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Purpose of Review: In patients with systemic lupus erythematosus (SLE), cardiovascular involvement is common and a major cause of morbidity and mortality. There have been few recent updates regarding the cardiac involvement in this clinical entity. The purpose of the review is to provide an update on the role of echocardiography in the management of these patients., Recent Findings: Echocardiography remains the imaging modality of choice and should be considered even in asymptomatic patients with SLE to detect cardiac abnormalities which are frequently not clinically apparent. Transesophageal echocardiography has higher sensitivity and specificity in identifying valvular lesions, and should be utilized in high risk patients when transthoracic echocardiography is negative. New advances such as speckle tracking echocardiography has shown promise in the detection of occult myocardial dysfunction, but more studies are needed to have a proper perspective of its role in SLE patients. SLE has protean cardiac manifestations. The most common involvement is pericarditis. Complicated pericarditis such as tamponade and constriction are rare but should be considered if the symptoms do not subside with treatment. Valvular involvement can take several forms. Libman-Sacks endocarditis is the most common form and is more prevalent in patients with high disease activity and with the presence of antisphopholipid antibodies. Myocardial involvement portends poor prognosis and should be sought and treated promptly to prevent morbidity and mortality., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Cardiac magnetic resonance (CMR) is a recommended imaging test for patients with heart failure (HF); however, there is a lack of evidence showing incremental benefit over transthoracic echocardiography. Our primary hypothesis was that routine use of CMR will yield more specific diagnoses in nonischemic HF. Our secondary hypothesis was that routine use of CMR will improve patient outcomes., Methods: Patients with nonischemic HF were randomized to routine versus selective CMR. Patients in the routine strategy underwent echocardiography and CMR, whereas those assigned to selective use underwent echocardiography with or without CMR according to the clinical presentation. HF causes was classified from the imaging data as well as by the treating physician at 3 months (primary outcome). Clinical events were collected for 12 months., Results: A total of 500 patients (344 male) with mean age 59±13 years were randomized. The routine and selective CMR strategies had similar rates of specific HF causes at 3 months clinical follow-up (44% versus 50%, respectively; P =0.22). At image interpretation, rates of specific HF causes were also not different between routine and selective CMR (34% versus 30%, respectively; P =0.34). However, 24% of patients in the selective group underwent a nonprotocol CMR. Patients with specific HF causes had more clinical events than those with nonspecific caused on the basis of imaging classification (19% versus 12%, respectively; P =0.02), but not on clinical assessment (15% versus 14%, respectively; P =0.49)., Conclusions: In patients with nonischemic HF, routine CMR does not yield more specific HF causes on clinical assessment. Patients with specific HF causes from imaging had worse outcomes, whereas HF causes defined clinically did not. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01281384.

Cardiovascular disease is an important extra-articular manifestation of rheumatologic diseases leading to considerable mortality and morbidity. Echocardiography emerges as a useful non-invasive technique for the screening and evaluation of cardiac involvement in these patients. With the technological advancement in echocardiographic techniques, we have gained a greater appreciation of the prevalence and nature of the cardiac involvement in these patients, as detection of subclinical disease is increasingly feasible. This review discusses cardiac involvement in patients with rheumatoid arthritis, systemic lupus erythematosus, anti-phospholipid antibody syndrome, systemic sclerosis and ankylosing spondylitis, and the role of different echocardiographic modalities in their evaluation.

Background: Left atrial volume (LAVol) is an important predictor of cardiovascular outcomes. Different formulas are applied to calculate LAVol using two-dimensional transthoracic echocardiography (2DTTE) with variable reference values. The objective of the study was to evaluate the accuracy of methods to calculate LAVol by 2DTTE or cardiac computed tomography (CT)., Methods and Results: Overall 177 consecutive patients who underwent both a 2DTTE and retrospective electrocardiogram (ECG)-gated coronary CT angiography (CTA) within 15 days were included for this study. LA volume measurements were calculated by 2DTTE and 2DCT using the biplane area-length, biplane Simpson's, prolate-ellipsoid-1 and prolate-ellipsoid-2 methods. These results were compared with those measured by CT using a volumetric method. There was very good correlation between the CT and echocardiographic measures for LAVol, but significant underestimation of the echocardiographic methods when compared to the reference standard (33.5%, 39.1%, 48.1%, and 53.2% for the biplane area-length, biplane Simpson's, prolate-ellipsoid-1, and prolate-ellipsoid-2 methods, respectively). The biplane area-length method using 2DTTE had the closest volume estimation of all echocardiographic methods to the reference standard (67.6 ± 25.5 mL vs. 106 ± 35.5 mL, r = 0.712). Similarly, the biplane area-length method using CT most accurately predicted LAVol (103.3 ± 36.0 mL, r = 0.965)., Conclusions: Compared to CT, 2DTTE provides reasonable assessment of LAVol, although all measurement methods underestimate LAVol. For both 2DTTE and CT, the biplane area-length method appears to provide the most accurate 2D estimate of LAVol., (© 2013, Wiley Periodicals, Inc.)

There have been major technological advances in echocardiography over the past decade. New and robust measures of myocardial function, both systolic and diastolic, have been identified and extensively evaluated. Some of the new measures such as annular velocities by tissue Doppler imaging have become an integral part of the echocardiographic examination, and other measures such as strain and strain rate have yet to be widely adopted. Three-dimensional (3D) echocardiography has evolved greatly since its introduction in the 1980s. Currently, its main clinical application is the perioperative assessment of the mitral valve. Though 3D echocardiography provides superior quantification of cardiac chamber size, its adoption has been limited by the lack of robust automated data analysis software with smooth integration of analysis packages into clinical workstations and suboptimal temporal and spatial resolution. With advancement in electronics and miniaturization, these limitations can be overcome. The history of contrast echocardiography is long and arduous. Use of a microbubble contrast for left ventricular opacification has become commonplace in most echocardiographic laboratories, but the routine use of microbubble contrast for myocardial perfusion will require standardization of the procedure and/or development of new contrast agents. The applications of 3D and microbubble contrast are also under active evaluation in vascular ultrasound. This review summarizes the current and future applications of these exciting developments in echocardiography and vascular ultrasound., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

In March of 2010, the Ontario Ministry of Health and Long-term Care and Ontario Medical Association jointly commissioned a Working Group to make recommendations regarding the provision and accreditation of echocardiographic services in Ontario. That commission undertook a process to examine all aspects of the provision, reporting and interpretation of echocardiographic examinations, including the echocardiographic examination itself, facilities, equipment, reporting, indications, and qualifications of personnel involved in the acquisition and interpretation of studies. The result was development of a set of 54 performance standards and a process for accreditation of echocardiographic facilities, initially on a voluntary basis, but leading to a process of mandatory accreditation. This article, and its accompanying Supplemental Material, outline the mandate, process undertaken, standards developed, and accreditation process recommended., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The introduction of devices for transcatheter aortic valve implantation, mitral repair, and closure of prosthetic paravalvular leaks has led to a greatly expanded armamentarium of catheter-based approaches to patients with regurgitant as well as stenotic valvular disease. Echocardiography plays an essential role in identifying patients suitable for these interventions and in providing intra-procedural monitoring. Moreover, echocardiography is the primary modality for post-procedure follow-up. The echocardiographic assessment of patients undergoing trans-catheter interventions places demands on echocardiographers that differ from those of the routine evaluation of patients with native or prosthetic valvular disease. Consequently, the European Association of Echocardiography in partnership with the American Society of Echocardiography has developed the recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease. It is intended that this document will serve as a reference for echocardiographers participating in any or all stages of new transcatheter treatments for patients with valvular heart disease., (Copyright © 2011 European Society of Cardiology and The Author. Published by Mosby, Inc. All rights reserved.)

Echocardiographic images often suffer from dropouts that lead to loss of signals on the ventricular boundary and cause the level set curve used to detect the boundary leaking out from the gaps on the boundary. In this paper, a novel method that incorporates temporal information into the level set functional is proposed to solve the leakage problem encountered when detecting the heart wall boundary from the echocardiographic image sequence. The ventricular boundary is quantitatively partitioned and classified into strong and weak segments. The weak segments are considered to be weakened by dropouts and there is low confidence on the presence of boundary. Temporal information from neighboring frames is exploited as a regularizer into the level set equation. Hence, the original boundary information in the weak segments can be reconstructed and the curve leakage problem can be remedied. Experimental results demonstrate the advantages of the proposed method for the intended task.

A new method which incorporates temporal information into the active contour function is proposed to solve the dropout and speckle noise problems encountered when detecting the inner heart wall boundary from echocardiographic image sequence. The ventricular boundary is considered to be composed of strong and weak segments. The weak segments are interfered by image degradations in ultrasound, and they are too weak to constrain the curve evolution. Temporal information is incorporated into the external energy of the active contour function to recover the missing boundary and strengthen the weak segments. Experimental results demonstrate the advantages of the proposed method for the intended task.

Recognizing the central role of echocardiographic examinations in the assessment of most cardiac disorders and the need to ensure the provision of these services in a highly reliable, timely, economical and safe manner, the Canadian Cardiovascular Society and Canadian Society of Echocardiography undertook a comprehensive review of all aspects influencing the provision of echocardiographic services in Canada. Five regional panels were established to develop preliminary recommendations in the five component areas, which included the echocardiographic examination, the echocardiographic laboratory and report, the physician, the sonographer and indications for examinations. Membership in the panels was structured to recognize the regional professional diversity of individuals involved in the provision of echocardiography. In addition, a focus group of cardiac sonograhers was recruited to review aspects of the document impacting on sonographer responsibilities and qualification. The document is intended to be used as a comprehensive and practical reference for all of those involved in the provision of echocardiography in Canada.

Background: When to perform surgery for aortic regurgitation is a difficult clinical decision. Occult left ventricular (LV) dysfunction may be present in patients with minimal or no symptoms, and in some patients LV dysfunction may persist after valvular replacement., Objectives: To examine the role of preoperative low dose dobutamine echocardiography (LDDE) in predicting postoperative outcome in patients who had aortic valve replacement for aortic regurgitation., Patients and Methods: The study group comprised 16 patients (15 men, aged 48 +/- 15 years) undergoing elective surgery for aortic regurgitation. Preoperative echocardiograms were obtained in the resting state and during dobutamine infusion at 7.5 micrograms/kg/min. Complete recovery was defined by normalization of LV size and function, and the absence of symptoms at the six-month follow-up visit. Patients with complete recovery (group 1) and without complete recovery (group 2) were compared in relation to their echocardiographic parameters at rest and during LDDE., Results: Of 16 patients in the study, nine were in group 1 and seven were in group 2. Age, functional class and LV end-diastolic dimensions were similar between the two groups. Group 1 patients had a smaller preoperative LV end-systolic dimension index (22.4 +/- 3.3 versus 29.9 +/- 5.9 mm/m2, P < 0.05) and a higher preoperative ejection fraction (53 +/- 8% versus 37 +/- 13%, P < 0.01). Dobutamine infusion augmented the difference in ventricular size and function between patients in group 1 and those in group 2 (LV end-systolic dimension index 18.9 +/- 3.9 mm/m2 versus 28.8 +/- 7.1 mm/m2, P < 0.01; ejection fraction 61 +/- 7% versus 41 +/- 12%, P < 0.01)., Conclusions: Dobutamine accentuates differences in ventricular size and function between those with and without subsequent complete recovery following valve surgery. Because preoperative ejection fraction during LDDE is highly predictive of postoperative ejection fraction, LDDE may have a role in predicting the clinical outcome of patients following aortic valve replacement for aortic regurgitation.

Abnormalities of diastolic filling are increasingly recognized as a cause of symptoms and predictors of outcome in patients with most forms of heart disease. Noninvasive assessment of diastolic filling is possible in almost all patients, but accurate evaluation must relate echocardiographic Doppler measurements to the complex physiologic and hemodynamic factors responsible for normal and abnormal filling. This evaluation has been facilitated by recent correlation of Doppler measurement of mitral and pulmonary venous inflow with hemodynamic studies. These studies have confirmed that when a careful, integrated approach is taken, Doppler flow patterns can document a progressive pattern of abnormality in many conditions. Impaired left ventricular (LV) relaxation is seen early and is recognized by a decrease in early transmitral LV filling and an increased proportion of filling during atrial contraction. As abnormalities progress, increasing LV chamber stiffness and elevated left atrial pressure lead to a "pseudonormal" filling pattern that previously has caused considerable confusion. This can be unmasked by careful evaluation of pulmonary venous inflow and the use of the Valsalva maneuver. When marked diastolic abnormalities are present, LV filling has restrictive features characterized by rapid early filling, a very stiff left ventricle with high filling pressures, and a poor prognosis. Routine measurement of indexes of diastolic filling have been hampered by uncertainty as to what should be measured, what techniques should be used, definition of normal values, and a clear method of reporting findings. This report represents the efforts of a Canadian consensus group to define a national standard for the performance and reporting of echocardiographic Doppler studies of diastolic filling.

Left ventricular cavity opacification can be produced by the intravenous injection of sonicated albumin (Albunex 422). A recent study suggested that sonicated albumin may be useful in dobutamine stress echocardiography, but its use in exercise echocardiography has not been reported. The purposes of the study were to assess the feasibility of using Albunex to enhance endocardial visualization and to evaluate the factors affecting Albunex kinetic in exercise echocardiography. Fifteen healthy volunteers underwent two exercise echocardiograms on the same day, with intravenous injection of Albunex during one of the studies. Two injections up to a maximum of 20 ml of Albunex per injection were given to enhance the four- and two-chamber views, both at rest and immediately after exercise. The degree of left ventricular enhancement and the percentages of endocardial visualization were measured in both resting and exercise images. Variables relating to the kinetics of Albunex, which included volume of contrast injected, transit time, heart rate, and cardiac output at the time of image acquisition, were also assessed. There was no difference in the image acquisition time between the two exercise echocardiograms. Albunex produced good left ventricular opacification both at rest and after exercise. More endocardial border was visualized with contrast injection than without (91.2% +/- 11.5% vs 85.8% +/- 14.2%, p = 0.007). The transit times and volumes of Albunex injected were significantly less after exercise than at rest. The parameters were inversely related to heart rate and cardiac output. In conclusion, intravenous injection of Albunex is a promising means to enhance left ventricular endocardial visualization in exercise echocardiography and can be readily incorporated without causing a significant delay in obtaining images after exercise. Whether its use can improve diagnostic accuracy of exercise echocardiography requires further studies.

The aim of this study was to determine the relative sensitivity, specificity, accuracy, and tolerance of dobutamine and dipyridamole stress echocardiography in patients with a lower likelihood of severe coronary artery disease. Previous comparative studies, which included patients with a history of myocardial infarction or a high incidence of coronary artery disease, showed both methods to have similar and acceptable diagnostic accuracy. To assess the role of these agents in evaluating patients with a lower likelihood of significant coronary artery disease, a lower-risk group was selected by excluding patients with known coronary artery disease, myocardial infarction, unstable angina, or strongly positive stress test results. Dobutamine and dipyridamole stress echocardiographic studies were performed in random order, before coronary angiography. Of the 46 patients enrolled (31 men and 15 women), 24 had atypical chest pain or none at all. Coronary angiography revealed no significant disease in 22 (48%), single-vessel disease in 11 (24%), and multivessel disease in only 13 patients (28%). Dobutamine and dipyridamole stress echocardiography were equally well tolerated, with identical accuracy (76%) that was maintained in patients with atypical symptoms. This confirms the usefulness of both dobutamine and dipyridamole stress echocardiography in evaluating patients with suspected coronary artery disease and extends this role to a lower-risk group for severe disease who often have atypical symptoms. The choice of which agent is used should reflect an institution's experience.

To compare the imaging capability of the multiplane probe with that of the biplane probe, 317 consecutive patients were randomized to undergo transesophageal echocardiography with either probe. Images of 24 cardiac structures and nine Doppler signals were graded prospectively on a three-grade system. Both multiplane and biplane probes provided excellent visualization of cardiac structures and Doppler signals, but the multiplane probe was significantly superior to the biplane probe. There were no differences in the number of attempts at esophageal intubation, the amount of sedation used, and the examination time. The number of complications was similar, although all failed intubations occurred with the multiplane probe.

Left ventricular (LV) ejection fraction (EF) is an important measure of systolic function, with radionuclide angiography being the accepted standard for its determination. Echocardiography is ideal for repeated measurements of EF, but most methods are either subject to error in the presence of regional wall abnormalities or require cumbersome off-line analysis. Acoustic quantification is a recently introduced method that allows for the continuous on-line display of LV cavity dimensions, but the on-line algorithm for the measurement of EF has not been validated against an independent standard in the clinical setting. This study attempted to validate acoustic quantification in the determination of EF by comparison with off-line echocardiographic analysis and radionuclide angiography in 54 patients referred for this latter procedure. Acoustic quantification correlated well with off-line analysis in both the apical 4-chamber (r = 0.89, n = 43) and 2-chamber (r = 0.86, n = 26) views. Similarly, it also correlated well with radionuclide angiography in the 4-chamber (r = 0.81, n = 44) and 2-chamber (r = 0.83, n = 26) views. The correlation between the 2 methods was further improved when only the last 30 patients were assessed (r = 0.91, n = 25 for 4-chamber views; r = 0.86, n = 16 for 2-chamber views). The correlation was worse in patients with regional asynergy (r = 0.69, n = 17 for 4-chamber views; r = 0.76, n = 10 for 2-chamber views). Moreover, acoustic quantification tended to underestimate EF when compared with radionuclide angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Infective endocarditis continues to be a cause of significant cardiac morbidity and mortality. To improve the prognosis of patients with this disorder, early diagnosis is crucial but difficult to establish on the basis of clinical parameters alone. Echocardiography, both transthoracic and transesophageal techniques, has a major role in the detection of vegetations that are the hallmark of endocarditis. Valvular and perivalvular complications can also be well assessed by echocardiography. With the improved resolution provided by recent technologic advances in echocardiography, vegetations can be reliably detected in most patients with endocarditis. We propose that present diagnostic criteria for endocarditis be revised to include echocardiographic findings as a major parameter in the diagnosis. Finally, a diagnostic approach incorporating transthoracic and transesophageal echocardiography in these patients will be discussed taking into consideration the different degrees of clinical suspicion for the existence of the disease.

Objectives: This study was conducted to determine the implications of negative findings on a transesophageal echocardiographic study in which neither a vegetation nor an abscess is identified in patients with clinically suspected infective endocarditis., Background: Echocardiography is the procedure of choice for evaluating suspected infective endocarditis in patients. Transesophageal echocardiography has been shown to be superior to transthoracic imaging. Although the importance of positive results or a diagnostic study is known, the significance of negative findings on a transesophageal study is not clear., Methods: All transesophageal echocardiographic studies performed over a 2-year period for suspected infective endocarditis were reviewed and the clinical course of patients with an initially negative study result was assessed to determine their final diagnosis., Results: Of the 105 patients identified, 65 had a negative transesophageal study result. In the majority of this group (56 of 65), an alternate diagnosis was made or there was no infective endocarditis on follow-up examination, or both. Of the remaining nine patients, four were treated for endocarditis without a definite diagnosis and five had infective endocarditis proved by either repeat transesophageal study (n = 3), pathologic findings (n = 1) or a diagnostic clinical course (n = 1). Gram-positive bacteremia and the presence of a prosthetic valve in the aortic position tended to be more common in the latter group., Conclusions: A negative transesophageal study result reduces the likelihood that endocarditis is present. Repeat examination, however, should be considered in high risk patients, such as those with prosthetic valves or unexplained bacteremia, to avoid a missed diagnosis.

Transesophageal echocardiography provides excellent images of intracardiac masses; however, its use among a series of patients with central venous lines has not been fully described. Nineteen patients (aged 52 +/- 16 years; 10 women) had masses detected by transesophageal echocardiography in the presence of a permanent (0.2 to 16 years) pacing wire (n = 8), and a current (n = 9) or recent (n = 2) (1 to 281 days) indwelling catheter. Transthoracic echocardiography suggested the presence of a mass in 5 patients (26%), although in only 2 cases were its findings consistent with transesophageal findings. Transesophageal echocardiography indicated the presence of a mass in or near the superior vena cava in 13 patients, in the right atrium in 6, and adjacent to the tricuspid valve in 3. Discrete masses measured 1.6 +/- 2.1 cm2 in area during transesophageal echocardiography. Eleven patients had positive blood cultures, 7 with staphylococcal species. Mass size was not significantly altered by the type of line or sepsis, but showed a weak correlation with line age (r = 0.56). Transesophageal echocardiography altered the management of 9 patients, prompting surgery (n = 3) and line removal (n = 3), and antibiotic (n = 2) or anticoagulation (n = 3) therapy.

A patient developed a tear of the anterior mitral leaflet following surgical resection of a stenotic subaortic membrane. This complication was diagnosed by intraoperative transesophageal echocardiography leading to successful repair of the mitral leaflet tear.

To determine the impact of transesophageal echocardiography (TE) on the treatment of patients with aortic dissection, the clinical course and outcome of 18 patients with TE diagnosis of dissection were analyzed. Ascending aortic dissection was present in nine patients, of whom six had surgery with confirmation of TE findings. Angiography was performed in only two of these patients and was falsely negative in one patient. Angiography was not performed in the three patients who were not surgical candidates. In the nine patients who had descending aortic dissection, angiography was performed in seven patients, of whom two underwent surgery. Information provided by angiography did not change the treatment of these patients. Thus, TE provides a prompt and accurate diagnosis in aortic dissection obviating the need for angiography in most patients.

We describe a case of left ventricular free-wall rupture of the heart in which the use of two-dimensional and Doppler echocardiography provided the diagnosis. The echocardiographic findings in this condition are discussed and a previously unreported finding is described.

Thrombosis is a serious complication of heart valve replacement. Diagnosis is often difficult with previously reported techniques, including precordial two-dimensional echocardiography, suffering from low sensitivity and specificity. Management is similarly difficult, with a 40% to 50% reported mortality rate in early surgical series. Three cases are presented in which thrombosis of a left-sided prosthetic valve (one aortic, three mitral) was diagnosed by means of transesophageal echocardiography. All three patients were treated with streptokinase and had clinical and echocardiographic resolution. In one patient, who had recurrent thrombosis and received a second course of streptokinase, the course was complicated by a massive embolic stroke and death. Another patient with a recurrence underwent successful valve replacement. Transesophageal echocardiography is ideal for the diagnosis and follow-up of patients with prosthetic valve thrombosis. Although effective, thrombolysis in this setting is associated with a high risk of thromboembolic phenomena and significant risk of death. Thrombolytic therapy may be considered in highly selected patients who have an unacceptable risk for reoperation.

The incidence of bacteremia related to transesophageal echocardiography was studied in 140 consecutive patients (71 women and 69 men with a mean age of 53.7 +/- 15 years). Thirty-four patients had one or more prosthetic heart valves. Blood cultures were obtained from each patient through separate venipuncture sites immediately before and after transesophageal echocardiography. An additional late blood culture was obtained in 114 patients 1 h later. The skin was cleaned with povidone-iodine and venipunctures were performed with separate butterfly needles with use of sterile gloves and drapes. Blood samples were drawn into separate syringes, transferred to aerobic and anaerobic culture bottles and processed with use of a semiautomated system. The overall incidence of blood cultures positive for bacteremia was 2% (8 of 394 bottles) and all positive cultures grew in a single blood culture bottle. Positive cultures occurred in 4 (1.4%) of 280 bottles before the procedure, in 2 (0.7%) of 280 bottles immediately after the procedure and in 2 (0.9%) of 228 late (1-h) blood culture bottles. Bacterial isolates were coagulase-negative staphylococci (n = 5), Propionibacterium (n = 2) and Moraxella (n = 1). All were considered contaminants. Mean endoscopic time in these patients was not significantly different from that in the other patients. Follow-up of patients with a blood culture positive for bacteremia revealed no clinical evidence of systemic infection. It is concluded that 1) the incidence of bacteremia related to transesophageal echocardiography is very low, and 2) the incidence of blood cultures positive for bacteremia after transesophageal echocardiography is indistinguishable from the anticipated contamination rate.

Transesophageal echocardiography is a new approach that can be used to image cardiac structures. It combines two existing technologies: cardiac ultrasound and endoscopy. To obtain a cardiac image, the transesophageal probe has to be positioned properly within the esophagus. The first 1500 consecutive transesophageal echocardiographic examinations in ambulatory adult patients from one center were analyzed to identify conditions associated with failed esophageal intubation and procedural complications. Esophageal intubation was not achieved in 11 patients (0.73%). The reasons for the failure of intubation were operator inexperience, hypersensitive pharynx despite topical anesthesia, and cervical spondylosis. Six of those patients also had a history of dysphagia. Procedural complications were identified in seven patients (0.47%). Tracheal intubation was present in four patients, with immediate development of stridor and incessant cough in two patients. Atrial fibrillation developed in two patients--one had atrial myxoma and one had mitral stenosis. Bronchospasm developed during the transesophageal examination in one patient who was receiving long-term treatment for bronchial asthma. We conclude that transesophageal echocardiography is feasible in most adult patients in the ambulatory setting and that the complication rate is very low. Proper patient selection and preparation are crucial to the successful performance of this procedure.

Between September 1987 and April 1989, forty patients suspected to have aortic dissection were evaluated by transesophageal echocardiography. Aortic dissection was identified in 18 patients. This study evaluated the ability of transesophageal echocardiography in the assessment of the 22 patients in whom aortic dissection was not found. A range of pathologic conditions was diagnosed in these patients. Five patients had ischemic heart disease when they were initially seen. Among the remaining 17 only one patient had a normal aorta. Aortic disease was present in the other 16 patients with aortic dilatation in 10. Atheromas were detected in seven patients with concomitant aortic dilatation in five of them. An extrinsic aortic mass was present in two patients. Transesophageal echocardiography correctly identified an anastomotic leak at the site of left coronary artery implantation in a patient with a recent Bentall procedure, and a large mobile clot within the proximal descending aorta in a patient with blunt chest trauma. These findings obviated the need for other tests in 15 patients and led to surgery in four with no ancillary tests performed in three of them. Thus transesophageal echocardiography has an important role in assessing patients with suspected dissection. Aortic disease is common even in patients in whom aortic dissection is excluded, and some of the conditions can be just as life-threatening as dissection. Transesophageal echocardiography not only reliably identifies dissection but can also detect luminal and extraluminal diseases not adequately visualized by other modalities.

The accuracy of transesophageal echocardiography was compared with that of transthoracic echocardiography in the detection of ruptured chordae tendineae (flail mitral leaflet) in 27 patients with mitral valve prolapse (MVP) who underwent valve repair or replacement for mitral regurgitation. Confirmation of the presence of ruptured chordae resulting in a flail leaflet was available at surgery in all cases. The echocardiographic studies were read blindly by 2 independent observers with any differences resolved by a third. Mean (+/- standard deviation) age was 63 +/- 13 years. Men (n = 20) outnumbered women (n = 7) (p less than 0.02), and tended to be younger (p = 0.06). Flail leaflets were identified in 20 of 27 patients. In 1 patient, both leaflets were involved and in the remaining 19 patients posterior leaflets (15 patients) were more frequently affected than anterior leaflets (4 patients). Transesophageal echocardiography correctly identified all 20 patients with flail leaflets, but 1 false positive study occurred among the 7 patients without a flail leaflet. In contrast, transthoracic echocardiography identified only 12 of 20 patients with flail leaflets, with no false positive studies. Transesophageal echocardiography was more accurate, correctly classifying 26 of 27 (96%) cases versus 19 of 27 (70%) by the transthoracic approach (p less than 0.01). This study suggests a higher incidence of chordal rupture to the posterior leaflet in patients with MVP and demonstrates improved accuracy of transesophageal over transthoracic echocardiography in the detection of flail leaflets.

Tomography of the heart and great vessels is limited during conventional transesophageal echocardiography by the inability to rotate the transducer at the end of the transesophageal echocardiographic endoscope. A biplane transesophageal echocardiographic probe has been developed recently with a second transducer capable of long-axis imaging that yields long-axis views in addition to the familiar short-axis views. We describe our experience with 37 patients with a variety of cardiovascular diseases. In 17 patients new diagnostic information was obtained, although management was not changed. Long-axis scanning was particularly useful in the assessment of diseases of the thoracic aorta, valvular morphology and regurgitation, and congenital heart disease. Important limitations of the biplane imaging system include reduced image quality and a continued inability to rotate the transducer to obtain any desired plane of imaging. Nonetheless, biplane imaging enhances the versatility of transesophageal echocardiography and improves three-dimensional conceptualization of cardiac disease.

The number of views obtainable during transesophageal echocardiography (TE) has been limited by the fixed position of the transducer at the end of the probe. This has confined standard TE studies to short-axis tomography of the heart and aorta. Recently, a biplane TE probe has become available that is capable of both long- and short-axis imaging. This study prospectively assessed the application of the long-axis plane of the biplane probe in providing complementary long-axis views in ambulatory patients. Six standard long-axis views could be obtained and were compared with corresponding anatomic sections to illustrate anatomic relations and facilitate structure identification. The long-axis views provide a better appreciation of the 3-dimensional nature of cardiac anatomy and function, especially in demonstrating the relation of vertically aligned structures.

Seven patients with prolapsed posterior mitral leaflet were identified in whom the clinical findings were suggestive of aortic stenosis. In each instance, the murmur was best appreciated at the parasternal area. The murmur radiated to the carotids in two patients. Spatial mapping with pulsed-wave Doppler as well as continuous-wave Doppler examination demonstrated the presence of mitral regurgitation and also that the regurgitant stream was directed to the anterior left atrial wall near the base of the aorta.

Simultaneous continuous wave Doppler echocardiography and right-sided cardiac pressure measurements were performed during cardiac catheterization in 127 patients. Tricuspid regurgitation was detected by the Doppler method in 117 patients and was of adequate quality to analyze in 111 patients. Maximal systolic pressure gradient between the right ventricle and right atrium was 11 to 136 mm Hg (mean 53 +/- 29) and simultaneously measured Doppler gradient was 9 to 127 mm Hg (mean 49 +/- 26); for these two measurements, r = 0.96 and SEE = 7 mm Hg. Right ventricular systolic pressure was estimated by three methods from the Doppler gradient. These were 1) Doppler gradient + mean jugular venous pressure; 2) using a regression equation derived from the first 63 patients (Group 1); and 3) Doppler gradient + 10. These methods were tested on the remaining 48 patients with Doppler-analyzable tricuspid regurgitation (Group 2). The correlation between Doppler-estimated and catheter-measured right ventricular systolic pressure was similar using all three methods; however, the regression equation produced a significantly better estimate (p less than 0.05). Use of continuous wave Doppler blood flow velocity of tricuspid regurgitation permitted determination of the systolic pressure gradient across the tricuspid valve and the right ventricular systolic pressure. This noninvasive technique yielded information comparable with that obtained at catheterization. Approximately 80% of patients with increased and 57% with normal right ventricular pressure had analyzable Doppler tricuspid regurgitant velocities that could be used to accurately predict right ventricular systolic pressure.

Transesophageal echocardiography (TE) is a new imaging modality which provides a unique acoustic window to assess cardiac structures. The feasibility of using TE to obtain eight tomographic views of the heart was examined prospectively in 25 patients within 4 h following cardiac surgery. With the exception of the left ventricular apical view, which was not obtainable in 32% of patients, all views were present in each patient. Thus, TE not only provides a comprehensive assessment of cardiac anatomy, but also allows detailed left ventricular regional wall motion evaluation in the majority of patients.