James P. Eichelberger

Aortic Dissection Without Intimal Tear: Case Report and Findings on Transesophageal Echocardiography

Transesophageal echocardiography (TEE) relies on the presence of an intimal flap for diagnosing aortic dissection; however, a small percentage of cases of dissection can occur without apparent intimal disruption. This case reviews unusual echocardiographic features of aortic dissection and previously undescribed echocardiographic findings in a patient with aortic dissection without intimal flap.

The development of valvular strands during thrombolytic therapy detected by transesophageal echocardiography

A case report of a patient who had valvular strands while undergoing treatment with thrombolytic therapy for prosthetic mitral valve thrombosis is presented. The development of valvular strands during thrombolytic therapy provides unique evidence supporting a thrombotic/fibrotic origin to this relatively common finding on transesophageal echocardiography.

Antibiotic Prophylaxis for Endocarditis Prevention During Transesophageal Echocardiography: Controversy, Consideration, and What Really Happens.

A survey was conducted in order to gain a better understanding of actual practice policies followed by academically affiliated institutions regarding the use of prophylactic antibiotics during transesophageal echocardiography. Results revealed that 10 of the 20 centers routinely used intravenous antibiotic prophylaxis for high risk transesophageal echocardiography. However, 5 of the 20 centers did not use any prophylactic antibiotics routinely, and the remaining 5 centers used primarily oral prophylactic regimens. In addition, the type of patient that was considered high risk for which antibiotic prophylaxis was used differed among institutions. Practice guidelines in 4 of the 20 institutions have changed in the last 5 years. These findings demonstrate a wide variation in the actual practice policies of different institutions, probably reflecting, in part, the lack of convincing evidence that prophylactic antibiotics benefit this subgroup of patients.

Echocardiographic Assessment of Epicardial Defibrillator Patch Electrodes

We performed a blinded controlled analysis of transthoracic echocardiograms on IK patients before and after epicardial defibrillator patch electrode placement to determine the accuracy of echocardiography in identifying defibrillator patches and to determine possible echocardiographic findings that may correlate with defibrillator function or perioperative complications. The sensitivity of two‐dimensional echocardiography in detecting defibrillator electrodes was 72% by one observer and 39% by a second observer. Corresponding specificities were 67% and 83%, respectively. The discordance rate was 27%. The echocardiographic finding of patch buckling was not observed, and echocardiographic estimates of the distance from patch to epicardium did not correlate with defibrillator threshold at the time of surgery. We conclude that: echocardiography is only moderately sensitive and specific in identifying epicardial defibrillator electrodes; significant interobserver variability does exist; and echocardiography therefore cannot be used reliably to assess for pericardia] changes or possible complications of patch electrode placement.

Tissue doppler echocardiography: A potential screening tool for anthracycline‐associated cardiotoxicity160

O ver the last 40 years great success has been achieved in the fight against childhood cancer with 5-year survival rates of some childhood cancers now exceeding 85% including ALL and Hodgkin lymphoma (HL) [1]. However, the very therapies that have helped achieve this success have come with a cost resulting in a legacy of late effects. In particular, anthracyclines and radiotherapy with involved field cardiac exposure have lead to an increased risk of cardiac morbidity and mortality. The article by Alehan et al. [2] in this issue of Pediatric Blood and Cancer addresses whether a relatively new echocardiography technique, Tissue Doppler Imaging (TDI), can assist in detecting anthracycline-associated cardiomyopathy in children treated for HL. This article has several strengths and highlights a very important underappreciated aspect of anthracycline-associated cardiomyopathy in childhood cancer survivors, that of diastolic dysfunction. This appears to be the first study to systematically evaluate diastolic as well as systolic cardiac function using TDI and more traditional methods of echocardiography specifically in a population treated for HL during the pediatric years and compare them to a reasonably age-matched set of controls. Second, while most studies of cardiac function in HL survivors have focused on patients that had received mediastinal radiation with or without chemotherapy [3–5], the population in this article had to have received chemotherapy, with 86.1% having received doxorubicin. The authors take advantage of this fact and are the first to compare function between those who received doxorubicin alone versus doxorubicin with mediastinal irradiation, though admittedly this comparison is underpowered. The results demonstrate that along with systolic dysfunction a key component of cardiomyopathy caused by anthracyclines given during childhood is decreased diastolic function, whether or not radiotherapy was also received. That diastolic dysfunction should occur is not surprising given that the heart grows throughout childhood by hypertrophy of existing cells, yet anthracycline causes cells to die decreasing the amount of cells that contribute to growth and replaces them with scar tissue [6]. These findings are even more remarkable considering that the median dose of doxorubicin was only 150 mg/m and that 69% of patients received <300 mg/m, a cutoff used to designate those at highest risk for systolic dysfunction [7]. These findings raise the question of whether current guidelines should be revised to include recommendations to screen survivors of childhood HL treated with anthracyclines for diastolic dysfunction using Tissue Doppler echocardiography. The authors claim that Tissue Doppler echo offers a cost-effective and efficient method of evaluating diastolic dysfunction, but they do not provide any information or references to justify this claim. Although TDI has been used clinically for about the last 10 years and is widely available in most major medical centers in the United States today, the addition of TDI to conventional echocardiography, including pulse wave Doppler techniques, adds time and therefore likely increases overall cost. However, except for isovolemic relaxation time (IVRT) and peak early diastolic filling velocity/peak late diastolic filling velocity at the mitral valve (E/A ratio), measures of diastolic filling do not indicate a consistent message of decreased diastolic so the clinical usefulness of having one abnormal finding amongst many indices would be difficult to interpret. While systolic velocity (S0) is also decreased consistently across the three locations, this is a measure of systolic function, and the conventional measures of shortening fraction and ejection fraction also demonstrate this decrease. Indeed, although TDI has the theoretical advantage of being load independent, within this population the information about diastolic function obtained by TDI is also seen in the conventional Doppler measures of diastolic function, the E/A ratio and IVRT. Thus, it would have been very helpful to demonstrate and discuss the differences in the number of individuals found to have diastolic dysfunction using TDI compared to conventional Doppler echocardiographic indices. The potential advantages of load independent echocardiographic techniques are that they may detect cardiac dysfunction earlier and that they may provide a less variable means of tracking any dysfunction that has occurred as compared to traditional loaddependent measures [8,9]. Indeed one of the primary reasons for evaluating diastolic dysfunction in this population is that it may indicate those most at risk for developing systolic dysfunction and then clinically evident congestive heart failure (CHF) later in life, although individuals with only the former can develop diastolic