Faculty Bibliography

An unusual right atrial mass was visualized on the transthoracic and single planar transesophageal echocardiograms of a young female patient. Biplane transesophageal echocardiography, however, clearly demonstrated this structure to be a prominent Chiari network. Large eustachian valves and Chiari networks may mimic tumor or thrombus formation when conventional noninvasive diagnostic techniques are used. Multiplanar imaging can be essential in defining anatomical relationships of normal variant structures, eliminating concern for pathological entities and the need for further invasive work-up

The intraaortic balloon pump has been shown to decrease myocardial oxygen demand by afterload reduction, while increasing myocardial oxygen supply by diastolic augmentation of coronary blood flow. This diastolic augmentation of coronary flow has been demonstrated experimentally with invasive methods. Noninvasively, transesophageal echocardiography has demonstrated efficacy in enabling visualization of the proximal left coronary artery and in recording coronary blood flow velocity. To assess the potential of this technique in demonstrating quantitatively the increase in coronary flow during counterpulsation, 6 patients were studied during intermittent balloon pumping. Peak diastolic coronary blood flow velocity increased by a mean of 117% (range 62 to 287) during balloon inflation (p = 0.002). Furthermore, coronary flow velocity integral increased by a mean of 87% (range 43 to 176; p = 0.003). Problems associated with intraaortic balloon pumping were discovered by transesophageal echocardiography in 4 patients (incorrect balloon placement, damage to the aortic wall [2 patients], and premature balloon deflation time). Transesophageal echocardiography can be used in evaluating intraaortic balloon positioning within the aorta and in monitoring coronary artery flow augmentation during counterpulsation. This relatively noninvasive technique adds another dimension to the evaluation of balloon function and may help in optimizing the benefits of counterpulsation

Stroke is an especially serious complication of cardiopulmonary bypass with an incidence of 2% to 5%. This prospective study used transesophageal echocardiography (TEE) in 97 patients more than 65 years of age (mean age, 73 years) to identify those at high risk for aortic atheroemboli. The atheromatous disease of the aorta was graded by TEE: grade I = minimal intimal thickening (n = 29); II = extensive intimal thickening (n = 33); III = sessile atheroma (n = 15); IV = protruding atheroma (n = 10); V = mobile atheroma (n = 10). Clinical evaluation was also performed by intraoperative aortic palpation. Four patients who were graded as having normal aortas by palpation had intraoperative strokes. In contrast, 3 of these 4 patients were in grade V on TEE. The relationship of TEE to incidence of stroke was statistically significant (p less than 0.006), whereas there was no significant correlation between clinical grade and stroke incidence. Four of 10 TEE grade V patients were treated with hypothermic circulatory arrest and aortic arch debridement, and none suffered strokes. The other 6 patients were treated with standard techniques, and 3 had strokes. These results suggest that patients with mobile atheromatous disease are at high risk for embolic strokes that are not predicted by routine clinical evaluation. Selective use of circulatory arrest in the presence of TEE-detected mobile arch atheromas may reduce the risk of intraoperative stroke

An 18-year-old patient underwent repair of traumatic aortic pseudoaneurysm. Postoperatively, the physical examination showed hypertension with 30 mm Hg gradient between the upper and lower extremities. Doppler echocardiographic evaluation demonstrated a new (secondary) aortic coarctation at the site of the repair. Transesophageal echocardiography revealed the detailed anatomy and the cross-sectional area of the coarctation

Transcervical balloon tuboplasty represents a noninvasive technique to treat proximal tubal occlusion. In a multicenter study, 77 women with confirmed bilateral proximal tubal occlusion underwent the procedure. In 71 patients (92%), at least one proximally obstructed fallopian tube was recanalized. Concomitant distal bilateral tubal occlusions were diagnosed after successful proximal tubal balloon recanalizations in 13 patients (17%). In the remaining 64 patients, 22 clinical pregnancies (34%) have been confirmed during a median follow-up period of 12 months. Among those, 17 (77%) resulted in normal deliveries and five (23%) resulted in a first-trimester miscarriage. One patient was diagnosed with an ectopic pregnancy. Among 25 patients who had not conceived within 6 months of the procedure, 17 (68%) demonstrated continuing tubal patency on repeated hysterosalpingogram. We conclude that transcervical balloon tuboplasty is a safe outpatient technique that may represent an alternative to in vitro fertilization or microsurgical reanastomosis of fallopian tubes.