Faculty Bibliography

OBJECTIVES: The study examined the value of contrast echocardiography in the assessment of left ventricular (LV) wall motion in intensive care unit (ICU) patients. BACKGROUND: Echocardiograms done in the ICU are often suboptimal. The most common indication is the evaluation of LV wall motion and ejection fraction (EF). METHODS: Transthoracic echocardiograms were done in 70 unselected ICU patients. Wall motion was evaluated on standard echocardiography (SE), harmonic echocardiography (HE), and after intravenous (IV) contrast echocardiography (CE) using a score for each of 16 segments. A confidence score was also given for each segment with each technique (unable to judge; not sure; sure). The EF was estimated visually for each technique, and a confidence score was applied to the EF. RESULTS: Uninterpretable wall motion was present in 5.4 segments/patient on SE, 4.4 on HE (p = 0.2), and 1.1 on CE (p < 0.0001). An average of 7.8 segments were read with surety on SE, 9.2 on HE (p = 0.1), and 13.7 on CE (p < 0.0001). Ejection fraction was uninterpretable in 23% on SE, 13% on HE (p = 0.14), and 0% on CE (p = 0.002 vs. HE; p < 0.0001 vs. SE). The EF was read with surety in 56% of patients on SE, 62% on HE (p = 0.47), and 91% on CE (p < 0.0001). Thus, wall motion was seen with more confidence on CE. More importantly, the actual readings of segmental wall motion and EF significantly differed using CE. CONCLUSIONS: CE should be used in all ICU patients with suboptimal transthoracic echocardiograms

Twenty patients with right atrial thrombi were identified through the use of transthoracic and transesophageal echocardiography. Transesophageal echocardiography identified right atrial thrombi in all 20 cases. Transthoracic echocardiography showed definite thrombi in only 6 (30%) cases and suggested thrombus in another 2 (10%) patients. Thus transthoracic echocardiography results were false-negative for right atrial thrombus in 60% of cases. All 3 thrombi found within the right atrial appendage and 2 of 3 thrombi on pacemaker wires were missed by transthoracic echocardiography. There was no significant difference in the mean size between those thrombi seen (1.37 +/- 0.6 cm) and those missed (1.5 +/- 0.9 cm) by transthoracic echocardiography. Transesophageal echocardiography also significantly affected treatment. Anticoagulation was initiated or amplified in 13 patients. In 8 of these 13, thrombi were seen only by transesophageal echocardiography. Surgery was performed to remove thrombi in 7 cases, and in 3 (43%) cases it was because of thrombi seen only by transesophageal echocardiography. This study suggests that transesophageal echocardiography should be performed whenever right atrial thrombi are suspected. Transesophageal echocardiography has a significant effect on the diagnosis and management of patients with right atrial thrombi

Cardiac compression is a potentially life-threatening complication of heart surgery. This syndrome often has atypical manifestations, challenging our ability to make a rapid diagnosis and to institute emergent, life-saving treatment. We recently evaluated one such patient who showed cardiac compression caused by an unusual paracardiac mass. The addition of transesophageal echocardiography to the usual transthoracic study may have played more than just a diagnostic role in this case

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

Background: Transesophageal echocardiography (TEE) is of proven value in the identification of intracardiac masses, TEE has been shown to be superior to transthoracic echocardiography (TTE) in the evaluation of left heart masses and right atrial (RA) tumors. To date no large series has addressed the role of TEE in the diagnosis and management of RA thrombi. Methods: Our echo database for all TTEs and TEEs done between 1988 and 1996 was retrospectively reviewed. Echoes showing RA thrombi were included in the present study. The location and extension of the thrombi were noted, as well as whether or not pt management was affected by the TEE results. Results: 20 cases of RA thrombi were identified by TEE, however TTE showed definite thrombi in only 6 of these (30%) and possible thrombi in an additional 2 pts. Therefore TTE was false negative in 60%. Demonstration of the size and site of attachment of the thrombus was better on TEE in 100% of pts. TEE only showed thrombi extending into the superior vena cava, the inferior vena cava, the right ventricle, and across a patent foramen ovale into the left atrium in 1 pt each. More than 1 thrombus was found on TEE in 11 of 20 pts (55%), whereas there was no pt in whom TTE showed more than one thrombus. Management: Anticoagulation was started or increased in 13 pts. In 8 (62%) of these, thrombus was seen only on TEE. Surgery was performed to remove thrombus in 6 pts, and in 3 (50%) the surgery was prompted by findings seen on TEE but missed by TTE. Therefore, management was changed in 11 of 20 pts (55%) because of findings seen only on TEE. Conclusions: 1. TEE is superior to TTE for the diagnosis and evaluation of RA thrombi. 2. TEE should be performed whenever RA thrombus is suspected, in spite of a negative TTE. 3. TEE has an important impact on clinical decision making in pts with RA thrombi

Transesophageal echocardiography (TEE) is superior to other imaging techniques for the diagnosis of aortic trauma. It can accurately, rapidly, and safely diagnose life-threatening conditions such as aortic rupture, pseudoaneurysm, traumatic aortic dissection, and intramural hematoma. TEE is useful for the diagnosis and prevention of iatrogenic aortic trauma induced by cardiovascular surgery, intraaortic procedures, and cardiopulmonary resuscitation. (ECHOCARDIOGRAPHY, Volume 13, March 1996)

Transesophageal echocardiography provided an accurate diagnosis of intimal flap prolapse into the left ventricle in all 6 of our patients. This complication of AD is a newly recognized and uncommonly discerned cause of severe AR