Raymond Gramiak

Echocardiography of the aortic root.

The echo pattern of the aortic root is elicited by locating the typical echo of the mitral valve and then angulating the transducer medially and sometimes cephalically. The characteristic echo pattern of the aortic root consists of paired undulating signals three to five cm apart. These signals move

Ultrasound Cardiography: Contrast Studies in Anatomy and Function

Ultrasound cardiography has become established as a valuable clinical tool in the detection of pericardial effusion (1) and the study of mitral valve disease (2, 3). The tricuspid valve can also be detected (4), and studies have been made of left ventricular stroke volume (5) and wall thickness (6). On the other hand, the extension of the ultrasonic method to the study of other cardiac structures has been slow because of the difficulty in recognizing the source of the echoes. Even here, however, Edler (7) has gained useful knowledge in the recognition of the origin of these echoes by the passing of needles into cadavers in duplication of the path of the ultrasonic beam and by the study of excised hearts. The purpose of this presentation is to describe a method for the ultrasonic identification of the cardiac chambers in the living subject. It is based on the intracardiac injection of substances that produce echoes at the site of injection as well as downstream in the flow pattern and permit identification...

Cinefluorographic analysis of the mechanism of swallowing.

In their work on the swallowing mechanism, the early investigators can at least be said not to have overlooked the anatomical probabilities. They found it logical to assume, for instance, that each of the mobile structures and muscles along the upper food channel must necessarily play an active part in the mechanism—“the uppermost first, and then according to their station.” This broad assumption, by the way, has never been successfully disputed, and it gives to the rather speculative views of 18th century authorities such as Boerhaave (1) and Haller (2) a comprehensiveness not always evident in more recent work on the subject. Even comprehensiveness, however, can be overdone, as in Boerhaaves over-elaborate and confusing explanation of laryngeal airway protection. The experimental physiologist Magendie (1783–1855) did much to clarify and give perspective to the older views. We know that he first became interested in the problem while he was still an aide in anatomy at the Paris Faculty, and that his the...

Echocardiography of the Normal and Diseased Aortic Valve

Abstract Echocardiography studies of the normal aortic valve and the valve involved by disease were accomplished with pulsed ultrasonic techniques and extended recording by oscilloscope record camera. In aortic stenosis, normal cusp architecture was obscured by a thick multilayered echo pattern usually heavier than that of the aortic wall. Occasionally, these echoes persisted through systole and diastole, in others, a systolic break occurred. A good correlation existed between this abnormal echo pattern and radiological, surgical, or pathological evidence of valve cusp calcification which, in the absence of normal systolic cusp motion, is a reliable indication of aortic stenosis.

Diagnosis of Aortic Root Dissection by Echocardiography

Six patients with aortic root dissection confirmed by angiography, surgery, or autopsy were studied by echocardiography. All showed marked parallel widening of the anterior (16 to 21 mm) and/or posterior (10 to 13 mm) aortic walls together with enlargement of the aortic root image. (Normal mean aortic wall thickness 5.7 mm, SD 1.2; aortic valve disease patients 6.7 mm, SD 1.5.) In five patients slender aortic valve cusps were recorded moving to the periphery of the inner lumen in systole and not extending to the outer lumen. This finding is useful in excluding calcification of the aortic valve which may produce confusing multiple echoes within the aortic root. Two patients showed 8 to 20 mm variations in the width of the aortic image with slight change in the direction of the transducer indicating that the dissecting hematoma was not uniform in thickness. Other associated findings on the echogram seen in three patients included the demonstration of pericardial fluid collection and mitral diastolic flutter suggestive of aortic regurgitation. Demonstration of enlargement of the aortic root with marked parallel widening of anterior and/or posterior walls appears to be specific for aortic root involvement in dissecting aneurysm of the aorta.

Echocardiographic Recognition of the Congenital Bicuspid Aortic Valve

Twenty-one patients (age four to 25 years) with bicuspid aortic valves proved by surgery and angiography (12) or angiography alone (9) were studied by echocardiography. Seventeen patients had aortic valve disease (11 stenosis, 6 incompetence) and four had coarctation of the aorta with normally functioning aortic valves. A comparison group of 16 patients (9 with aortic valve disease and 7 without aortic valve disease) who had proven tricuspid aortic valves was also studied. Echocardiograms in tricuspid aortic valve patients showed the closed position of the cusps near the middle of the aortic lumen. In contrast marked eccentricity of the aortic valve cusp echoes in diastole could be demonstrated in all with bicuspid aortic valves. The Eccentricity Index (½ aortic lumen diameter/minimum distance of the diastolic cusp echo from the nearest aortic margin) was low (range 1.0-1.25) with tricuspid aortic valves and high (range 1.5-5.6) with bicuspid aortic valves (P < 0.001). This index was not significantly affected following successful valvotomy. Bicuspid aortic valve cusps showed normal systolic motion pattern resulting in marked asymmetry of leaflet images. About half of patients with bicuspid aortic valves also showed multilayered echoes in diastole in the absence of fluoroscopic evidence of valvular calcification. Echocardiography appears to be specific in the recognition of the bicuspid aortic valve.

Echocardiographic Detection of the Pulmonary Valve

A relatively easy, reproducible ultrasonic technique for detection of the pulmonary valve is described. Echoes are obtained from the aorta one interspace above the valve, and the beam is angled slowly toward the patients left shoulder until the pulmonary valve is seen. This valve shows a wide range of cusp motion patterns. Echograms appear to reflect the diastolic pressure gradient between the pulmonary artery and the right ventricle.

Is routine angiography necessary prior to carotid endarterectomy

The records of 111 consecutive patients undergoing evaluation for possible carotid endarterectomy at the University of Rochester were reviewed. All patients had noninvasive evaluation (oculoplethysmography-Gee and direct, continuous-wave Doppler ultrasonography) as well as selective carotid angiography. Patients were grouped by clinical presentation to ascertain the relative importance of angiography in determining the need for surgery. Arteriography added nothing to clinical and noninvasive evaluation in over two thirds of patients with hemispheric cerebral symptoms or asymptomatic carotid bruits. In contrast, we found that almost all patients with nonhemispheric symptoms required angiography for adequate evaluation prior to surgery. The implication of these findings on preoperative evaluation of patients with carotid surgery is discussed.

Echocardiography in the Diagnosis of Idiopathic Hypertrophic Subaortic Stenosis Co-existing With Aortic Valve Disease

Echocardiographic studies demonstrated the presence of co-existing idiopathic hypertrophic subaortic stenosis (IHSS) in six patients with aortic valve disease (four calcific aortic stenosis, two pure aortic incompetence). The characteristics of IHSS were a narrow left ventricular outflow tract, a systolic anterior movement of the mitral valve (SAM), and asymmetric ventricular septal hypertrophy. Large SAMs were observed in two patients with pure aortic incompetence and one with aortic stenosis. Relatively small, inconstant, and often incomplete SAMs were noted in the remaining three patients with aortic stenosis. In contrast to isolated IHSS, the small SAMs observed in this group did not become prominent with the Valsalva maneuver or amyl nitrite inhalation. These features may be related to the afterload provided by the fixed, distal stenosis. Echocardiographic evidence of aortic valve disease was present in all patients. Clinically, co-existence of IHSS was not suspected in five patients. Associated IHSS was established using provocative measures during cardiac catheterization in three cases, while in the remainder it was substantiated at surgery. Three of four patients who underwent myotomy/myectomy concomitant with aortic valve replacement survived and postoperative echocardiographic studies revealed complete absence of SAMs in two of them. Echocardiography appears to be useful in the diagnosis of associated IHSS in the presence of aortic valve disease.

Determinants of Atrial (S4) and Ventricular (S3) Gallop Sounds in Primary Myocardial Disease

Abstract Clinical, hemodynamic and angiographic correlates in 23 patients with primary myocardial disease and either atrial (S4) or ventricular (S3) gallop sounds differentiated the two groups. Tho...