Norbert Wittlich

Ambulatory follow-up of aortic dissection by transesophageal two-dimensional and color-coded Doppler echocardiography.

Follow-up of 18 patients with aortic dissection (five with type I, one with type II, 11 with type III dissection according to DeBakey) by transesophageal, two-dimensional and color-coded Doppler echocardiography showed a persistence of the false lumen in five of seven patients (71%) after surgery and in nine of 11 patients (82%) after medical therapy. In two patients treated with surgery, the dissected part of the aorta had been resected, whereas in two patients treated medically, a progressive and complete obliteration of the false lumen was observed. In the false lumen, thrombus formation was absent in four, localized in four, and progressive in six patients. Flow within the false lumen could be registered in 14 patients, and two distinct flow patterns were differentiated (laminar biphasic flow or slowly circulating flow). Persisting intimal tears were visualized by two-dimensional echocardiography in four patients, whereas color-coded Doppler showed an additional one to three intimal tears in the descending aorta in 10 patients. Flow across these intimal tears was biphasic in 75% of patients; that is, systolic flow was directed from the true to the false lumen with diastolic flow reversal. Unidirectional flow was detected in 25% of the communications, directed in 20% from the true to the false lumen, serving as an entry only and in one (5%) as reentry only. Additional information concerning complications like extension of the dissection (one of 18 patients), localized dilatation of the regurgitation (three of 18 patients) were detected by this method. Concerning the morphologic findings and the detection of flow characteristics, the transesophageal approach was superior to conventional echocardiography especially in the descending thoracic aorta. Thus, transesophageal two-dimensional and color-coded Doppler echocardiography seems to be an ideal method not only for the easy detection of aortic dissection but also for follow-up.

Detection of Central Pulmonary Artery Thromboemboli by Transesophageal Echocardiography in Patients with Severe Pulmonary Embolism

Transthoracic echocardiography generally provides only indirect signs of pulmonary embolism. In contrast, with transesophageal echocardiography the thromboembolus itself can be visualized in the central parts of the pulmonary artery. The aims of our study were to evaluate, first, the incidence of central pulmonary artery thromboemboli in patients with severe pulmonary embolism, and second, the accuracy of the echocardiographic diagnosis. Our study group comprised 60 patients with proved severe pulmonary embolism. All patients were examined by transthoracic and transesophageal echocardiography. The echocardiographic findings concerning the absence or presence of central pulmonary artery thromboemboli were compared with the results of different reference methods. Central pulmonary thromboemboli were found in 35 patients (58.3%) by echocardiography. Two types of thrombus were differentiated. Type A is a long, highly mobile thrombus, and type B is an immobile wall-adherent thrombus. In comparison with the reference methods, we determined a sensitivity of 96.7% and a specificity of 88% for the echocardiographic detection of central pulmonary artery thromboemboli in patients with severe pulmonary embolism. Transesophageal echocardiography seems to be a useful method for the diagnosis of severe pulmonary embolism. In our series, central pulmonary artery thromboemboli were present in more than half of the patients. In these cases, transesophageal echocardiography can clarify the diagnosis within a few minutes without further invasive diagnostic procedures.

Measurement of intracardiac dimensions and structures in normal young adult subjects by transesophageal echocardiography

Transesophageal echocardiography (TEE) has proven to be an excellent diagnostic means of diagnosing different cardiac diseases. To distinguish between normal and pathologic findings, standardized measurements of well-defined cross-sectional planes are necessary. Therefore, the 2-dimensional echocardiographic data of 25 healthy volunteers were obtained. In 13 men and 12 women, aged 19 to 30 years, recordings of the left ventricular short-axis view, the 2- or 4-chamber view with the left and right atria, the long axes of the left and right ventricles, the mitral and tricuspid valve ring and the atrial septum were analyzed. Furthermore, the aortic valve plane and the ascending and descending aorta were also measured. All data are given as mean values +/- 2 times the standard deviation. End-diastolic and end-systolic left ventricular anterior-to-posterior diameter of the left ventricular short axis was 2.5 +/- 0.3 cm/m2 and 1.7 +/- 0.3 cm/m2, with the fractional shortening ranging from 27 to 42%. The end-systolic lateral diameter was 2.4 +/- 0.5 cm/m2 for the left atrium and 2.4 +/- 0.4 cm/m2 for the right atrium, and the end-systolic anterior-to-posterior diameter was 1.5 +/- 0.6 cm/m2 for the left atrium and 2.1 +/- 0.6 cm/m2 for the right atrium. End-diastolic diameters of 3.4 +/- 0.6 cm/m2 and 2.8 +/- 0.4 cm/m2 were obtained for the long axis of the left ventricle and for the right ventricle. Measurements ranged from 1.5 to 2.2 cm/m2 for the end-diastolic diameter of the mitral ring and from 1.3 to 2.0 cm/m2 for the tricuspid ring.(ABSTRACT TRUNCATED AT 250 WORDS)

Value and Limitations of Transesophageal Echocardiography in the Evaluation of Aortic Prostheses

Results of 34 transesophageal (TEE) studies in patients with suspected aortic prosthetic dysfunction were compared with transthoracic echocardiographic (TTE) results and to anatomic findings. Mass lesions noted at surgery (autopsy) were correctly described in 93% by TEE versus 43% by TTE. Abscesses were detected in 88% by TEE versus 18% by TTE. Bioprosthetic degeneration was visualized in 88% versus 38% and prosthetic obstruction correctly identified in 75% versus 50% by TEE and TTE, respectively. Anatomic aortic regurgitant lesions were identified in 96% by TEE versus 77% by TTE, whereas the correct origin was detected in 88% of cases by TEE versus 54% of cases by TTE. TEE provides valuable additional information on morphologic conditions and flow pathology in aortic valve prostheses.

Three-dimensional Imaging of Cardiac Mass Lesions by Transesophageal Echocardiographic Computed Tomography

Three-dimensional echocardiography is a new imaging technique that allows more realistic visualization of cardiac morphology. This study presents data about the diagnostic potentials of this technique concerning cardiac mass lesions, as well as its feasibility in clinical application. After the conventional investigation, multiple cross-sectional images were obtained during automatic forward advancement of a monoplane transducer mounted on a transesophageal probe. Three-dimensional reconstruction and volume determination were performed off line. Twenty-four patients were studied. In 14 cases results of echocardiographic computed tomography (echo-CT) were compared with those of monoplane/biplane transesophageal echocardiography. In 23 patients a conventional transesophageal investigation with the echo-CT probe and in 20 patients tomographic scanning were possible. Data acquisition required 12 +/- 4 minutes and three-dimensional reconstruction required 35 +/- 14 minutes. In 13 patients mass lesions were found; in 11 of 13 patients echo-CT provided diagnostic information about the precise spatial orientation and morphology of cardiac structures that could not be obtained by monoplane/biplane transesophageal echocardiography. The technique revealed accurate distance measurements and volume determination of mass lesions. Echo-CT is a further step toward the application of clinically useful three-dimensional echocardiography.

Semiquantitative grading of mitral regurgitation by color-coded Doppler echocardiography

We evaluated patients with mitral regurgitation by color-coded Doppler echocardiography using a semiquantitative score system, which is useful in the clinical setting, by providing rapid discrimination between mild, moderate and severe regurgitation. The study was performed in 42 patients (19 female, 23 male) mean age 58 years, range 23-75 years with mitral regurgitation of different etiology. Color-coded Doppler measurements were compared to angiographic findings using a three point score system. In addition to such parameters as maximal jet length, area and the ratio jet area/left atrial area, we also considered the duration of regurgitant flow. The best correlation was obtained for the maximal area of the jet multiplied by the duration of regurgitant flow/cycle length (r = 0.88), determined in the apical plane where the jet was best visualized. For the parameter area of jet alone, the correlation coefficient was 0.81, for the length of the jet the value was r = 0.65 and comparison of the areas of jet and left atrium gave a coefficient of 0.77. A clear separation between mild and severe regurgitation was observed only for the parameter calculated by multiplying the area of the jet by the duration of mitral regurgitation. In only 7% of the patients with moderate and severe regurgitation could we observe an overlap. This parameter, therefore, represents a useful method for estimating in a semiquantitative manner the severity of mitral regurgitation by color-coded Doppler echocardiography.

Diagnostic value of transesophageal echocardiography in patients with coronary artery disease and mitral insufficiency

Any diagnosis of mitral regurgitation must always include the etiology. The clinical history is only rarely informative, as are chest x-ray examinations. The ECG is of value to diagnose coronary artery disease with or without previous myocardial infarction — but further differentiation is not possible. During heart catheterization mitral insufficiency can be diagnosed and quantified according to Seller’s classification [1]. A differentiation of etiology is only rarely possible. Rheumatic heart disease and mitral valve prolapse can be differentiated.

Left ventricular contrast echocardiography — echoventriculography

Echographic contrast agents were first used for structure identification [1, 2]. Pooled data analysis revealed a high safety [3]. Special agents have been developed in order to standardize right heart opacification [4] and to enhance echocardiographic Doppler signals [5–9]. The latter effect was not expected [9]. All agents contain air as reported by others between 12 and 35 µl/ml [9]. The stability reaches more than 5 min. Injections of up to 20 ml are necessary. The osmolality is between 345 and 1740 mosm/kg H2O [9].

Quantitative comparison of new image processing methods for volumetric analysis of left ventricular contrast echocardiograms

An effort has been made to develop image processing methods which allow a definite and precise tracking of the borderline of the ventricle in two-dimensional echocardiograms. Experience is reported with two new methods, which are based on the gray-level rise (GL) and the signal-to-noise ratio (SNR) in combined heart-phase-triggered image series. A quantitative comparison of these time-series methods is presented with respect to the interpretation of a single native image (noncontrast image), a single contrast-material image, the corresponding subtraction image, and the corresponding color superposition image. The comparison is based on the calculation of the ejection fraction using the above-mentioned methods, interobserver variability, and intraobserver variability. The color superposition method and the two new methods described here (GL and SNR) are shown to be especially well suited for left-ventricle function evaluation.<<ETX>>

Hämodynamische Effekte einer einmaligen intravenösen Applikation von Prostaglandin E1 bei einem Patientenkollektiv mit chronischer Herzinsuffizienz im NYHA-Stadium II/III

Wir untersuchten die hämodynamischen Effekte einer einmaligen PGE1-Infusion (60 μg über 2 h=ED zur Therapie der pAVK) bei Patienten mit einer chronischen Herzinsuffizienz NYHA II–III (EF <55%; mittleres Alter: 58,4 J, STD 10 J; stabiler Krankheitszustand). Bei 19 Patienten lag eine koronare Herzkrankheit, bei einem Patient ein Z. n. Myokarditis vor. Die hämodynamische Analyse erfolgte invasiv mittels Rechts- und Linksherzkatheter. Blutdruck und Puls wurden manuell gemessen. Die intravenöse Infusion von PGE1 in einer Konzentration von 60 μg über zwei Stunden führte zu keiner signifikanten Änderung der Kontraktilität und Hämodynamik. Fakt: Dp/dtmax, dp/dtmax/p und dp/dt/DP40, als Parameter für die linksventrikuläre Kontraktilität mittels Katheter-Tipmanometer bestimmt, zeigten gegenüber der Placebo-Kontrollgruppe keine signifikante Änderung im Verlauf. Die weiteren erhobenen Parameter ergaben ebenfalls keinen Hinweis auf eine hämodynamische bzw. myokardiale Wirkung der PGE1-Gabe, so daß die Anwendung bei der pAVK als hämodynamisch unbedenklich anzusehen ist. We investigated the hemodynamic effects of a single infusion of PGE1 (60 μg infused over a period of 2 h (this is the single dose used in courses of treatment for peripheral occlusive arterial disease) in patients with chronic heart failure NYHA class II–III. The ejection fraction of these patients was <55%, their average age was 58.4 years (standard deviation 10 years), and their condition was stable. Nineteen of the patients had coronary heart disease and one patient had myocarditis. The hemodynamic data were obtained invasively by catheterization of the right and left heart. Blood pressure and pulse rate were measured manually. Intravenous infusion of 60 μg PGE1 over a period of 2 hours did not significantly alter contractility or hemodynamics. Dp/dtmax, dp/dtmax/p, and dp/dt DP40, which are parameters of left ventricular contractility, determined with the aid of a catheter-tip manometer, did not differ significantly over time from those in the placebo control group. Similarly, the other data furnished no evidence that administration of PGE1 had any hemodynamic or myocardial effects. Hence, it is reasonable to state that it is safe to administer PGE1 to patients with peripheral occlusive arterial disease.