Edward F. Mahan

Utility of transesophageal echocardiography in interatrial septal puncture during percutaneous mitral balloon commissurotomy

Percutaneous mitral balloon commissurotomy is an alternative to surgical therapy in selected patients with symptomatic mitral stenosis.1 Transseptal cardiac catheterization is the most common approach and complications are rare with experienced personnel but include perforation of the aorta, atria and left ventricular wall.2 Transthoracic 2-dimensional echocardiography has also been used to guide balloon valvuloplasty catheters as well as the transseptal needle across the atrial septum3 but may be limited by an inadequate acoustic window, transducer and catheter images superimposed in the fluoroscopic field and suboptimal atrial septum and fossa ovalis visualization. In contrast, transesophageal echocardiography (TEE) encounters minimal acoustic impedance due to lung or skeletal tissue and yields very high quality images.4 Using TEE, successful visualization of the atrial septum and the membranous portion of fossa ovalis is practically always achieved. The purpose of the current study is to evaluate the usefulness of TEE as an aid to transseptal cardiac catheterization during balloon commissurotomy.

Usefulness of transesophageal echocardiography in the diagnosis of ventricular septal rupture secondary to acute myocardial infarction

Abstract Ventricular septal rupture is a rare complication of acute myocardial infarction and is usually fatal if not surgically repaired. 1 Two-dimensional 2 and color Doppler 3–6 surface echocardiography are sensitive in its detection, but their main limitation is the presence of small acoustic windows in some patients. However, the recently introduced technique of transesophageal echocardiography has circumvented this limitation to a large extent. This study evaluates the usefulness of color Doppler transesophageal echocardiography in the diagnosis of ventricular septal rupture after acute myocardial infarction.

Aortic and mitral valve perforation: Diagnosis by transesophageal echocardiography and Doppler color flow imaging

Fig. 4. Diagram of two shunts. Long arrows indicate shunt through the atrioventricular defect (bidirectional); short arrows indicate flow through the patent foramen ovale (continuous and unidirectional). Black-headed arrows indicate systolic flow; open-headed arrows indicate diastolic flow. D, Diastolic flow; LA, left atrium; LV, left ventricle; M, mitral valve; RA, right atrium; RV, right ventricle; S, systolic flow; T, tricuspid valve.

Transesophageal echocardiographic assessment of congenital coronary artery to coronary sinus fistulas in adults

Coronary artery to coronary sinus fistula is a rare congenital disorder. Aortography and selective coronary angiography are currently the diagnostic modes of choice for the evaluation of congenital coronary artery fistulas, but recent reports have demonstrated the usefulness of noninvasive techniques.1–3 We describe 3 patients in whom the relatively new technique of transesophageal echocardiography was found useful not only in the diagnosis and precise localization of these lesions but also in the intraoperative evaluation of the surgical repair (Table I, Figures 1 to 3). All transthoracic 2-dimensional and color Doppler examinations were done in the standard manner using a commercially available system and a 2.0 or 2.5 MHz transducer.4 Intraoperative transesophageal echocardiographic studies were also performed in the standard manner5 using a 5 MHz transducer (Hewlett-Packard 77760A system for patients 1 and 2 and Aloka 870 biplane system for patient 3). The proximal coronary arteries were examined using the standard basal shortaxis view6 and the coronary sinus outlined in the right ventricular inflow plane.

Live/Real Time Three‐Dimensional Transesophageal Echocardiography in Percutaneous Closure of Atrial Septal Defects

This study assessed the ability of live/real time three‐dimensional transesophageal echocardiography (3DTEE) in measuring (1) atrial septal defect (ASD) maximum dimension, area, and adjacent rim size, (2) ASD occluder left and right atrial disk size, (3) length of contact between the left atrial (LA) disk and the aorta, and in (4) assessing device related complications such as residual shunt, device embolization, and device encroachment upon adjacent cardiac structures.

Heparin and Infarct Coronary Artery Patency After Streptokinase in Acute Myocardial Infarction

Anticoagulant therapy is frequently used after thrombolytic agents in the treatment of acute myocardial infarction (AMI) although it is unclear that such therapy will prevent subsequent infarct vessel reocclusion. The role of duration of heparin therapy in maintaining infarct artery patency was studied retrospectively in 53 consecutive AMI patients who received streptokinase therapy and underwent coronary angiography acutely and at 14 +/- 1 days. Of the 39 patients with initial infarct vessel patency, patency at follow-up angiography was observed in 100% (22 of 22) of those who received greater than or equal to 4 days of intravenous heparin but in only 59% (10 of 17) of those patients who received less than 4 days of heparin (p less than 0.05). Of the 14 patients not initially recanalized after streptokinase, patent infarct-related arteries at follow-up angiography were found in 3 of 8 (38%) treated with greater than or equal to 4 days of heparin therapy but in none of the 6 patients treated for less than 4 days (difference not significant). No significant difference in hemorrhagic complications was noted between the short- and long-term heparin treatment groups. Thus, greater than or equal to 4 days of intravenous heparin therapy after successful streptokinase therapy in AMI is more effective in maintaining short-term infarct vessel patency than a shorter duration of therapy and it may maintain the short-term patency of the infarct vessel in those patients who later spontaneously recanalize.

Value and limitations of color doppler echocardiography in the evaluation of percutaneous balloon mitral valvuloplasty for isolated mitral stenosis

The limitations of 2-dimensional and pulsed Doppler echocardiography in patients undergoing mitral valvuloplasty are well known. This study was undertaken to assess the value of color Doppler flow imaging in 36 symptomatic mitral stenosis patients who subsequently underwent successful balloon mitral valvuloplasty by comparing the results to those obtained at cardiac catheterization. Color Doppler-guided conventional Doppler assessment agreed well with cardiac catheterization results in classifying mitral stenosis as mild, moderately severe and severe, both before and after valvuloplasty. Color Doppler was also useful in identifying patients who had moderate to severe mitral regurgitation before and after valvuloplasty. Color Doppler flow mapping was more sensitive than oximetry in the detection of iatrogenic atrial septal defects, which were noted in 25 patients. The defects of those patients with smaller defects by color Doppler (diameter less than 0.7 cm) or echocardiographic shunt volume less than 0.7 liters/min tended to close, usually within 6 months, as opposed to those with larger defects or higher shunt volumes, which tended to persist. Echocardiographic shunt volumes revealed a fair correlation with oximetric results.

Superior vena cava, right pulmonary artery or both: real time two- and three-dimensional transthoracic contrast echocardiographic identification of the echo-free space posterior to the ascending aorta.

We describe the usefulness of contrast echocardiography and live/real time three‐dimensional transthoracic echocardiography in characterizing the normal structures imaged posterior to the proximal ascending aorta as superior vena cava, right pulmonary artery, or both.