Larry E. Jacobs

Penetrating atherosclerotic aortic ulcers

Penetrating atherosclerotic aortic ulceration is a unique disease with distinct management and prognostic implications. It is an important clinical entity that must be distinguished from classic aortic dissection and rapid expansion or contained rupture of a thoracic aortic aneurysm. Although symptoms of penetrating aortic ulceration may mimic dissection, the characteristic signs of dissection are absent. New imaging modalities have made it possible to establish the diagnosis of penetrating aortic ulceration with a high degree of accuracy and to tailor management according to the presence of complications. Physicians should be aware of the possibility of atherosclerotic aortic ulceration, particularly in elderly patients with systemic atherosclerosis and hypertension who have sudden onset of chest or back pain.

Right atrial compression in postoperative cardiac patients: Detection by transesophageal echocardiography

Four patients developed hypotension after heart surgery. Hemodynamic measurements revealed elevated right atrial pressure with normal pulmonary capillary wedge pressure. Conventional transthoracic two-dimensional echocardiography was technically suboptimal for detection of pericardial effusion. In each patient transesophageal echocardiography demonstrated significant compression of the right atrium by a localized mass. At reoperation atrial compression by an organized hematoma was found and in each instance successfully drained. Thus, transesophageal echocardiography is superior to transthoracic echocardiography in evaluating critically ill postoperative hypotensive patients and can differentiate isolated right atrial tamponade from other causes of hemodynamic deterioration such as prosthetic valve dysfunction or left ventricular systolic dysfunction, or both.

Significant Mitral Regurgitation is Protective Against Left Atrial Spontaneous Echo Contrast and Thrombus as Assessed by Transesophageal Echocardiography

This retrospective study examines whether a relationship exists between the severity of mitral regurgitation (MR) and the presence of left atrial spontaneous echo contrast and/or thrombus (SEC/THR) as assessed by transesophageal echocardiography in 427 consecutive patients. Clinical data were evaluated in 316 of these patients. Nine percent of patients with MR < or = 2+ versus < 1% of those with MR > or = 3+ had SEC/THR (p < 0.03). Atrial fibrillation, left ventricular dysfunction, mitral stenosis, and mitral valve prosthesis were demonstrated to be independent positive predictors of left atrial SEC/THR, whereas MR > or = 3+ was an independent negative predictor of SEC/THR. SEC/THR was less common in patients with MR > or = 3+ than in patients with MR < or = 2+ for any given number of independent positive predictors of SEC/THR. This relationship did not hold true in patients with a mechanical mitral prosthetic valve. Clinical data revealed a trend towards a lower prevalence of stroke or transient ischemic attacks in patients with MR > or = 3+. Stroke and transient ischemic attacks were significantly more common in patients with SEC/THR (p < 0.001). We suggest that significant MR may be protective against the formation of left atrial SEC/THR.

Patent foramen ovale: a nonfunctional embryological remnant or a potential cause of significant pathology?

A patent foramen ovale (PFO) is an embryological remnant found in 27% of adults. It is a potential right-to-left intracardiac shunt. Shunting may be the result of reversal in the interatrial pressure gradient or abnormal streaming of blood in the right atrium. The pathologic consequences of right-to-left shunting include hypoxemia and paradoxical embolism. PFO may exacerbate preexisting hypoxemia or be its primary cause. Paradoxical embolism through a PFO is well documented. Its role in cryptogenic stroke remains controversial. A PFO may be detected by both invasive and noninvasive techniques. Contrast transesophageal echocardiography with provocative maneuvers is the diagnostic method of choice allowing visualization of the shunt. Patients with cryptogenic stroke should be screened for a PFO. If detected, noninvasive studies for deep vein thrombosis are recommended. Treatment must be tailored to the presentation. Surgical or transcatheter closure is recommended for hypoxemia. Prevention of venous embolism (air or thrombus) with or without closure of the PFO is recommended for paradoxical embolism.

Flow Patterns in Dilated Cardiomyopathy: A Pulsed-wave and Color Flow Doppler Study

In 48 patients with dilated cardiomyopathy, pulsed-wave and color Doppler examination were performed. In addition, 14 normal patients served as control subjects. Peak inflow velocity at the level of the mitral valve, middle left ventricle, and apex and outflow velocity at the level of the apex, middle left ventricle, and subaortic area were measured. In normal patients there was brisk propagation of inflow velocity to the apex. Patients with dilated cardiomyopathy demonstrated delayed propagation and prolongation of the duration of inflow compared with control subjects (p less than 0.04). Continuous apical flow was visualized in 25% of dilated cardiomyopathies and in no normal patients. Apical velocities were significantly increased in cardiomyopathies with significant mitral regurgitation. Outflow velocities were decreased in dilated cardiomyopathy. In patients with dilated cardiomyopathy and apical dyskinesis, flow directed toward the base was measured in the middle left ventricle during isovolumic relaxation secondary to dyskinetic rebound. Patterns of abnormal flow in dilated cardiomyopathies are readily apparent by color M-mode and two-dimensional color Doppler.

Epidemiology and Outcome of Infective Endocarditis in Hemodialysis Patients

BackgroundSurvival in patients with infective endocarditis (IE) ranges from 4 to 50% depending on the type of organism, the type of valve involvement and the type of treatment. MethodsWe conducted a retrospective analysis of data in hemodialysis (HD) patients at our center from 1990 to 2000. Demographics, risk factors, and outcome data were extracted in the subgroup of patients with first-episode IE diagnosed primarily by echocardiography. ResultsA total of 2239 patients underwent HD at our center. Thirty-two (1.4%) had IE defined using the Duke Criteria. Permanent and temporary venous dialysis catheters, arteriovenous (AV) grafts, and AV fistulae were used in 19 (59%), 12 (38%), and 1 (3%) patient respectively. Mean access duration was 7.6 ± 7.9 months. Thirty (94%) patients had positive blood cultures, with the majority having Staphylococcus aureus bacteremia. Two (7%) patients had positive echocardiographic findings but negative blood cultures due to the commencement of empiric antibiotic therapy prior to blood cultures. The mitral valve was mainly affected. Transesophageal echocardiography was performed in 23 (72%) patients and detected an intracardiac mass in all 23 patients. One-year mortality was 56.3%. A poor 1-year prognosis was associated with presenting features of low hemoglobin, elevated leukocyte count, hypoalbuminemia, severe aortic and mitral regurgitation, and annular calcification in mitral valve IE. ConclusionThe prevalence of IE in HD patients is 1.4%. One-year mortality was 56.3%. Close observation is required during the first year when patients with severe valvular regurgitation and hematological abnormalities have a high mortality.

Penetrating atherosclerotic aortic ulcers: The role of transesophageal echocardiography in diagnosis and clinical management

Penetrating aortic ulceration is a disease of the descending thoracic aorta characterized by ulceration of an atheromatous plaque disrupting the internal elastic lamina. The ulcerated atheroma may extend into the media, resulting in intramural hematoma; it may penetrate the media; resulting in pseudoaneurysm formation; or it may perforate through the adventitia, resulting in transmural aortic rupture.l Penetrating aortic ulceration has similar chnical features to aortic dissection and rapid expansion or contained rupture of a thoracic aortic aneurysm.1-3 However, it represents a unique pathology with distinct radiographic and echocardiographic features. While aortography has been regarded as the gold standard in the diagnosis of penetrating aortic ulcers, computed tomography2 and mag-

Long-term Follow-up of Mitral Paraprosthetic Regurgitation by Transesophageal Echocardiography

Paravalvular regurgitation (PVR) is an uncommon complication of mitral valve replacement (MVR). Although severe PVR is almost always repaired immediately when recognized during surgery, there are little data available on the management of patients with mild and moderate PVR. This study includes eight patients with mild (n = 6) and moderate (n = 2) PVR identified by transesophageal echocardiography at the time of MVR who were treated conservatively. Clinical and echocardiographic follow-up was obtained at a mean of 16.3 months. Two of six patients with mild PVR at the time of MVR and two of two patients with moderate PVR at the time of MVR deteriorated clinically and echocardiographically over time. We suggest that moderate PVR should be corrected at the time of valve-replacement surgery, if this can be performed without high operative risk. Mild PVR should probably also be repaired, if this can be performed at low risk, because some will progress. Patients left with mild PVR after surgery, or patients in whom PVR is recognized only after surgery, should be followed up carefully with serial clinical and echocardiographic examinations.

Bacteremia and Infective Endocarditis in Patients on Hemodialysis

&NA; The number of patients with end‐stage renal disease (ESRD) has risen dramatically over the last decade. There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year. Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient‐care months. Few other medical conditions, except for chemotherapy‐induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia. IE occurs in approximately 2% to 6% of patients receiving HD. The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD.

Role of echocardiography in perioperative management of patients undergoing open heart surgery

TEE has assumed a pivotal role in the perioperative management of patients undergoing open-heart surgery. The information obtained influences important therapeutic decisions in thoracic aortic surgery, valvular surgery, and coronary artery bypass surgery. TEE also assists in determining the reason for failure to wean from cardiopulmonary bypass and allows rapid detection of the etiology of hypotension in the patient after surgery. Advances in technology have resulted in three-dimensional images of cardiac structures, and this will further enhance the usefulness of echocardiography for the surgeon. TEE should no longer be regarded as an imaging tool available only in academic centers, but should be routinely used by qualified operators in centers performing open-heart surgery.