Nelson B. Schiller

Improved evaluation of the location and mechanism of mitral valve regurgitation with a systematic transesophageal echocardiography examination.

UNLABELLED Mitral regurgitation (MR) is a major determinant of outcome in cardiac surgery. The location and mechanism of mitral lesions determine the approach to various repairs and their feasibility. Because of incomplete evaluations or change in patient condition, detailed intraoperative transesophageal echocardiography (TEE) examination of the mitral valve may be required. We hypothesized that a systematic TEE mitral valve examination would allow precise identification of the anatomic location and mechanism of MR in patients undergoing mitral surgery. We designed a systematic mitral valve examination consisting of six views: five-chamber, four-chamber, two-chamber anterior, two-chamber mid, two-chamber posterior and short-axis. We used this examination prospectively in 13 patients undergoing mitral valve surgery for severe MR and compared the results with the surgical findings. We then retrospectively interpreted 11 similar patients who had undergone intraoperative TEE studies before this examination. TEE correctly diagnosed the mechanism and precise location of pathology in 12 of 13 patients in the prospective group, but in only 6 of 10 patients in the retrospective group. TEE also correctly identified 75 of 78 mitral segments (96%) as being normal or abnormal. In the retrospective group, only 42 of 60 segments (70%) were correctly identified (P < 0.001). We conclude that this systematic TEE mitral valve examination improves identification of mitral segments and precise localization of pathologies and may also improve the diagnosis of the mechanism of MR. IMPLICATIONS In this article, we describe how a systematic examination of the mitral valve by using transesophageal echocardiography allows identification of the different segments of the mitral valve, precise localization of pathology, and helps to diagnose the mechanism of mitral regurgitation. This is important in determining an approach to mitral valve repair and its feasibility.

C-reactive protein, diastolic dysfunction, and risk of heart failure in patients with coronary disease: Heart and Soul Study.

High‐sensitivity C‐reactive protein (CRP) is an inflammatory marker that predicts coronary heart disease (CHD) and, in recent studies, incident heart failure (HF). Whether the association of inflammation with incident HF is explained by worse baseline left ventricular dysfunction or by underlying CHD is unknown.

Pulmonary Valve Endocarditis: Improved Diagnosis with Biplane Transesophageal Echocardiography

Pulmonary valve endocarditis is an uncommon disease. Improved visualization of the pulmonary valve on the longitudinal views provided by biplane transesophageal echocardiography (TEE) improves the diagnostic utility of TEE in pulmonary valve endocarditis. We report three cases of isolated pulmonary valve endocarditis diagnosed with biplanar TEE.

Upper airway obstruction after transesophageal echocardiography

Although transesophageal echocardiography is considered a generally safe procedure, occasional complications have been reported. Serious esophageal trauma and Mallory Weiss tear have been described, as well as post-transesophageal echocardiography dysphagia. However, to our knowledge, upper airway and esophageal obstruction have not been previously cited. A case of upper airway obstruction resulting from a transesophageal echocardiography procedure is herein detailed.

Left-Ventricular Power-to-Mass Ratio at Peak Exercise Predicts Mortality, Heart Failure, and Cardiovascular Events in Patients with Stable Coronary Artery Disease: Data from the Heart and Soul Study

Background: Quantitative stress echocardiography enables calculation of left-ventricular power-to-mass ratio (LVPMR) at peak exercise, a novel measure of cardiac performance per unit mass of myocardial tissue. We hypothesized that LVPMR at peak exercise provides prognostic information beyond established echocardiographic indices such as left-ventricular ejection fraction (LVEF) and left-ventricular mass index (LVMI). Methods: LVPMR (watts/kilogram) at peak exercise was defined as (k × heart rate × mean arterial pressure × stroke volume)/LV mass. We measured LVPMR in 918 adults with stable ambulatory coronary artery disease recruited for the Heart and Soul Study. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for all-cause mortality, cardiovascular death, nonfatal myocardial infarction, heart failure hospitalization, and combined adverse cardiovascular events. Multivariate adjustments were made for established risk factors including LVEF and LVMI. The prognostic value of LVPMR was also compared with established exercise parameters using receiver-operating characteristic curve analysis. Results: Compared with patients in the highest LVPMR quartile, those in the lowest quartile were at increased risk of all-cause mortality (adjusted HR 1.9; 95% CI 1.1–3.3), heart failure hospitalization (adjusted HR 2.9; 95% CI 1.2–6.9), and combined adverse cardiovascular events (adjusted HR 1.9; 95% CI 1.1–3.4). In comparison with the rate-pressure product and the Duke treadmill score, LVPMR did not add significant prognostic value (p > 0.1 for c-statistic comparisons). Conclusions: In patients with stable ambulatory coronary artery disease, LVPMR at peak exercise predicts mortality, heart failure hospitalization, and adverse cardiovascular events. However, LVPMR does not add significant prognostic information beyond established exercise test parameters.

Oblique Reformatting Of Multislice MR Images For Improved Visualization Of Coronary Arteries

A technique for reformatting multislice magnetic resonance imaging (MRI) data into arbitrary oblique planes has been developed and implemented on a DEC uVax system and allows flexible user interaction for the definition of the desired plane. The user identifies with a cursor features of interest on 2 or 3 different image levels to be combined in the resulting oblique image. The reformatted image can have arbitrary angulation and is created with a pixel dimension equivalent to the original data set. Resolution ranges from the original in-plane resolution to the slice thickness depending on angulation. This method has been applied to the particular problem of improving the presentation of coronary arteries on a conventional set of multislice spin echo cardiac images. In a study including 16 patients it was found that the visible length of coronary segments was increased on average by a factor of 2.