George R. Leopold

Comparison of Ultrasound and Cineangiographic Measurements of the Mean Rate of Circumferential Fiber Shortening in Man

It has been shown that cineangiographic measurement of the mean rate of circumferential fiber shortening (mean VCF) at the minor left ventricular equator is a reliable method for evaluating the mechanics of cardiac performance. Since fiber shortening can be derived from the echocardiogram, we sought to validate the measurement of mean VCF by this noninvasive technic in patients studied by both methods. In 15 patients considered to have normal left ventricular function, the average mean VCF determined by ultrasound was 1.29 ± 0.23 circumferences/sec, while in the 13 patients with reduced left ventricular performance this value was 0.75 ± 0.16 circumferences/sec (P < 0.001). Values of mean VCF by the two technics were similar and separated normal from abnormal ventricular function in 27 of 28 patients. The average mean velocity of posterior wall motion was 4.7 ± 1.1 cm/sec in normal patients and 3.9 ± 1.3 cm/sec in abnormals, but posterior wall velocities did not correlate well with either ultrasound or cineangiographic determinations of mean VCF. Ejection fraction calculated from ultrasound measurements correlated significantly with the ejection fraction calculated by cineangiography (r = 0.83, P < 0.0001). The ejection fraction and mean VCF, as determined by ultrasound in the 28 patients, correlated well (r = 0.92, P < 0.0001), but there were six discordant points.From these studies we conclude that the ultrasound determination of mean VCF is a valid method for distinguishing normal from abnormal myocardial performance of the left ventricle. These data also support the use of ultrasound in determining ejection fraction. Estimation of posterior wall velocity, although perhaps useful in the serial study of the same patient, seems limited in its ability to assess cardiac performance accurately.

Noninvasive evaluation of ventricular hypertrophy in professional athletes.

Athletes often exhibit ECG findings which are considered to be abnormal. Therefore, we used noninvasive graphic methods to study 42 active professional male basketball players, ranging in age from 21 to 31 years, without clinically evident heart disease. Of the 42, 11 (25%) met the Romhilt-Estes ECG voltage criteria for left ventricular hypertrophy, and 12 (29%) satisfied VCG criteria for left ventricular enlargement; nine (21%) had left ventricular hypertrophy by both methods. In 33 subjects (79%) the 0.04 sec vector in the horizontal plane was anterior, and 29 of these exhibited one or more standard criteria for right ventricular hypertrophy by ECG, while 18 satisfied VCG criteria for right ventricular enlargement; the ECG and VCG were concordant for right ventricular hypertrophy in 16 subjects (38%). Submaximal treadmill exercise tests (Bruce protocol) were normal in eight athletes, while in one subject ventricular premature beats occurred during the test. In 24 of 25 athletes (96%) from whom phonocardiograms were obtained a third heart sound was recorded, while in 14 (56%), a fourth heart sound was present. Of the 14 athletes who had a fourth heart sound, 12 (86%) had either ECG or VCG evidence of ventricular hypertrophy. Only four of 23 athletes had an increased cardiothoracic ratio (> .50) on routine chest X-ray.Ten athletes and ten control subjects matched for height, weight and body surface area had echocardiograms satisfactory for analysis. The left ventricular end-diastolic dimension in the athletes averaged 53.7 ± 1.3 (SE) mm compared with a value of 49.9 ± 0.7 mm in the control subjects (P < 0.02), and was increased (> 56 mm) in four. Left ventricular posterior wall thickness averaged 11.1 ± 0.6 mm, compared with a value of 9.8 ± 0.5 mm in the control subjects (P < 0.05), and was increased (. 11 mm) in six athletes. The right ventricular end-diastolic dimension averaged 20.8 ± 1.1 mm compared with a value of 12.9 ± 2.2 mm in the controls (P < 0.004), and was increased (> 23 mm) in four athletes. No athlete or control subject exhibited paradoxical septal motion. In the athletes, ejection fraction (cube method) averaged 79 ± 2.0% and mean Vcf averaged 1.13 ± 0.04 circ/sec; these values did not differ from those of the control subjects. Thus, both right and left ventricular enlargement (“physiological hypertrophy”) are often present in the well-trained athlete, but left ventricular performance remains normal in the basal state in such individuals. We conclude that these individuals represent a selected subgroup of subjects who are variants of normal.

Induction of ovulation and pregnancy with pulsatile luteinizing hormone releasing factor: dosage and mode of delivery *

The efficacy of intravenous and subcutaneous routes for pulsatile delivery of differing dosages of synthetic luteinizing hormone releasing factor (LRF) for ovulation induction were evaluated sequentially in two patients with presumed deficiency of endogenous LRF: isolated gonadotropin deficiency and pituitary stalk transection with hyperprolactinemia. Observations were made of the amplitude and duration of the induced LH-FSH pulses, of follicular growth and ovulation (via ultrasound), and of ovarian steroids. Remarkable differences in each of these parameters were found between the two modes of LRF delivery. LRF pulses administered subcutaneously resulted in inappropriate gonadotropin secretion, arrest of follicular development, elevated ratios of E 1 /E 2 and androgens/estrogens, and the appearance of acne—features of polycystic ovary syndrome. In contrast, the first intravenous course of pulsatile LRF induced orderly follicular maturation and ovulation with subsequent pregnancy in both subjects. From these findings we conclude that, in these patients, the intravenous mode of delivery of LRF pulses was superior to the subcutaneous route at all doses tested.

High-Resolution Ultrasonography of Scrotal Pathology

A prototype high-resolution (10-MHz) real-time ultrasonic system was used to study 22 patients who were ultimately proved to have intra- and extratesticular tumors, scrotal fluid collections, and inflammatory processes. In 5 of 6 patients with primary testicular masses, there were areas of decreased echogenicity within the testis when compared with surrounding normal tissue. In general, the method was highly effective in differentiating and characterizing testicular and extratesticular processes.

Second-trimester echogenic bowel and chromosomal abnormalities

OBJECTIVE Our objective was to examine the outcomes of pregnancies in which echogenic bowel was detected in the second trimester. STUDY DESIGN Twenty-two cases with a prospective diagnosis of echogenic bowel were reviewed. Karyotypic studies were performed in 19 cases, and 17 families had deoxyribonucleic acid-based risk assessment for cystic fibrosis. The echogenicity of the bowel was retrospectively reviewed and graded as mild or bright. RESULTS Five cases of trisomy 21 and one case of trisomy 18 were detected; four of these had other ultrasonographic abnormalities. Twenty-seven percent of fetuses with echogenic bowel were aneuploid. Risk was greatest for cases with brightly echogenic bowel. No cystic fibrosis mutations were detected. The diagnosis of echogenic bowel was reproducible. CONCLUSION Brightly echogenic bowel in the second trimester was found to be associated with a significant risk of fetal aneuploidy.

Lipomatous tumors of the kidney and adrenal: apparent echographic specificity.

Several fatty tumors of the kidney and adrenal gland were evaluated by gray scale ultrasound. An extremely dense echogenic pattern was common to all lesions. There were three solitary angiomyolipomata (renal hamartoma), a presumed diffuse hamartomatous involvement of the kidney in a patient with tuberous sclerosis, and one myelolipoma of the adrenal gland. This marked echogenicity is thought to be a feature of fatty tumors and enables relatively specific preoperative diagnosis of these lesions, all of which are benign. With regard to renal angiomyolipoma, this assessment may allow conservative treatment and preservation of functioning renal tissue.

Multiple Crystal Cross-Sectional Echocardiography in the Diagnosis of Cyanotic Congenital Heart Disease

A new multiple crystal echocardiographic system was used to assess cross-sectional cardiac anatomy in real time in fifty infants and children with cyanotic heart disease, and the findings were compared to normals. Four standard transducer positions were employed to evaluate sagittal and transverse cardiac cross-sections. Studies in patients with tetralogy of Fallot demonstrated an enlarged aorta overriding the septum with preservation of mitral-aortic continuity. In the absence of pulmonary atresia the main pulmonary artery could be identified in all of these patients. The diagnosis of d-transposition of the great vessels was established by viewing great vessel orientation in transverse section at the second intercostal space and observing a rightward and anteriorly placed great artery. In sagittal projections a retrosternal aorta and mitral-pulmonic continuity was observed. In one patient with d-transposition, apposition in systole of the ventricular septum and anterior leaflet of the mitral valve was identified as the cause of left ventricular outflow tract obstruction. Descriptions are provided of the findings in patients with l-transposition, double outlet right ventricle, and truncus arteriosus. The new multiscan method allows a substantially more precise determination of intra- and extra-cardiac spatial relationships than single crystal techniques. Multiscan echocardiography is safe, widely applicable, and provides clinically important information to assist in the diagnosis and management of infants and children with cyanotic heart disease.

The Dilated Pancreatic Duct: Ultrasonic Evaluation

Eight patients with signs and symptoms of obstructive jaundice were evaluated by gray-scale echography. In each, ultrasonic identification of a dilated pancreatic duct was helpful in confirming the diagnosis of an obstructing lesion at the level of the ampulla of Vater. In only 3 could the tumor mass itself be seen on ultrasound. With the recognition of pancreatic duct dilatation, it is no longer essential for a tumor in the region of the ampulla of Vater to be large or contour-deforming before it can be identified by ultrasound.

Multiple Crystal Echocardiographic Evaluation of Endocardial Cushion Defect

A prototype multiple crystal echocardiographic system developed by Bom and associates was used to evaluate cross-sectional cardiac anatomy in real time in twenty infants and children with endocardial cushion defect (ECD). The findings were compared to fifty normal infants and children and nineteen patients with normal mitral valve anatomy but right ventricular enlargement (RVE). Three standard transducer positions for evaluation of sagittal and transverse cardiac cross-sections are outlined and the normal group and RVE subgroup described. Studies in patients with ECD demonstrated several distinctive abnormalities, consisting of multiple echoes in the mitral valve area, anterior mitral leaflet - septal apposition in diastole with reduced posterior motion in systole, and reduced excursion of the anterior mitral leaflet. In patients with complete atrioventricular (A-V) canal defects, the anterior leaflet was often observed passing across the plane of the ventricular septum into the right ventricle during diastole, and in some of these patients the anterior mitral leaflet was related to the tricuspid annulus. Multiple crystal cardiac ultrasonography allows a more precise determination of intra- and extracardiac spatial relationships and is easier to perform than single crystal echo. The new technique provides clinical information helpful in evaluating patients with possible ECD and gives some indication of the severity of the defect.

Ultrasonic imaging of the carotid arterial system

The ability of a B-mode, real-time, high frequency ultrasonic imager to diagnose carotid arterial disease was evaluated in 81 carotid arteries. The imager was relatively sensitive in detecting the presence of significant stenosis but was relatively insensitive in its ability to quantitate the degree of stenosis. The imager was unable to detect the presence of ulcerations. The oculoplethysmograph had a greater sensitivity, specificity and accuracy than the ultrasonic imager in diagnosing carotid arterial stenosis in the same group of patients. Ultrasonic imaging appears to be useful as a screening test of cerebrovascular disease when used in combination with the oculoplethysmographic test.