Faculty Bibliography

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE

BACKGROUND: Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. METHODS: The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n=25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n=10), left atrial appendage obliteration (n=11), left atrial or pulmonary vein ablation for atrial fibrillation (n=5), percutaneous closures of prosthetic valve dehiscence (n=10), percutaneous aortic valve replacement (n=6), and percutaneous closures of ventricular septal defects (n=2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. RESULTS: The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an 'en face' view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. CONCLUSION: RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures

OBJECTIVE: The inflammatory process of aortic stenosis involves the differentiation of aortic valve myofibroblasts into osteoblasts. Osteopontin, a proinflammatory glycoprotein, both stimulates differentiation of myofibroblasts and regulates the deposition of calcium by osteoblasts. Osteopontin levels are increased in patients with such conditions as end-stage renal disease, ectopic calcification, and autoimmune disease. We hypothesized that increased plasma osteopontin levels might be associated with the presence of aortic valve calcification and stenosis. METHODS: Venous blood from volunteers older than 65 years undergoing routine echocardiographic analysis or aortic valve surgery for aortic stenosis was collected. Plasma osteopontin levels were measured by means of enzyme-linked immunosorbent assay. The presence of aortic stenosis was defined as an aortic valve area of less than 2.0 cm(2). Aortic valve calcification was assessed by using a validated echocardiographic grading system (1, none; 2, mild; 3, moderate; 4, severe). Comparisons were performed with nonpaired t tests. RESULTS: Aortic stenosis was present in 23 patients (mean age, 78 years) and was absent in 7 patients (mean age, 72 years). Aortic valve calcification scores were 3.5 +/- 0.6 and 1.3 +/- 0.5 in patients with and without aortic stenosis, respectively (P < .001). Patients with no or mild aortic valve calcification had lower osteopontin levels compared with patients with moderate or severe aortic valve calcification (406.1 +/- 165.8 vs 629.5 +/- 227.5 ng/mL, P = .01). Similarly, patients with aortic stenosis had higher osteopontin levels compared with patients without aortic stenosis (652.2 +/- 218.7 vs 379.7 +/- 159.9 ng/mL, P < .01). CONCLUSION: Increased levels of plasma osteopontin are associated with the presence of aortic valve calcification and stenosis. These findings suggest that osteopontin might play a functional role in the pathogenesis of calcific aortic stenosis

We present an adult patient who had an acute myocardial infarction complicated by a ventricular septal defect and had it repaired percutaneously. Real-time three-dimensional echocardiography (RT3D) before and during the closure procedure were performed. RT3D provided anatomical and functional information of the defect as well as real-time guidance during the procedure. This case highlights the utility of three-dimensional echocardiography in guiding transcatheter procedures

OBJECTIVES: This study sought to assess the use of real-time (RT) 3-dimensional (3D) transthoracic and transesophageal echocardiography (TEE) in the evaluation of post-operative mitral valve dehiscence. BACKGROUND: Mitral valve replacement or repair may be complicated by post-operative dehiscence of the valve or annuloplasty ring resulting in clinically significant mitral regurgitation or hemolysis. Diagnosis is generally performed using 2-dimensional transthoracic echocardiography and TEE. Recently, an RT 3D TEE probe has been developed to produce high-quality real-time images. METHODS: We used RT 3D TEE to evaluate mitral regurgitation after mitral valve repair or replacement as a result of mitral ring dehiscence. We studied the additional information and diagnostic utility provided by RT 3D TEE. RESULTS: Eighteen patients were studied (8 patients after repair and 10 after replacement). Real-time 3D TEE allowed accurate evaluation of the pathology, including definition of the type of ring or prosthesis used; description of the site, size, shape, and area of the dehisced segment; and clear definition of the origin of the mitral regurgitation. CONCLUSIONS: In mitral valve dehiscence, RT 3D TEE provides additional information about the exact anatomic characteristics of the dehiscence that can be used to help in planning the most appropriate corrective intervention

Over the recent years, strain echocardiography has emerged as a quantitative technique for the evaluation of global and segmental cardiac function. Strain is a measure of deformation, expressed as a percent change in a segment's length compared to its predeformation length. Strain rate (SR) is the local rate of deformation or strain per unit time. Recently non-Doppler two dimensional strain imaging has been developed. This technique is based on tracking ultrasonic speckles from the two dimensional echocardiographic images. These speckles are followed over a number of successive frames, and myocardial velocity is calculated by measuring frame-to-frame changes. This technique is independent of the Doppler angle of incidence and allows measurement of several vectors of strain within myocardial tissue. Non-Doppler strain is a powerful tool, enabling detection of subtle abnormalities in myocardial function. Current evidence shows that non-Doppler strain imaging may allow identification of the early changes that occur with ischemic insult to the myocardium. It may also provide a tool for identification of scarred, non-viable myocardium, with similar accuracy to that of cardiac MRI. Non-Doppler strain imaging is likely to become a standard tool in the evaluation of patients with ischemic heart disease

A 74-year-old woman presented with an acute cerebrovascular infarct involving multiple vascular territories, suggestive of an embolic event. The initial transesophageal images create the impression of an echogenic mass in the left atrial appendage. A small pericardial effusion was also seen surrounding the left atrial appendage. After further views were obtained, the echogenic mass appeared to be in this fluid-filled space rather than in the appendage itself. To confirm this finding, echo contrast (Definity) was administered. After contrast injection, the left atrial appendage was opacified, while the effusion around the appendage and the echodensity within this space were not opacified. Our case highlights the utility of contrast-enhanced echocardiography in clearly delineating the boundaries of the endocardium in cases, when a pericardial effusion surrounds the left atrial appendage