Mark F. Victor

Recognition and embolic potential of intraaortic atherosclerotic debris.

Atherosclerotic disease of the thoracic aorta is common in the elderly and patients with clinical coronary artery disease. Although embolization can occur from atherosclerotic debris within the thoracic aorta, it is not commonly considered in the differential diagnosis of the source of a systemic embolism. In the current study, the prevalence, clinical significance and embolic potential of intraaortic atherosclerotic debris as detected by transesophageal echocardiography was determined. Intraaortic atherosclerotic debris was identified in 38 (7%) of 556 patients undergoing transesophageal echocardiography. An embolic event occurred among 11 (31%) of the 36 study patients with intraaortic atherosclerotic debris. The incidence of an embolic event was higher when the debris was pedunculated and highly mobile (8 [73%] of 11 patients) than when it was layered and immobile (3 [12%] of 25 patients) (p less than 0.002). Among 15 patients undergoing an invasive procedure of the aorta, the incidence of embolism was 27%. In conclusion, in a patient with an embolic event, the thoracic aorta should be considered as a potential source. Transesophageal echocardiography can reliably detect intraaortic atherosclerotic debris, and when it is identified, an invasive aortic procedure should be avoided if possible.

The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study.

Previous studies assessing the value of transthoracic echocardiography (TTE) in blunt chest trauma are limited because patients with severe chest wall injury often have suboptimal echocardiographic findings. Transesophageal echocardiography (TEE) can provide high quality images when the transthoracic image quality is poor. To provide complete echocardiographic assessment of cardiac structure and function we prospectively performed TTE in 105 patients with severe blunt chest trauma and TEE in 20 of the 105 patients (19%) whose TTE examination results were suboptimal. Myocardial contusion was diagnosed in 31 patients (30%), 22 by TTE and nine by TEE. Cardiac complications developed in 8 of 31 patients (26%) with myocardial contusion compared with 2 of 74 patients (3%) with normal echocardiographic findings (p = 0.001). Cardiac complications required treatment in only four patients. Echocardiography was of value in detecting severe right ventricular dysfunction as the cause of hypotension in two patients with suspected cardiac tamponade. Four patients with myocardial contusion died compared with two patients with normal echocardiographic findings (p = NS). No death was related to the cardiac status. In addition, TEE detected aortic injury in five patients, four with focal intimal tears and one with an aortic transection. We conclude that myocardial contusion is common following blunt chest trauma, rarely requires treatment, and is associated with a favorable prognosis. Only patients who develop cardiac complications benefit from echocardiography. Transesophageal echocardiography is of value when the TTE examination results are suboptimal and when aortic injury is suspected.

Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta

The aim of this study was to evaluate the risk of performing cardiac catheterization or intraaortic balloon pump placement in patients with transesophageal echocardiographically detected atherosclerotic aortic debris. Cardiac catheterization was performed in 70 patients with atherosclerotic aortic debris (in 11 via the brachial approach and in 59 via the femoral approach) and in 71 control patients. An embolic event occurred in 10 (17%) of 59 patients with atherosclerotic aortic debris after femoral catheterization compared to 2 (3%) of 71 control patients without atherosclerotic aortic debris (p = 0.01). None of the 11 patients with atherosclerotic aortic debris who underwent brachial catheterization had an embolic event. An intraaortic balloon pump was placed in 10 patients with atherosclerotic aortic debris and in 12 control patients. An embolic event related to placement of the intraaortic balloon pump occurred in 5 (50%) of 10 patients with atherosclerotic aortic debris; no control patient had an embolic event (p = 0.02). Patients with mobile atherosclerotic aortic debris were at the highest risk for catheter-related embolism. The strongest clinical predictors of atherosclerotic aortic debris were advanced age and peripheral vascular disease. Transesophageal echocardiographic recognition of atherosclerotic aortic debris identifies patients at high risk of stroke or peripheral embolism after cardiac catheterization or intraaortic balloon pump placement. If the aortic debris is mobile, the risk is particularly high. When atherosclerotic aortic debris is detected, especially if the debris is mobile, substituting brachial for femoral catheterization and avoiding placement of an intraaortic balloon pump may reduce the risk of embolism.

Two dimensional echocardiographic diagnosis of aortic dissection

The usefulness of two dimensional echocardiography in establishing the diagnosis of aortic dissection was evaluated. Forty-two patients were referred for study; 15 had a dissection and 27 did not. Two dimensional echocardiography detected the intimal flap in 12 of 15 patients with a dissection, the three false negative studies were in patients with a localized dissection. There was one false positive study in the 27 patients who did not have a dissection.

Two-dimensional echocardiographic identification of surgically correctable complications of acute myocardial infarction.

The appearance of a new, loud systolic murmur in a patient with congestive heart failure after an acute myocardial infarction suggests a surgically correctable cause of the heart failure. Using twodimensional echocardiography, we studied 14 patients who presented in this manner. Four patients had rupture of a papillary muscle with a flail mitral valve. All four had surgery; three survived. Five patients had fibrosis of the posteromedial papillary muscle. All five had surgery; three survived. Five patients had a ventricular septal defect. Three of the five had surgery; one survived. Two-dimensional echocardiography is useful in studying patients with a new systolic murmur and congestive heart failure after acute myocardial infarction to detect

Natural history of the flail mitral leaflet syndrome: A serial 2-dimensional echocardiographic study

Abstract The syndrome of a flail mitral leaflet results in acute mitral regurgitation (MR). Twenty-nine patients with a flail mitral leaflet had serial 2-dimensional echocardiographic (2-D echo) examinations. Left ventricular (LV) and left atrial (LA) volumes and ejection fraction (EF) were obtained using a computerized light-pen system. Fifteen patients with the 2-D echo criteria of a flail mitral leaflet were treated medically and followed for a mean of 19 months. Eleven patients did not undergo surgery (Group IA). Four patients initially were treated medically, but ultimately required surgery (Group IB). On initial examination there was no difference in volumes and EF between these 2 groups. On follow-up, Group IA patients remained in New York Heart Association class I or II. The LV end-diastolic volume increased in the Group IA patients from 164 ± 27 to 203 ± 54 ml (p Fourteen patients were initially treated surgically (Group II). All but 1 were in New York Heart Association Class III or IV. On Initial examination LVEF was lower than in Group IA patients (51 ± 5 versus 43 ± 7, p = 0.05), but there was no difference in LV or LA volumes. On follow-up, a mean of 19 months after surgery, LVEF and LA volumes decreased. We conclude that a subset of patients with a flail mitral leaflet may be followed clinically without deterioration in LV function. Initial LVEF and hemodynamics are reasonably normal. Because increasing LV and LA volumes and changing clinical status are not a function of time, frequent 2-D echo and clinical evaluations are warranted in these patients. After mitral valve replacement, LVEF decreases without a significant change in LV volume.

Cavernous hemangioma of the mitral valve: a case report and review of literature.

Cardiac hemangiomas are rare cardiac tumors with fewer than 50 surgically treated cases reported in the literature. Incidence of valvular hemangiomas is extremely low, as cardiac valves are predominantly avascular structures. In this case report, we describe a 33-year-old woman who presented with progressively worsening cardiovascular symptoms. Echocardiography revealed a mitral valve mass for which she underwent surgical resection and mitral valve replacement. Histological examination of the mass revealed cavernous hemangioma of the mitral valve. Postoperative course was uncomplicated, and the patients symptoms improved after surgery. Surgical excision of valvular hemangiomas appears to be curative in most cases and is the treatment of choice. Periodic echocardiographic follow-up is advised for early detection of tumor recurrence.

Pulmonary Embolism from In Situ Right Atrial Thrombus after Coronary Artery Bypass Surgery

Pulmonary embolism after cardiac surgery is attributed to embolization from thrombus within the deep venous system. We report two cases of pulmonary embolism after coronary artery bypass surgery in which transesophageal echocardiography detected in situ right atrial thrombus. The right atrium should be screened for thrombus in patients who have pulmonary embolism after cardiac surgery.

Calcification of the tricuspid anulus diagnosed by two-dimensional echocardiography.

An 84-year-old female who previously underwent repair of an atrial septal defect had evidence of increased reflectiveness of the posterior tricuspid anulus in the apical four-chamber view and the right ventricular two-chamber view. In addition, the inferior vena cava was dilated and during contrast echocardiography, contrast echoes appeared during systole suggesting tricuspid regurgitation. Tricuspid annular calcification was confirmed by fluoroscopic examination. Tricuspid annular calcification is extremely rare and in the present series occurred in 1 of 80 patients with mitral annular calcification. Lateral resolution echoes from a calcified aortic valve and echoes originating from a calcified right coronary artery have to be distinguished from tricuspid annular calcification.