Joseph Kisslo

Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements.

SUMMARY Four hundred M-mode echocardiographic surveys were distributed to determine interobserver variability in M-mode echocardiographic measurements. This was done with a view toward examining the need and determining the criteria for standardization of measurement.Each survey consisted of five M-mode echocardiograms with a calibration marker, measured by the survey participants anonymously. The echoes were judged of adequate quality for measurement of structures. Seventy-six of the 400 (19%) were returned, allowing comparison of interobserver variability as well as examination of the measurement criteria which were used.Mean measurements and percent uncertainty were derived for each structure for each criterion of measurement. For example, for the aorta, 33% of examiners measured the aorta as an outer/inner or leading edge dimension, and 20% measured it as an outer/outer dimension. The percent uncertainty for the measurement (1.97 SD divided by the mean) showed a mean of 13.8% for the 25 packets of five echoes measured using the former criteria and 24.2% using the latter criteria.For ventricular chamber and cavity measurements, almost one-half of the examiners used the peak of the QRS and one-half of the examiners used the onset of the QRS for determining end-diastole. Estimates of the percent of measurement uncertainty for the septum, posterior wall and left ventricular cavity dimension in this study were 10-25%. They were much higher (40-70%) for the right ventricular cavity and right ventricular anterior wall. The survey shows significant interobserver and interlaboratory variation in measurement when examining the same echoes and indicates a need for ongoing education, quality control and standardization of measurement criteria. Recommendations for new criteria for measurement of M-mode echocardiograms are offered.

Report of the American Society of Echocardiography Committee on Nomenclature and Standards in Two-dimensional Echocardiography.

The Committee recommends that when the transducer is placed in the suprasternal notch that it be referred to as in the suprasternal location. When the transducer is located near the midline of the body and beneath the lowest ribs, the transducer should be referred to as in the subcostal location. When the transducer is located over the apex impulse, the Committee recommends that this be referred to as the apical location. If the term apical is used alone, it will be assumed that this refers to a left-sided apical position. The area bounded superiorly by the left clavicle, medially by the sternum and inferiorly by the apical region will be referred to as the parasternal location. If the term parasternal is used alone, it will be assumed to be the left parasternal location. In those unusual situations in which the apex impulse is palpated on the right chest, a transducer placed over the right-sided apex impulse will be referred to as in the right apical location. The region bounded superiorly by the right clavicle, medially by the sternum and inferiorly by the right apical region will be referred to as the right parasternal location.

The role of the exercise test in the evaluation of patients for ischemic heart disease.

A cohort of 1472 patients who underwent both exercise stress testing and coronary angiography within six weeks was examined. The data indicated that a combination of exercise parameters is both diagnostically and prognostically important. Almost all patients (> 97%) who had positive exercise tests at Stage I or Stage II had significant coronary artery disease. More than half of these (> 60%) had three vessel disease and over 25% had significant narrowing (> 50%) of the left main coronary artery. Patients who achieved Stage IV or greater exercise durations with either negative or indeterminate ST-segment response had less than a 15% prevalence of three vessel disease and less than a 1% prevalence of left main coronary artery disease. A low risk subgroup (75% of all nonoperated patients) was identified with a twelve month survival greater than 99%. A high risk subgroup (11% of all nonoperated patients) was identified with a twelve month survival of less than 85%. The exercise test is a noninvasive, reproducible method to assess the presence and extent of anatomic disease and the prognosis when significant disease has been defined. It should be used in conjunction with other noninvasive tests to determine optimal management in patients evaluated for ischemic heart disease.

Opacification and border delineation improvement in patients with suboptimal endocardial border definition in routine echocardiography : results of the phase III albunex multicenter trial

OBJECTIVES This study was designed to assess the safety and efficacy of intravenously administered sonicated human serum albumin for enhancing echocardiographic delineation of the left ventricular endocardium and improving assessment of wall motion in patients with incomplete depiction of noncontrast echocardiography. BACKGROUND Echocardiographic regional wall motion analysis is impaired by incomplete endocardial definition in as many as 10% of patients. Sonicated human serum albumin is a stable contrast material that, unlike other agents, opacifies the left ventricle when administered intravenously. METHODS One hundred seventy-five patients were enrolled at eight centers on the basis of incomplete echocardiographic endocardial depiction. Sonicated 5% human serum albumin, a stable preparation of air-filled microspheres (size range 1 to 10 microns), was administered intravenously in divided doses: 0.08 ml/kg body weight in all patients, followed by 0.14 and 0.08 ml/kg or a single dose of 0.22 ml/kg, depending on the result of the initial dose. Investigators and independent reviewers blinded to the protocol scored the echocardiograms for degree of left ventricular opacification and improvement of endocardial border depiction. RESULTS Overall, 81% of patients had at least moderate left ventricular chamber opacification with at least one contrast dose, and endocardial definition was improved in 83%. In the subgroup with inadequate left ventricular opacification from the initial dose, a second, larger dose (0.22 ml/kg) improved endocardial depiction in 64%. No significant side effects occurred. CONCLUSIONS In patients with incomplete echocardiographic endocardial definition, sonicated human serum albumin is a safe, effective contrast agent that, when administered intravenously, produces left ventricular chamber opacification, improves endocardial depiction and enhances regional wall motion analysis.

Echocardiographic documentation of vegetative lesions in infective endocarditis: clinical implications.

SUMMARYEighty-seven patients with the clinical syndrome of infective endocarditis were examined by M-mode and two-dimensional echocardiography. Patients were divided into two groups based on the presence or absence of echocardiographically detected vegetative lesions. Group 1 consisted of 47 patients with one or more vegetations. Group 2 consisted of 40 patients without evidence of vegetations. Group 1 patients had a higher rate of complications: emboli, congestive heart failure and the need for surgical intervention. Analysis of morphologic characteristics of the vegetations in group 1 was of no predictive value for complications in individual patients. Two-thirds of the vegetations persisted unaltered well beyond the period of bacteriologic cure without significant complications. No characteristic alteration of the vegetations predicted the efficacy of medical therapy.Although the detection of vegetations by echocardiography in patients with the clinical syndrome of endocarditis clearly identifies a subgroup at risk for complications, decisions regarding clinical management made solely on the basis of the presence or absence of vegetative lesions are hazardous. Management of such patients must continue to be based on the clinical integration of multiple factors.

The prognostic spectrum of left main stenosis.

SUMMARY Three-year survival for 163 consecutive medically treated patients with 50% or greater left main stenosis was 50%. Survival was significantly higher for patients with 50 to 70% left main stenosis (one and three-year survivals of 91% and 66%) than for patients with 70%o or greater left main stenosis (one and three-year survivals of 72% and 41%). In fact, left main lesions of less than 70% were not associated with the increased risk usually attributed to patients with left main stenosis. A number of noninvasive and catheterization characteristics were significant predictors of survival for patients with 70% or greater left main stenosis. Noninvasive descriptors defined a low risk subgroup (one and three-year survivals of 97% and 74%) and a high risk subgroup (one- and three-year survivals of 59%o and 25%). These observations have important implications both in assessing therapeutic interventions and in managing individual patients.

Real-time Three-dimensional Echocardiography for Determining Right Ventricular Stroke Volume in an Animal Model of Chronic Right Ventricular Volume Overload

BACKGROUND The lack of a suitable noninvasive method for assessing right ventricular (RV) volume and function has been a major deficiency of two-dimensional (2D) echocardiography. The aim of our animal study was to test a new real-time three-dimensional (3D) echo imaging system for evaluating RV stroke volumes. METHODS AND RESULTS Three to 6 months before hemodynamic and 3D ultrasonic study, the pulmonary valve was excised from 6 sheep (31 to 59 kg) to induce RV volume overload. At the subsequent session, a total of 14 different steady-state hemodynamic conditions were studied. Electromagnetic (EM) flow probes were used for obtaining aortic and pulmonic flows. A unique phased-array volumetric 3D imaging system developed at the Duke University Center for Emerging Cardiovascular Technology was used for ultrasonic imaging. Real-time volumetric images of the RV were digitally stored, and RV stroke volumes were determined by use of parallel slices of the 3D RV data set and subtraction of end-systolic cavity volumes from end-diastolic cavity volumes. Multiple regression analyses showed a good correlation and agreement between the EM-obtained RV stroke volumes (range, 16 to 42 mL/beat) and those obtained by the new real-time 3D method (r=0.80; mean difference, -2.7+/-6.4 mL/beat). CONCLUSIONS The real-time 3D system provided good estimation of strictly quantified reference RV stroke volumes, suggesting an important application of this new 3D method.

Two-dimensional echocardiographic assessment of mitral stenosis.

SUMMARYA real-time, phased-array, two-dimensional echocardiography system was used to assess mitral valve motion in 30 catheterized patients with pure mitral stenosis. Suitable images for analysis of mitral valve motion were obtained in 25 patients. The valve leaflets were most thickened and immobile at the leaflet tips while maximum mobility was at the leaflet body. Diastolic movement of anterior mitral leaflet toward the septum pulled the posterior mitral leaflet mid-portion inferiorly. Systolic bulging of the mid-portion of the anterior mitral leaflet into the left atrium was seen in 40% (10 of 25). Movement of the anterior mitral leaflet in diastole is primarily due to movement of the whole mitral apparatus in patients with mitral stenosis. The anterior mitral leaflet E to F slopes did not correlate (r = 0.38) with the mitral valve area determined at catheterization. Planimetry of the mitral valve area directly from the videotape images compared favorably to the valve area determined at catheterization (r = 0.95). Thus, mitral valve area determined by this technique is an accurate noninvasive method for assessing the severity of mitral stenosis.

A comparison of real-time, two dimensional echocardiography and cineangiography in detecting left ventricular asynergy.

SUMMARYLeft ventricular wall motion was assessed in 105 consecutive patients both invasively, using biplane cineangiography, and noninvasively, by a real-time, phased-array, two-dimensional echocardiography system. Ventricular wall motion in five anatomic areas of the ventricle (anterolateral, posterolateral, apical, septal, and inferior) was analyzed by both methods in a double-blind manner. Twodimensional echocardiographic images were deemed adequate for analysis in 82% of the regions (430 of 525). Fifty-five discrepancies were noted in the comparison of the remaining 430 regions.The reasons for discrepancies in interpretation between the two methods were established for 54 during retrospective review: 33 were due to echocardiography (inadequate target visualization, observer error, or tangential echo views). Fifteen were related to angiography (overlay of silhouettes or observer error), and six were due to other reasons including definition problems or spatial orientation difficulties.Both real-time, two-dimensional echocardiography and cineangiography have advantages and disadvantages. The techniques used together could provide more complete information concerning ventricular wall movement than is now currently available.

Mitral valve prolapse. Two-dimensional echocardiographic and angiographic correlation.

SUMMARY In order to define baseline descriptive criteria for the diagnosis of mitral valve prolapse with cross-sectional echocardiography, 49 patients undergoing catheterization were examined by a real-time, two-dimensional phased array echocardiographic imaging system. Angiography was used to separate patients into two distinct groups: 15 with normal mitral valve function and 34 with definite mitral valve prolapse. Systolic mitral leaflet and annulus motion were then observed in each patient and similarities and differences were noted between the two groups of patients. Correlative M-mode echocardiographic data were available in 37 patients.Certain two-dimensional echocardiographic findings restrited to the angiographically proven mitral valve prolapse group were defined: 1) posteriorly displaced coaptation of the leaflets, 2) systolic superior movement of one or both mitral leaflets above the level of the mitral ring, and 3) a systolic curling motion of the posterior mitral ring on its adjacent myocardium. One or more of these abnormalities were found in all 34 patients with angiographic mitral valve prolapse. When mitral valve prolapse does occur, the results of two-dimensional echocardiography would suggest that both leaflets are usually involved.