Ehud Grenadier

Clinical utility of two-dimensional doppler echocardiographic techniques for estimating pulmonary to systemic blood flow ratios in children with left to right shunting atrial septal defect, ventricular septal defect or patent ductus arteriosus.

Range gated two-dimensional Doppler echocardiographic methods were evaluated for quantifying pulmonary (QP) to systemic (QS) blood flow ratios. Twenty-one patients were studied, 4 with patent ductus arteriosus, 6 with atrial septal defect and 11 with ventricular septal defect. The Doppler pulmonary to systemic flow (QP:QS) estimation method involved calculating volume flow (liters/min) at a variety of intracardiac sites by using imaging information for flow area and Doppler outputs to calculate mean flow velocity as a function of time. Area volume flows were combined to yield QP:QS ratios. The sites sampled were main pulmonary artery, ascending aorta, mitral valve orifice and subpulmonary right ventricular outflow tract. The overall correlation between Doppler QP:QS estimates and those obtained at cardiac catheterization (n = 18) or radionuclide angiography (n = 3) was r = 0.85 (standard error of the estimate = 0.48:1). These preliminary results suggest that clinical application of this Doppler echocardiographic method should allow noninvasive estimation of the magnitude of cardiac shunts.

Normal intracardiac and great vessel doppler flow velocities in infants and children

Normal two-dimensional pulsed Doppler echocardiographic velocity profiles for sites within the heart and great vessels in a group of 102 normal infants and children are presented. Qualitatively, waveforms mimic expected hemodynamic events at the various sites. All waveforms had a rapid initial deflection followed by spectral broadening after attainment of peak velocity. Quantitative angle-corrected peak velocities were generally lower on the right side than on the left side of the heart. Differences in tricuspid (mean 61.8 cm/s) versus mitral (mean 81.1 cm/s) outflow and pulmonary (mean 76.1 cm/s) versus aortic (mean 88.5 cm/s) outflow were significant (p less than 0.01). The only significant age-related differences were in the pulmonary artery (mean for newborns 67.7 cm/s versus 79.6 cm/s for older children, p less than 0.01). Aortic data obtained from interrogation sites in which flow was close to 0 or 180 degrees were similar, whereas aortic peak velocity data obtained from apical long-axis or subcostal views were greater. These differences were probably induced from inaccuracies in azimuthal (elevational) angles that cannot be measured. These normal Doppler data should be useful for comparisons with data obtained for children with various forms of congenital heart disease that affect flow dynamics.

Two-dimensional echo Doppler study of congenital disorders of the mitral valve.

To define the use of two-dimensional echocardiography (2DE) and Doppler methods for diagnosis of forms of congenital mitral stenosis, we studied 16 children, age range 2 months to 13 years, with congenital deformities of the mitral valve documented at cardiac catheterization. Thirteen had additional congenital heart defects, most commonly aortic stenosis or aortic coarctation. In eight patients features of mitral valve anatomy were observed and described during cardiac surgery and in one child the anatomy was verified by postmortem examination. 2DE studies allowed anatomic subclassification of 10 valves which had asymmetric or single dominant papillary muscles (parachute) and six which had arcade mitral valve attached by short chords to multiple diminutive papillary muscle heads. All patients echoes exhibited shortened and thickened mitral chordae and doming of the mitral leaflets during diastole, and seven children had restricted mitral orifices imaged on the short-axis imaging plane. All seven of the patients studied by Doppler echocardiography had increased maximal transmitral inflow velocity (range 111 to 260 cm/sec) greater than the 95% confidence limits for mitral flow velocities in 34 normal children who served as the control group. Our study suggests that 2DE studies, especially when combined with Doppler interrogation, are sensitive for defining forms of congenital mitral stenosis.

Detection of deterioration or infection of homograft and porcine xenograft bioprosthetic valves in mitral and aortic positions by two-dimensional echocardiographic examination

Results of two-dimensional echocardiographic examinations were compared with angiographic, hemodynamic and surgical results in 44 patients with bioprosthetic valves in mitral and aortic positions who were undergoing elective or urgent reinvestigation 24 to 87 months (mean 34) after implantation. In these patients, there were 18 homograft aortic valves in the aortic position, 9 stent-mounted homograft aortic valves in the mitral position, 13 porcine xenograft valves in the mitral position and 12 in the aortic position. Poor cusp support, gross fluttering and prolapse of cusps behind or below the anulus identified aortic insufficiency by two-dimensional echocardiography in six patients with an aortic homograft and four patients were identified with insufficiency of a stent-mounted aortic homograft in the mitral position. Two-dimensional echocardiographic examination revealed mitral stenosis in three patients with a porcine xenograft valve in the mitral position and suggested mitral insufficiency in two others. Bacterial endocarditis on homograft or porcine xenograft valves was associated with easily imaged vegetations by two-dimensional echocardiography in 10 patients. Despite difficulties in imaging valve cusps, and the skill required to obtain good echocardiographic images of bioprosthetic valves, significant valve deterioration or infected prostheses were quite effectively imaged by two-dimensional echocardiography in this study.

Prognostic value of left ventricular size measured by echocardiography in infants with total anomalous pulmonary venous drainage

Abstract Left ventricular size may be a determinant of survival in infants with total anomalous pulmonary venous drainage. Right and left ventricular size were measured by M-mode and 2-dimensional (2-D) echocardiography in 13 patients aged 1 day to 4 months (mean weight 4.3 ± 0.42 kg [standard error of the estimate]) who underwent surgery before age 4 months because of severe cyanosis or cardiac failure. Seven patients had venous drainage to a vertical vein, 4 had drainage to the right atrium, and 2 had drainage to the inferior vena cava. Patients were divided into 2 groups: survivors (Group A, n = 8) and nonsurvivors (Group B, n = 5). Death was not statistically related to pulmonary artery pressure, pulmonary venous obstruction, age, or weight at the time of surgery. Right and left ventricular sizes at end-diastole measured from M-mode traces and 2-D echocardiographic 4-chamber views were compared with those from 15 weight-matched control infants. On M-mode and 2-D echocardiography, nonsurvivors had significantly larger right ventricles and smaller left ventricular dimensions than did either control subjects or surviving patients with total anomalous pulmonary venous drainage. The ratio of right to left ventricular size on M-mode and 2-D echocardiography also differed among the 3 infant groups (p

Two-dimensional echocardiography for evaluation of metastatic cardiac tumors in pediatric patients.

We have studied five patients with metastatic cancer in whom two-dimensional echocardiography (2DE) demonstrated cardiac or pericardial involvement. Echo studies may guide the clinician in instituting and/or modifying cardiac and cancer therapy in such patients.

Two-dimensional echocardiographic study of right ventricular outflow and great artery anatomy in pulmonary atresia with ventricular septal defects and in truncus arteriosus

In this study, we reviewed M-mode and two-dimensional (2DE) echocardiographic observations in 13 patients with pulmonary atresia with ventricular septal defect and in six patients with truncus arteriosus in order to attempt to identify echocardiographic features distinguishing these two abnormalities in which no anatomic connection exists between the right ventricle and the pulmonary artery. M-Mode features compatible with the diagnosis of pulmonary atresia with a ventricular septal defect (VSD) were a small but identifiable space anterior to the aorta and/or immobile pulmonic valve echoes appearing to open during diastole rather than systole. By 2DE, the proximal and distal segments of the right ventricular outflow tract could be imaged and the length of the atretic segment estimated. In truncus arteriosus, no outflow tract of the right ventricle could be identified by 2DE or M-mode echocardiography, and the origin of the pulmonary artery from the truncus could be imaged directly in four patients with type I and in one patient with type II truncus. Abnormalities of the truncal valve were also present and were imaged by 2DE in three of our five patients. Our study identified specific echocardiographic criteria for diagnosing truncus arteriosus and pulmonary atresia with VSD and for differentiation between them.

Serial two-dimensional echocardiography for detection of coarctation of the aorta in the postnatal period

SummaryWe describe the ultrasound appearance of postnatal development of an angiographically proven coarctation of the aorta in a full-term infant. The diagnosis of a discrete coarctation was subsequently supported on a repeat two-dimensional echocardiogram, after an initial clinical and two-dimensional study at 6 h of age that had revealed only minimal juxtaductal aortic deformity. We stress the importance of two-dimensional echocardiography as a reliable noninvasive method for detecting the change in aortic contour occurring with ductal closure in infants with predisposing aortic anatomy who will go on to develop coarctation of the aorta.

Left ventricular wall motion abnormalities in Kawasaki's disease

Two-dimensional (2DE) and M-mode echocardiographic examinations were reviewed for 21 patients with Kawasakis disease. Cardiac catheterization including coronary angiography was performed in 14 patients. 2DE detected regional myocardial contraction deficits in four patients later proven to have coronary disease. Coronary aneurysms were detected by echocardiography in two of four patients with proven coronary lesions. Although a minor pericardial effusion was detected in two patients and an increased left ventricular (LV) cavity dimension was found in one patient, M-mode function studies were not helpful for detection of cardiac involvement. ECG and chest x-ray examination were also noncontributory. We conclude that 2DE detection of LV wall contraction abnormalities may be a sensitive method for detecting cardiac contraction abnormalities may be a sensitive method for detecting cardiac involvement in Kawasakis disease. 2DE may be better for assessing LV contraction than for imaging aneurysms in Kawasaki patients.