Sujood Ahmed

Quantification of Mitral Regurgitation by Live Three-Dimensional Transthoracic Echocardiographic Measurements of Vena Contracta Area: 3D TTE VENA CONTRACTA AREA FOR MR

We evaluated 44 consecutive patients who underwent standard two‐dimensional (2D) and live three‐dimensional (3D) transthoracic echocardiography (TTE), as well as left heart catheterization with left ventriculography. Mitral regurgitant vena contracta area (VCA) was obtained by 3D TTE by systematic and sequential cropping of the acquired 3D TTE data set. Assessment of mitral regurgitation (MR) by ventriculography was compared to measurements of VCA by 3D TTE and to 2D TTE measurements of MR jet area to left atrial area (RJA/LAA), RJA alone, vena contracta width (VCW), and calculated VCA. VCA from 3D TTE closely correlated with angiographic grading (rs= 0.88) with very little overlap. VCA of <0.2 cm2 correlated with mild MR, 0.2–0.4 cm2 with moderate MR, and >0.4 cm2 with severe MR by angiography. Ventriculographic grading also correlated well with 2D TTE measurements of RJA/LAA (rs= 0.79) and RJA alone (rs= 0.76) but with more overlap. Assessment of VCW and calculated VCA by 2D TTE agreed least with ventriculography (rs= 0.51 and rs= 0.55, respectively). Live 3D TTE color Doppler measurements of VCA can be used for quantitative assessment of MR and is comparable to assessment by ventriculography.

Transthoracic and Transesophageal Echocardiographic Assessment of Mitral Regurgitation Severity: Usefulness of Qualitative and Semiquantitative Techniques

In this report, we review the advantages, limitations, and optimal utilization of various transthoracic and transesophageal echocardiographic (TTE and TEE) methods used for assessing mitral regurgitation (MR) as published in full‐length, peer‐reviewed articles since the color Doppler era began in 1984. In addition, comparison is made to other imaging modalities including catheter‐based, magnetic resonance and surgical assessment of MR. Although left ventricular (LV) angiography has been traditionally used for validation of various TTE methods and is time‐honored, its considerable limitations preclude it from being a real “gold standard.” Based on the reviewed literature, no clear “gold standard” for the assessment of MR can be identified at present, but newly emerging TTE and TEE techniques, such as three‐dimensional color Doppler, may have the potential to overcome some of the limitations of the two‐dimensional methods.

Volume quantification of intracardiac mass lesions by transesophageal three-dimensional echocardiography

As compared with two-dimensional (2-D) transesophageal echocardiography (TEE), 3-D echocardiography now permits more realistic visualization of cardiac anatomy and of intracardiac lesions. The aim of this study was to apply newer 3-D echocardiographic techniques to quantify volumes of intracardiac masses undergoing surgical resection seen during an intraoperative TEE. The calculated volumes were compared with actual in vitro measurements of surgically resected masses. A total of 14 patients (9 men; 5 women; age range between 21 and 77 years) with intracardiac mass lesions (4 tumors: 3 left atrial myxomas and 1 mitral valve fibroelastoma, and 10 vegetations: 5 aortic valve, 3 mitral valve, 1 tricuspid and 1 pulmonary valve) were studied. Using commercially available 3-D reconstruction software (TomTec v. 4.1), the volumes of intracardiac masses were estimated using both the average rotation (rotation around the long axis, AR) and disk summation (parallel short axis cuts, DS) methods. Volumes of these lesions were also measured in vitro by water submersion. They ranged from 0.20 mL to 24 mL (mean +/- SD = 8.07 +/- 9.21 mL). Both 3-D TEE AR and 3-D TEE DS calculated volumes correlated excellently with in vitro measured volumes (r = 1.00 and r = 0.98, respectively, p = < 0.0001). The correlation between 3-D TEE AR and 3-D TEE DS calculated volumes was also excellent (r = 0.98, p = < 0.0001). In conclusion, the volume assessments by 3-D TEE of intracardiac mass lesions correlated well with in vitro measured volumes of surgical specimens. This technique may prove to be valuable in further defining intracardiac pathology and is a further advancement toward the application of clinically useful 3-D echocardiography.

Transesophageal Three‐Dimensional Echocardiographic Demonstration of Ebstein's Anomaly

We report three‐dimensional transesophageal echocardiographic findings in an adult patient with Ebsteins anomaly. Using the anyplane technique and multiple views, especially the short‐axis view of tricuspid valve, three‐dimensional transesophageal echocardiography clearly demonstrated the intermittent tethering of all three leaflets of tricuspid valve to the right ventricular walls giving a “bubble‐like” appearance. On the other hand, two‐dimensional transesophageal echocardiography demonstrated well the tethering of the septal tricuspid leaflet, but tethering of the other two leaflets was not well seen. To our knowledge, these findings have not been demonstrated by three‐dimensional transesophageal echocardiography before. (ECHOCARDIOGRAPHY, Volume 20, April 2003)

Contrast Transesophageal Echocardiographic Detection of a Pulmonary Arteriovenous Malformation Draining Into Left Lower Pulmonary Vein

We report the identification of a pulmonary arteriovenous malformation draining into the left lower pulmonary vein by contrast two‐dimensional transesophageal echocardiography in an adult with no evidence of hereditary hemorrhagic telangiectasia. To our knowledge, this has not been reported previously. This study also emphasizes the importance of transesophageal echocardiographic examination of the left lower pulmonary vein in the detection of a pulmonary arteriovenous malformation. (ECHOCARDIOGRAPHY, Volume 20, May 2003)

Platypnea-Orthodeoxia in a Patient With Ostium Primum Atrial Septal Defect With Normal Right Heart Pressures

We describe an adult patient with an ostium primum atrial septal defect (ASD) and a patent foramen ovale (PFO) with normal right heart pressures who presented with platypnea and orthodeoxia. A dilated aortic root encroaching into the region of the ASD and PFO, along with a tricuspid regurgitant jet moving into the left atrium through the ASD found on the transesophageal echocardiogram may have been responsible for orthodeoxia. Surgical closure of these defects resulted in the disappearance of both platypnea and orthodeoxia. (ECHOCARDIOGRAPHY, Volume 20, April 2003)

Three‐Dimensional Transesophageal Echocardiographic Demonstration of Innominate Artery Dissection

We describe an adult patient with type I aortic dissection in whom it was feasible to demonstrate the extension of the dissection into the innominate artery using color Doppler three‐dimensional transesophageal echocardiography. (ECHOCARDIOGRAPHY, Volume 20, August 2003)

Transesophageal echocardiographic identification of right vertebral artery.

We describe a transesophageal technique for identifying the origin and precervical course of the right vertebral artery with the probe positioned in the upper esophagus. The technique was successful in 9 of 11 patients in whom it was attempted.

Can Transthoracic Echocardiography with Subcostal View Predict Abdominal Aortic Atherosclerosis

Background: Prompt detection of atherosclerosis (ATH) may profoundly impact therapy and patient outcome. During transthoracic echocardiography (TTE), subcostal views may suggest abdominal (ABD) aortic (AO) ATH, but this diagnosis may be inaccurate due to suboptimal images, which may in part relate to use of nonlinear probes. Therefore, we investigated the accuracy of TTE assessment of ABD AO ATH relative to transesophageal (TEE) AO images. Methods: Routine clinical TTE and TEE studies of 100 patients (44 men), aged 30–92 years old, were reviewed retrospectively and blindly. ABD AO ATH by TTE was graded qualitatively as grade (GR) 0 = smooth wall surface; GR 1, 2, and 3 = mild, moderate, and severe irregularities, respectively; and GR 4 = mobile/complex plaque. TEE images were graded quantitatively as the maximal intimal‐medial, or plaque thickness, imaged in the AO arch or descending AO, as: GR 0 ≤ 1.5 mm, GR 1 = 1.5–2.4 mm, GR 2 = 2.5–4 mm, GR 3 = >4 mm, or GR 4 = mobile/complex plaque >4 mm. TTE ability to detect the presence (>GR 0) of ABD AO ATH on TEE was measured in terms of sensitivity (SN), specificity (SP), positive (PPV) and negative (NPV) predictive accuracy—in patients with adequate and suboptimal images—compared to TEE. Results: TTE image quality was adequate in 75 patients and suboptimal in 25. SP and PPV of grading ATH by TTE were directly related to grading by TEE; however, SN and NPV demonstrated an inverse relationship with increasing grading of ATH. TTE correlated with TEE grading with an r = 0.42 (P = 0.0001) for patients (n = 75) with adequate TTE and r = 0.32 (P = 0.001) for all patients (n = 100), including those with suboptimal TTE images. Conclusion: Routine TTE imaging is usually correct in predicting ATH on TEE, but with modest error, it should generally not be relied on as a definitive test for ATH. Adequate image quality improves the correlation of TEE and TTE grading of ABD ATH, and more severe ATH on TTE is more predictive of ATH on TEE.

Normal Lymph Nodes Mimicking a Mediastinal Mass During Transesophageal Echocardiography

We report a transesophageal echocardiographic (TEE) study in an adult patient with ischemic stroke, in whom a nodular mass lesion consistent with tumor or mediastinal lymphadenopathy appeared to be interposed between the esophageal probe and the proximal descending aorta/aortic arch. Computed tomography (CT) scan of the chest revealed no pathologic lesions, only the presence of normal mediastinal lymph nodes and a rightward displaced esophagus. This unusual, but normal rightward position of the esophagus appears to have facilitated the visualization of these normal mediastinal lymph nodes on TEE. CT scan of the chest helped clarify the benign nature of these lymph nodes, which mimicked a mediastinal mass on TEE. (ECHOCARDIOGRAPHY, Volume 20, July 2003)