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Background: Bicuspid aortic valve (BAV) is the leading cause of aortic stenosis in patients younger than the age of 50. A classification scheme of BAVs is based upon leaflet orientation: Type I (fusion of right and left coronary cusps) and Type II (fusion of right and noncoronary cusps). The correlation between BAV leaflet orientation and aortic root pathology however remains ill defined., Objective: The objective was to describe a potential relationship between BAV leaflet morphology and aortic root measurements in the ASTRONOMER study, a multicenter study to assess the effect of rosuvastatin on the progression of AS., Methods: BAV morphology was classified as Type I or Type II orientation based on the parasternal short-axis view. Echo measurements including left ventricular and aortic root dimensions were obtained., Results: The study population included 89 patients (56 +/- 11 years; 44 males). There were 63 patients with Type I and 26 patients with Type II BAV. Baseline demographics, hemodynamics, and left heart dimensions were similar between both groups. Patients with Type I BAV had larger aortic annulus and ascending root dimensions compared to those patients with Type II BAV (P < 0.05)., Conclusion: In patients with mild to moderate aortic stenosis due to a BAV, the presence of Type I valve orientation was associated with significantly greater aortic root parameters compared to Type II valve orientation.

Aims: Mitral annular calcification (MAC) is characterized by calcium and lipid deposition in the annular fibrosa of the mitral valve. Although individuals with MAC are at increased risk of cardiovascular events, little is known about the significance of this finding in patients with concurrent aortic stenosis (AS). The aim of this study was to describe the association of baseline MAC and aortic valve morphology in asymptomatic patients enrolled in the ASTRONOMER study, a multicentre study to assess the effect of Rosuvastatin on the progression of AS., Methods and Results: At baseline, transthoracic echocardiography was performed with two-dimensional and Doppler imaging following a standardized protocol. Echo measurements including left ventricular (LV) dimensions and aortic root dimensions were obtained according to the ASE recommendations. MAC was identified by bright echoes at the base of the mitral leaflets or annulus on 2D imaging, and aortic valve calcification by visualization of bright echoes on the aortic valve leaflets. The degree of calcification was semi-quantitated from absent to severe. The study population included 219 patients (57 +/- 14 years; 129 males), divided into two pre-specified categories; bicuspid (n = 133) and tricuspid (n = 86) aortic valves. Baseline LV dimensions, aortic valve haemodynamics, and cholesterol profiles were similar between the two groups at baseline. Individuals with tricuspid aortic valves were older, more hypertensive, with higher degrees of MAC and AV calcification (P < 0.001). The higher degree of MAC persisted in patients with tricuspid AV after adjustment for age and systolic blood pressure (P = 0.004)., Conclusion: In patients with asymptomatic mild to moderate AS, MAC is more prevalent in those individuals with tricuspid AV, independent of age, and systolic blood pressure. Whether the degree of MAC may be a surrogate for atherosclerosis, and predict the subset of patients who will respond to statin therapy in preventing the progression of AS, remains to be determined.

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.

Normal transesophageal echocardiographic measurements have not been presented previously relative to the effects of age, sex, and body surface area. This comparison was obtained by measuring cardiac and aortic dimensions in 60 patients (20 to 75 years old; 33 women) with normal transesophageal echocardiograms. We found a variable and usually important relationship between body surface area and 11 of 20 structures measured. A gender effect was not significant after indexing for body surface area for all but one structure. Age correlated with the diameter of the aortic root, descending aorta, superior vena cava, and right pulmonary artery. Similar dimensions were noted for certain paired structures as the two atria, the mitral and tricuspid annuli, and the aortic root and right ventricular outflow tract. Although multiple factors underlie what is normal in a given individual, our reference values serve to facilitate recognition of cardiac and aortic disease.

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.

Objective: To examine the role of transoesophageal echocardiography in the assessment of patients with coronary artery anomalies., Background: Coronary artery anomalies are difficult to detect clinically. Most are benign but some may produce symptoms that can be life threatening. Until recently the non-invasive assessment of coronary artery anomalies has been limited., Methods: The data base of transoesophageal echocardiographic studies performed between September 1988 and April 1991 were reviewed to identify all cases of coronary artery anomalies. There were six patients with such anomalies who had also had coronary angiography. The findings of these two imaging techniques were analysed to determine whether transoesophageal echocardiography added useful data in these cases., Results: Of the six patients, the coronary anomaly was discovered during angiography in four patients, during a transthoracic echocardiographic study in one patient, and as an incidental finding in the other patient. Aberrant origins of the left coronary artery were detected in two patients, and coronary artery fistulae were present in the other four. Transoesophageal echocardiography provided unique information on the course of an aberrant left coronary artery in one patient and the precise location of drainage sites of coronary artery fistulas in three patients., Conclusion: Transoesophageal echocardiography was complementary to angiography in the assessment of coronary artery anomalies. It can locate and delineate the course of an ectopic coronary artery and the drainage site of a coronary fistula. These anatomical data can be crucial to the management of these patients.

Paradoxical embolism-in-transit is an uncommon presentation of the thromboembolism complex. The advent of echocardiography has permitted its antemortem diagnosis and serves to guide treatment; this is illustrated by the case of a 51-year-old female who presented with paradoxical embolism-in-transit and pulmonary embolism following craniotomy. Echocardiography demonstrated mobile clot straddling the atrial septum and embolus in the right pulmonary artery. Surgery successfully removed all clots as demonstrated by intraoperative echocardiography, and the patient had an uneventful recovery.

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.

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.

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.

Paravalvular abscesses, which occur in up to 30% of cases of native valve endocarditis, are being detected with increasing frequency with the use of transesophageal echocardiography. Abscesses of the mitral aortic intervalvular fibrosa have been described but only in association with native or prosthetic aortic valve endocarditis. We describe a patient with native mitral valve endocarditis complicated by an abscess in the fibrosa. A 51-year-old diabetic man presented with Staphylococcus aureus mitral valve endocarditis. A transesophageal echocardiographic study done 8 days after admission revealed two large masses at the base of the anterior mitral leaflet with extension into the fibrosa consistent with a paravalvular abscess that was not detected by precordial echocardiography. A repeat transesophageal echocardiographic study done 20 days after admission showed spontaneous drainage of the abscess and a subsequent fistula between the left atrium and left ventricle. This case highlights the important role that transesophageal echocardiography has in suspected and known cases of endocarditis. Its major advantage of delineating posterior cardiac structures allowed accurate diagnosis and serial evaluation of this previously unreported complication of endocarditis.

Echocardiography can detect pulmonary emboli-in-transit as mobile masses within the right heart. In this case report, a patient with biventricular failure had both transthoracic and transesophageal echocardiograms which revealed a thromboembolus entrapped within the right atrium. Surgery confirmed the echocardiographic findings.

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.

The hepatojugular reflux (HJR) test was studied to assess the ability to clinically predict response during cardiac catheterization and to determine its significance in patients without heart failure and correlate it to their baseline hemodynamic parameters. Sixty-five patients considered to be free of heart failure undergoing routine cardiac catheterization were enrolled. The HJR test, defined as the venous pressure response to sustained abdominal compression, was performed in a standardized manner at the bedside assessing change in internal jugular venous pressure and during right-sided cardiac catheterization measuring change in right atrial pressure. For comparison a sustained increase greater than or equal to 1 cm was considered positive. In 62 of 65 patients the HJR test stabilized by 15 seconds. The results during examination at the bedside agreed with those at catheterization (K = 0.74, p less than 0.001). The HJR test result correlated best with baseline mean right atrial pressure (r = 0.59) and right ventricular end-diastolic pressure (r = 0.51), and in bivariate regression analysis predicted right atrial (F(1,63) = 32.8, R2 = 0.34, p less than 0.0001) and right ventricular end-diastolic (F(1,63) = 22, R2 = 0.26, p less than 0.0001) pressures. A positive test had high sensitivity and specificity for predicting right atrial pressure greater than 9 mm Hg (1.0, 0.85) and right ventricular end-diastolic pressure greater than 12 mm Hg (0.90, 0.89). It is concluded that 15 seconds is adequate for interpretation, and bedside observation predicts the response during right-sided cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)