally long periods of time. The tricuspid valve was best visualized in the parasternal right ventricular long-axis and short-axis views. The apical four-chamber view was less helpful. Thus, 2DE demonstrated specific tricuspid valve abnormalities in the carcinoid syndrome with thickening, shortening, and immobility of the leaflets when valvular regurgitation was present and thickening and doming when the valve was stenotic. 2DE should be a useful method in the diagnosis and sequential evaluation of patients with carcinoid heart disease.

Breast cancer report

The recent increased public awareness of the necessity for early diagnosis of breast cancer has been accentuated by an intense exposure by the news media centering about the disease. This publicity includes the unfortunate but timely clinical sources of the wives of the President and the Vice President of the United States, Mrs. G. F. Ford and Mrs. N. A. Rockefeller. This paper attempts to quantitate in a subjective manner the impact of the events on the American public by comparing the incidence of operative procedures in similar populations in the Nashville community during October through December, 1973, and October through December, 1974, the latter period following the operative procedures upon Mrs. Ford and Mrs. Rockefeller. A statistically significant increase was noted in patients seen, biopsies performed, and cancers detected.

Right ventricular plasticity and functional imaging

Right ventricular (RV) function is a strong independent predictor of outcome in a number of distinct cardiopulmonary diseases. The RV has a remarkable ability to sustain damage and recover function which may be related to unique anatomic, physiologic, and genetic factors that differentiate it from the left ventricle. This capacity has been described in patients with RV myocardial infarction, pulmonary arterial hypertension, and chronic thromboembolic disease as well as post-lung transplant and post-left ventricular assist device implantation. Various echocardiographic and magnetic resonance imaging parameters of RV function contribute to the clinical assessment and predict outcomes in these patients; however, limitations remain with these techniques. Early diagnosis of RV function and better insight into the mechanisms of RV recovery could improve patient outcomes. Further refinement of established and emerging imaging techniques is necessary to aid subclinical diagnosis and inform treatment decisions.

Optimal Albunex Dosing for Enhancement of Doppler Tricuspid Regurgitation Spectra

Intravenous albunex was more effective than agitated saline in enhancing incomplete Doppler echocardiography spectra for tricuspid regurgitation without a significant alteration in the maximal detected velocity. The optimal dose was 1 to 4 ml in most patients, using an initial dose of 1 ml and titrating further dosing on the basis of the initial contrast effect.

Feasibility and Diagnostic Potential of Pulmonary Transit Time Measurement by Contrast Echocardiography: A Pilot Study

Pulmonary transit time (PTT; the time for ultrasound contrast to travel from the right ventricle [RV] to the left atrium) may provide a single metric that reports on cardiopulmonary function while overcoming some of the challenges of standard echocardiographic measures. We conducted a pilot study to test the feasibility and reproducibility of echocardiographically derived PTT and to determine its association with established measures of cardiopulmonary function.

Mitral valve replacement and endocavitary patch repair for a giant left ventricular pseudoaneurysm.

We present a case of a giant inferior left ventricular (LV) wall pseudoaneurysm. The patient had New York Heart Association class IV heart failure due to severe mitral valve regurgitation and poor LV function. Our operative approach included right thoracotomy, excision of the mitral valve, and patch repair of the pseudoaneurysm neck from inside of the dilated LV cavity followed by mitral valve replacement. Surgery was performed without aortic cross-clamping on a normothermic perfused beating heart. The patient had an uncomplicated cardiac recovery and is doing well 15 months after surgery.

Pulmonary vein Doppler flow patterns specific for elevated left ventricular filling pressures in older cardiac patients are common in healthy adults < 40 years old

In older cardiac patients, elevated left-sided heart filling pressures are predicted by both a systolic PV flow fraction < 40% and a greater duration during atrial systole of reversal flow into the PVs than forward flow through the mitral valve. However, this study shows that these Doppler findings are not uncommon in younger subjects without cardiac disease. Use of these PV Doppler flow parameters to assess LV filling pressures should be limited to older patients.

Doppler Echocardiography in Cardiac Tamponade and Constrictive Pericarditis

Doppler echocardiography has greatly facilitated the assessment of patients with compressive cardiac disease. Patients in whom cardiac tamponade or pericardial constriction are suspected should undergo a complete echocardiographic examination including careful Doppler analysis of transmitral flow and inflow through the hepatic vein or superior vena cava (SVC). Monitoring of both the electrocardiogram and the phase of respiration are an integral part of this examination. Patients with cardiac tamponade exhibit a > 25% reduction in E wave velocity during the first inspiratory cardiac cycle; they exhibit predominant systolic inflow through the hepatic vein or SVC (with a predominant X descent with little or no Y descent). In constrictive pericarditis the pattern of transmitral flow variation is comparable to that observed in cardiac tamponade, however, a prominent Y descent is often observed on hepatic vein or SVC Doppler study. Similar changes with respiration may be observed in mitral inflow in obese patients or in those with chronic obstructive pulmonary disease, however, in these conditions the nadir of E wave velocity is observed 2–3 cardiac cycles after the first inspiratory beat. Restrictive cardiomyopathy may produce a similar systemic venous flow pattern, but increased inspiratory flow reversals and lack of respiratory variation in transmitral flow velocity distinguish it from constrictive pericarditis.

Mixed Aortic Stenosis and Regurgitation Demands Our Attention

As the assessment of aortic valve disease has evolved over the last 60 years, newer methods have largely added to our armamentarium rather than replacing previous ones. In 1951, the Gorlins recognized that what could be measured—pressure gradients—depends not only on orifice size but also on

Congenital heart disease in adults: echocardiographic evaluation of left and right ventricular outflow tract obstruction

Abstract Ventricular outflow tract obstruction commonly occurs as part of complex congenital heart disease syndromes. Outflow tract obstructions of congenital origin are often first diagnosed by echocardiography in adulthood, among patients with no evidence of congenital heart disease in childhood. Such outflow tract obstructions may be of either ventricle, at the valvular, subvalvular, or supravalvular level, and either fixed or dynamic in nature. Echocardiography facilitates both early detection and long term follow-up of these cardiac abnormalities. Advances in echocardiography, such as M-mode echo in the 1970s, 2D echo and color Doppler echo in the 1980s, and transesophageal echocardiography in the past two decades, have made the diagnosis of outflow tract obstruction almost entirely a noninvasive endeavor. Transesophageal echocardiography also has an important role in the operating room when intracardiac tissue is being removed to relieve obstruction. This article describes the pathophysiology of several conditions causing left or right ventricular outflow tract obstruction, with special emphasis on key echo points critical to correct diagnosis and treatment.