Faculty Bibliography

Transesophageal echocardiography (TEE) is the procedure of choice for identifying aortic atheromas, which may result in stroke, transient ischemic attack and peripheral embolization. However, because of anatomic constraints, the innominate artery may not be visualized. We investigated gadolinium-enhanced MR angiography (MRA) as an alternative technique for evaluation of suspected atheromas of the innominate artery. From a retrospective review of 520 examinations, we identified five patients who had innominate artery atheromas diagnosed prospectively with gadolinium-enhanced MRA who also underwent TEE within 1 month. A total of 10 innominate artery atheromas were demonstrated on MRA; none of these were visualized on TEE. One patient had three atheromas, two patients had two atheromas and three patients had one atheroma. They ranged in size from 3 mm to 1.5 cm (mean 6.5 mm). One atheroma was flat, two were filiform, and seven were protruding. Gadolinium-enhanced MRA is superior to TEE for the diagnosis of atheromas of the innominate artery. In the setting of right cerebral or right arm embolization, when no source is seen in the arch on TEE, gadolinium-enhanced MRA should be considered

Transesophageal echocardiography (TEE) is now widely used in the evaluation of patients with unexplained stroke or transient ischemic attack, in part to exclude the presence of protruding aortic arch atheromas. We report two cases in which repeated TEE revealed an aortic clot not seen on the earlier transesophageal echocardiogram performed immediately after embolization. These cases illustrate the dynamic nature of aortic thrombus and the role of TEE in its diagnosis

BACKGROUND: The outcome of aortic valve replacement for severe aortic stenosis is worse in patients with impaired left ventricular function. Such dysfunction in aortic stenosis may be reversible if caused by afterload mismatch, but not if it is caused by superimposed myocardial infarction. METHODS: From our echocardiography database, 55 patients with severe aortic stenosis (valve area < or =0.75 cm2) and ejection fractions of 30% or lower who subsequently underwent aortic valve replacement were included. The operative mortality and clinical follow-up were detailed. RESULTS: There were 10 perioperative deaths (operative mortality, 18%). Twenty (36%) of the 55 patients had a prior myocardial infarction. In the 35 patients without prior myocardial infarction, there was only 1 death (3%). In contrast, 9 of 20 patients with prior myocardial infarction died (mortality rate, 45%; P< or =.001). The factors significantly associated with perioperative death on univariate analysis (functional class, mean aortic gradient, and prior myocardial infarction) were entered into a model for stepwise logistic regression. This multivariate analysis showed that only prior myocardial infarction was independently associated with perioperative death (odds ratio, 14.9; 95% confidence interval, 2.4-92.1; P = .004). CONCLUSIONS: The risk of aortic valve replacement in patients with severe aortic stenosis and severely reduced left ventricular systolic function is extremely high if the patients have had a prior myocardial infarction. This information should be factored into the risk-benefit analysis that is done preoperatively for these patients, and it may preclude operation for some

Since they were first described in 1990, there has been great interest in protruding atheromas in the aortic arch and descending thoracic aorta as an important source of stroke and other embolic phenomena. This report describes a patient with severe protruding aortic atheromas who died of documented embolic phenomena, in whom actual emboli in transit were seen for the first time during transesophageal echocardiography of the aorta

Plasma homocyst(e)ine [H(e)] levels correlate with the prevalence of arterial occlusive diseases. Recently, transesophageal echocardiography (TEE) has been used to evaluate patients with atherosclerotic plaques in the thoracic aorta. The purpose of this study was to determine whether H(e) levels correlate with the degree of atherosclerotic plaque in the thoracic aorta (ATH) as seen on TEE. Maximum plaque areas for three locations in the thoracic aorta (arch, proximal descending, and distal descending) were measured with TEE in 156 patients. Maximum plaque areas for these locations were added to yield an estimate of ATH. ATH and H(e) levels, and levels of folic acid, vitamin B12, and pyridoxal 5'-phosphate were measured in a double-blind manner. Univariate analysis demonstrated a significant correlation of H(e) with ATH (r = 0.3, p< 0.001). On multivariate analysis, H(e) was independently predictive of ATH (r for the model including H(e) was 0.63, p < 0.0001). Plasma H(e) levels are therefore significantly and independently correlated with the degree of atherosclerosis in the thoracic aorta

High density lipoprotein has been shown to have a strong negative correlation with the presence of coronary artery atherosclerosis, whereas total cholesterol and low density lipoprotein are positively correlated and the role of triglycerides is complex. The purpose of this study was to determine whether levels of these lipids also correlate with large vessel atherosclerotic plaque burden (ATH) as seen in the thoracic aorta on transesophageal echocardiography. Maximal plaque area in the aortic arch and the proximal and distal descending thoracic aorta was measured by planimetry in 100 pts (mean age 68.5±1.4; 51% males). Maximal plaque areas were added to yield an estimate of total plaque burden. Both plaque burden and lipid measurements were performed in a double-blind manner. Results: There was a significant negative correlation of high density lipoprotein with ATH (R = -0.26, p = 0.009). However, neither total cholesterol (R = 0.08, p = 0.4), low density lipoprotein (R = 0.11, p = 0.28, nor triglycerides (R = 0.06, p = 0.54) were significantly correlated with ATH. Conclusion: Serum high density lipoprotein levels are significantly negatively correlated with thoracic aortic atherosclerotic plaque burden as imaged by transesophageal echocardiography

The purpose of this study was to define the contribution of transesophageal echocardiography to the diagnosis of right atrial tumors in a large series of patients with this rare finding. Transesophageal echocardiography (TEE) has been found to be valuable in evaluating patients with intracardiac masses and has been shown to be superior to transthoracic echocardiography (TTE) in evaluating left heart masses. Between 1989 and 1993, 23 patients with either known tumors elsewhere or right atrial masses that were detected on TTE were evaluated with TEE. TEE studies were performed in the noninvasive cardiology laboratory. All patients were studied with 5 MHz biplane or omniplane transducers. The right atrium was evaluated for the presence, characteristics, extent, and attachment of any masses and for extension of these masses into the great vessels or other cardiac chambers. No complications occurred. Six patients had primary right atrial tumors. In 10 patients the tumors reached the right atrium via the inferior vena cava. Seven patients had malignant secondary tumors. TEE demonstrated three tumors not detected by TTE. Furthermore TEE provided 16 additional findings not seen on TTE. In conclusion, TEE is superior to TTE in the evaluation of right atrial tumors. TEE should be considered in patients with right atrial tumors even when these tumors have been demonstrated with TTE

OBJECTIVES. We attempted to determine the prevalence of strands on native and prosthetic valves, as detected by transesophageal echocardiography, and to assess the relative risk for systemic emboli associated with these strands. BACKGROUND. Fine threadlike strands, seen on native and prosthetic valves by transesophageal echocardiography, have been implicated in systemic embolization. METHODS. During a 2-year period, 1,559 patients underwent transesophageal echocardiography at our center. Of these, 41 patients had strands and no other identifiable source of systemic emboli. They were matched for age, gender, history of hypertension and history of smoking with a control group of 41 patients without strands who also had no identifiable source of emboli. The risk of embolization in the two groups was compared. RESULTS. Of 1,559 patients studied by transesophageal echocardiography, 86 (5.5%) had strands. Strands were far more common on mitral valves than on aortic valves. Of the patients with strands, 38% had had an event consistent with a systemic embolus, whereas 62% had not. Of 597 patients with an embolic event, 63 (10.6%) had strands, whereas only 23 (2.3%) of 962 patients without emboli had strands. In the case-control study, 33 (83%) of the 41 patients with strands without another source of embolism had emboli compared with only 12 (29%) of the 41 control patients without another source (odds ratio 10.0, 95% confidence interval 3.6 to 27.8, p = 0.00001). CONCLUSIONS. Valvular strands visualized by transesophageal echocardiography are associated with systemic embolization