Faculty Bibliography

A 50-year-old man was evaluated following a motor vehicle accident. Chest X-ray showed a widened mediastinum. Transesophageal echocardiography was helpful in identifying the left subclavian artery and in demonstrating an isolated subclavian artery aneurysm. The TEE findings correlated well with the results of chest CT. Using TEE for the identification of the aortic branches in patients with chest trauma may be critical

In patients with mitral regurgitation (MR), there is a high pressure gradient between the left ventricle (LV) and left atrium that Doppler echocardiography can easily detect. We present a case where transthoracic echocardiography (TTE) failed to provide an accurate evaluation of a patient who presented in cardiogenic shock. A transesophageal echocardiogram diagnosed MR because of a flail leaflet caused by a ruptured papillary muscle in the setting of normal ventricular function

Echocardiography has become the diagnostic technique of choice for delineating the intracardiac hemodynamics in a host of pathophysiologic states. Pressures and flows can be estimated or measured with enough accuracy to allow for clinical decision-making. We present a case with an unusual Doppler echocardiographic finding and discuss its derivation

Pulmonary artery obstruction may be caused by tumor within or external to the arteries. Presented here is a patient with life-threatening compromise in pulmonary flow that was caused by a pulmonary neoplasm. The Doppler echocardiogram showed subtotal narrowing of the right pulmonary artery and total occlusion of the left pulmonary artery. In addition, the beneficial effects of chemotherapy were documented by Doppler

Aplastic anemia is a rare but serious complication of systemic lupus erythematosus (SLE) with an often dramatic and unanticipated onset. The peripheral destruction of formed blood elements, which frequently accompanies the syndrome, may obscure or delay the diagnosis of bone marrow suppression, and the number of published cases may be an underestimate of the actual incidence of the disease. Furthermore, the disease course may differ significantly from other forms of acquired aplastic anemia and seems to carry a more favorable prognosis once effectively diagnosed and treated. In addition, aplastic anemia may precede other manifestations of SLE. Therefore, the possibility of bone marrow aplasia should be excluded in all SLE patients with severe pancytopenia, and conversely, the diagnosis of SLE should be explored in cases of aplastic anemia. Two patients with aplastic anemia in SLE, one with aplastic anemia preceding the onset of SLE, are described along with 15 cases reviewed from the English language literature. The presentation, prognosis, treatment, and pathogenesis of aplastic anemia complicating SLE are discussed. Recognition that cytopenias, especially pancytopenia, may occur on the basis of inhibited myelopoesis rather than peripheral destruction as either a harbinger of SLE or as a manifestation of disease flare is important. This knowledge will prompt the astute clinician to obtain screening antinuclear antibodies in the setting of otherwise unexplained bone marrow acellularity or, given the prognosis of SLE associated aplastic anemia, give early consideration to more aggressive immunosuppression

A patient in whom transesophageal echocardiography was performed to evaluate a possible source of cerebral embolization. The fact that the probe could not be passed easily beyond 35 cm from the incisors suggested esophageal obstruction or compression. A mass was seen posterior to the left atrium that was heterogenous and contained blood vessels, suggesting a malignancy. There were no complications of the procedure. Esophageal adenocarcinoma was confirmed on biopsy. Transesophageal echocardiography may be diagnostic of paracardiac mediastinal masses, both benign and malignant. Great care must be taken if passage of the probe through the esophagus is met with resistance, to avoid serious complications

BACKGROUND: Stroke occurs in 1% to 7% of heart surgery. Aortic arch atherosclerosis is a risk factor for intraoperative stroke, and endarterectomy has been proposed to prevent stroke during heart surgery in patients with arch atheromas. METHODS AND RESULTS: Intraoperative transesophageal echocardiography was performed in 3404 patients undergoing heart surgery between 1990 and 1996. Use of transesophageal echocardiography was unselected and based on equipment availability. Aortic arch atheromas (>/=5 mm, or mobile) were seen in 268 (8%) patients. They were evaluated for intraoperative stroke (confirmed by a neurologist and cerebral infarction on computed tomography or magnetic resonance imaging). Arch endarterectomy was performed in 43 patients as an adjunct to their cardiac procedure in an attempt to prevent intraoperative stroke. The intraoperative stroke rate in all 268 patients with atheromas was high (15.3%). On univariate analysis, age, previous stroke, and arch endarterectomy were significantly associated with intraoperative stroke. On multivariate analysis, age (odds ratio 3.9, P =.01) and arch endarterectomy (odds ratio 3.6, P =.001) were independently predictive of intraoperative stroke. Mortality rate in all 268 patients was high (14.9%). These patients with atheromas also had a long recovery room, intensive care unit, and total hospital length of stay (48 days). CONCLUSIONS: Patients with protruding aortic arch atheromas are at high risk for intraoperative stroke, significant and multiple morbidity, prolonged hospital stay, and death resulting from heart surgery. Aortic arch endarterectomy is strongly associated with intraoperative stroke; its use should be carefully considered in light of these results