The intraoperative assessment of ascending aortic atheroma: epiaortic imaging is superior to both transesophageal echocardiography and direct palpation

Effective models of delivery of directly observed therapy (DOT) for tuberculosis in resource-poor settings are needed. Intermittent chemotherapy may be an important component of DOT delivered in the community as it means fewer visits to supervisors. There is no published evidence on the efficacy of twice weekly therapy given from the start of treatment without an intensive daily phase. We analysed data from 3 large cohort studies in a migrant, urban workforce in South Africa between 1975 and 1983. All patients received 4 drugs (isoniazid, rifampicin, pyrazinamide and streptomycin) twice weekly under direct observation by a nurse in the workplace. Of 444 patients, 378 (85.1%) completed treatment. Cure could be assessed in 362, and 348 (96.1%, 95% confidence interval 93.7-97.8%) were bacteriologically cured. Sputum status was assessed at 2-3 months in 343 patients and 309 (90.1%) were sputum negative. Eighteen patients relapsed (5.7%; 2.9/100 patient-years of observation). DOT can be effectively delivered to a migrant, urban workforce, and 4-drug therapy given twice weekly under direct observation is efficacious.     

Usefulness of multiplane transesophageal echocardiography to improve the assessment of severity of mitral regurgitation

This study was designed to examine the accuracy of multiplane transesophageal echocardiography (TEE) color Doppler measurements in comparison to monoplane or biplane measurements in estimating the severity of mitral regurgitation (MR). Multiplane TEE potentially increases diagnostic accuracy of transesophageal examinations; it is unknown if multiplane is more accurate in assessing the severity of MR than monoplane or biplane TEE. Left ventricular cineangiograms of 91 patients with MR (40 no or mild, 30 moderate, and 21 severe) were compared with systolic pulmonary venous flow reversal and transesophageal color Doppler measurements: jet area and length in the transverse and longitudinal plane, maximal and average of those 2 planes (biplane), and maximal and average of 11 different planes (multiplane). Flow reversal (16 patients) identified severe MR with a specificity of 96% and a sensitivity of 62%; these were 96% and only 10% to 43%, respectively, for color Doppler measurements. In the absence of flow reversal, multiplane maximal jet area predicted severe MR with a sensitivity of 88% and a specificity of 75%, which were 85% and 76%, respectively, for no or mild MR; this did not differ significantly from results obtained by monoplane or biplane measurements. Color Doppler measurements of eccentric jets were not reliable for identification of severe MR. Systolic pulmonary venous flow reversal identifies 2 of 3 patients with severe MR with a high accuracy. In patients without flow reversal, multiplane color Doppler TEE is very capable of assessing MR severity, but biplane and monoplane TEE are equally accurate.     

Does multiplane transesophageal echocardiography improve the assessment of prosthetic valve regurgitation?

All health-care providers need to understand the effects of alcohol, nicotine, and other drugs on the mother and developing fetus and the ways to promote abstinence or at least a decrease in use. The use of these substances may produce chronic and/or catastrophic effects that force the pregnant woman into contact with the health-care system. Such contact can produce a healthier outcome for both the mother and fetus if it includes identification of substance use and intervention to promote abstinence. In this article, the author describes the consequences of prenatal substance use for the mother and fetus, identifies techniques used to screen and assess prenatal substance use, and explains strategies used to intervene in prenatal substance use.     

Clinical usefulness of the effective regurgitant orifice area determined by transesophageal echocardiography in patients with eccentric aortic regurgitation

BACKGROUND AND AIMS OF THE STUDY: The aortic regurgitant jet is frequently eccentric, and Doppler color flow mapping techniques of the distal jet is influenced by this eccentricity. The aim of the present study was to determine whether the effective regurgitant orifice area (EROA), determined by the proximal isovelocity surface area (PISA) method using multiplane transesophageal echocardiography (m-TEE), could be used to evaluate the severity of aortic regurgitation (AR) in patients with an eccentric jet. METHODS: Forty-eight patients with eccentric AR were studied. Values of EROA determined by the PISA method were compared with results from cross-sectional area (CSA), vena contracta (VC) width, aortic angiography, and regurgitant fraction. RESULTS: Values of EROA correlated well with results from CSA (r = 0.73, p < 0.001), VC (r = 0.74, p < 0.001), angiographic grade (rs = 0.90 p < 0.001), and regurgitant fraction (r = 0.84, p < 0.001) in patients with eccentric aortic regurgitation. Values of EROA > 0.27 cm2 were always associated with a regurgitant fraction > 0.4, while EROA values < 0.27 cm2 were always associated with a regurgitant fraction < 0.4. CONCLUSIONS: We conclude that, in patients with an eccentric jet, measurement of EROA values by the PISA method using m-TEE is a reliable method of assessing the severity of AR.     

Comparison of vena contracta width by multiplane transesophageal echocardiography with quantitative Doppler assessment of mitral regurgitation

OBJECTIVE: To compare prostacyclin with an analogue, iloprost, in treatment of severe pulmonary hypertension. PATIENTS: Eight patients with severe pulmonary hypertension: primary in five, thromboembolic pulmonary hypertension in three. METHODS: All patients underwent right heart catheterisation. Mean (SEM) right atrial pressure was 9.9 (2.2) mm Hg, mean pulmonary artery pressure 67.4 (3.0) mm Hg, cardiac index 1.75 (0.13) l/min/m2 and mixed venous oxygen saturation 59.1(3.1)%. Continuous intravenous epoprostenol (prostacyclin, PGI2) or iloprost was given for phase I (three to six weeks); the patients were then crossed over to receive the alternate drug in an equivalent phase II. MAIN OUTCOME MEASURES: Exercise tolerance was measured at baseline and at the end of phase I and II with a 12 minute walk; distance covered, rest period, percentage drop in arterial oxygen saturation (delta Sao2%) and percentage rise in heart rate (delta HR%). RESULTS: Walking distance covered rose from (mean (SEM)) 407.5 (73) to 591 (46) m with PGI2 (p = 0.004) and to 602.5 (60) m while on iloprost (p = 0.008). Rest period decreased from 192 (73) seconds at baseline to 16 (16) seconds with PGI2 (p = 0.01) and to 58 (34) seconds with iloprost (p = 0.008). Delta HR% was 37.5(6)% at baseline, 35(3)% on PGI2, and 24(6)% on iloprost (p = 0.04). CONCLUSIONS: Both intravenous PGI2 and iloprost caused significant improvement in exercise tolerance. Iloprost offers an alternative to PGI2 treatment of severe pulmonary hypertension.     

Thoracic aortic dissection: diagnosis with transesophageal echocardiography versus MR imaging

PURPOSE: To compare transesophageal echocardiography (TEE) and magnetic resonance (MR) imaging in the diagnosis of dissection of the thoracic aorta. MATERIALS AND METHODS: Thirty-one consecutive patients with clinically suspected aortic dissection and 10 postoperative patients underwent transesophageal color Doppler echocardiography and MR imaging. Imaging results were compared at independent double-blind readings. Final diagnosis was obtained from consensual review of all corroborative studies. RESULTS: MR imaging depicted the intimal flap in 95% of aortic dissections; TEE, in 86% (P < .05). In surgical patients, the sensitivity of MR in detection of residual dissection was 100% versus 86% with TEE (P < .05). The inferior extent of the dissected lumen was seen only with MR imaging. False-positive results occurred in two cases with TEE and in one with MR imaging. CONCLUSION: MR imaging is superior to TEE in the evaluation and follow-up of dissection of the thoracic aorta. Because the availability of MR is limited, however, TEE should remain the standard modality for diagnosis.     

Transgastric Doppler echocardiographic assessment of the severity of aortic stenosis using multiplane transesophageal echocardiography

We investigated whether multiplane transesophageal Doppler echocardiography using transgastral views allows determination of pressure gadients and valve areas in patients with aortic stenosis. This technique was feasible in 35 of 39 patients (90%), with highly significant correlations with results obtained from transthoracic Doppler echocardiography and cardiac catheterization, thus offering an alternative approach for quantification of aortic stenosis.     

Pro: intraoperative transesophageal echocardiography is a cost-effective strategy for cardiac surgical procedures

TEE is an expensive but useful intraoperative diagnostic strategy for cardiac surgical procedures. It can alter surgical management with tremendous potential benefits to the patient. It also has the potential to avoid unnecessary surgery and reduce the risk of complications such as reoperation, thromboembolism, and stroke. As with any new technology, the indications for its use must be evaluated on the basis of cost, benefits, and efficacy to determine the true value and cost-effectiveness in a particular application. Based on the information presented in this report, it can be concluded that TEE is a cost-effective strategy for valvular and congenital heart repairs. Current data are very convincing that TEE has the potential to be cost-effective in reducing the risk of stroke in selected populations of cardiac surgical patients. As experience with the use of TEE in its various applications increases and the technology itself continues to improve, it will undoubtedly become a more valuable and cost-effective strategy for cardiac surgery.     

An integrated approach to the quantification of aortic regurgitation by Doppler echocardiography

BACKGROUND: Although different Doppler methods have been proposed for the quantification of aortic regurgitation, no study has prospectively compared these methods with each other and their correlation with angiography. The aim of this study was to prospectively analyze the usefulness of different Doppler echocardiography parameters by testing all such parameters in each patient. METHODS: Fifty-one patients with aortic regurgitation underwent 2-dimensional and Doppler echocardiographic studies and catheterization. The following Doppler indexes were analyzed and compared with aortography. Color Doppler: (1) jet color height/left ventricular outflow tract height in parasternal long-axis view, and (2) jet color area/left ventricular outflow tract area in short-axis view. Continuous Doppler: (3) regurgitant flow pressure half-time, (4) regurgitant flow time velocity integral (in centimeters), and (5) regurgitant flow time velocity integral (in centimeters)/diastolic period (in milliseconds). Pulsed Doppler in thoracic and abdominal aorta: (6) time velocity integral of diastolic reverse flow (in centimeters), (7) time velocity integral of systolic anterograde flow/integral of diastolic reverse flow, (8) (time velocity integral of diastolic reverse flow/diastolic period) x 100, and (9) diastolic reverse flow duration/diastolic period (as a percentage). We compared these parameters with severity of regurgitation measured by angiography and classified as mild, moderate, or severe. RESULTS: The most useful parameters were (1) jet color height/left ventricular outflow tract height (correctly classified 42 of 49 patients), (2) (time velocity integral of diastolic reverse flow/diastolic period) x 100 in the thoracic aorta (correctly classified 41 of 46 patients), and (3) (time velocity integral of diastolic reverse flow/diastolic period) x 100 in the abdominal aorta (correctly classified 42 of 49 patients). Sequential integration of these 3 parameters correctly classified 96% of patients (44 of 46 patients) and was achieved in 90% of cases. CONCLUSION: An integrated combination of several Doppler parameters can quickly and accurately classify the degree of aortic regurgitation as determined by angiography.     

Dual-helical CT for detecting aortic atheromas as a source of stroke: comparison with transesophageal echocardiography

We examined the relationship between acute hypertension following cerebral embolization and subsequent hemorrhagic transformation (HT) in a rabbit embolic stroke model. We have shown previously that the likelihood and severity of hemorrhage were significantly correlated with the magnitude of an acute hypertensive response to embolization. It was not clear, however, whether hypertension actually caused hemorrhage or was merely a marker of more severe stroke. In the current studies, we attempted to clarify the relationship between acute hypertension and HT by either pharmacologically inducing or attenuating the brief hypertensive response to embolization in rabbits. Under halothane anesthesia, two catheters were implanted in the right carotid arteries of male New Zealand white rabbits, one oriented toward the heart and one toward the brain. The animals were allowed to awaken and were embolized using blood clot emboli injected into the middle cerebral artery. Blood pressure was monitored via the second carotid catheter. In the first experiment, hypertension was induced with angiotensin II, administered at the time of embolization or 1 h later. In the second experiment, we attempted to attenuate the hypertensive response using intravenous labetalol. The animals were sacrificed 18 h after embolization and the brains evaluated for hemorrhage. In the first experiment, administration of angiotensin II immediately after embolization did not increase the hypertensive response to embolization further than that spontaneously occurring, and no angiotensin II-related HT was observed. In contrast, an additional angiotensin-II-induced hypertensive episode 1 h after embolization significantly increased the number of 5-mm serial brain sections displaying HT, from 3.0 +/- .3 (mean +/- SE) in Controls to 5.4 +/- .8 in treated animals. In the second experiment, administration of labetalol (15 mg/kg) significantly reduced the number of brain sections with visible HT, from 3.2 +/- .5 in controls to 1.6 +/- .4 in treated animals. Acute hypertension during the first hour after cerebral embolization promotes HT in this rabbit embolic stroke model. Labetalol prevents blood pressure elevation and reduces the extent of HT in the same model.     

Detection of thrombotic cuspal obstruction of an aortic bioprosthesis with transesophageal echocardiography

Bioprosthetic thrombotic obstruction is a rare complication which occurs relatively early after implantation. We present the transesophageal echocardiographic findings in a case of cuspal thrombosis of a Hancock aortic prosthesis which required valve replacement.     

Aortic complications after aortic valve replacement in patients with dilated ascending aorta and aortic regurgitation

AIMS/BACKGROUND: Compared with nanosecond (ns) pulses of conventional Nd-YAG lasers, picosecond (ps) laser pulses allow intraocular surgery at considerably lower pulse energy. The authors report initial clinical experiences using a Nd:YLF ps laser for the treatment of various indications for photodisruption. METHODS: A Nd:YLF laser system (ISL 2001, wavelength 1053 nm) was used to apply pulse series of 100-400 microJ single pulse energy at a repetition rate of 0.12-1.0 kHz. Computer controlled patterns were used to perform iridectomies (n = 53), capsulotomies (n = 9), synechiolysis (n = 3), and pupilloplasties (n = 2). Other procedures were vitreoretinal strand incision (n = 2) and peripheral retinotomy (n = 1). For comparison, 10 capsulotomies and 20 iridotomies were performed with a Nd:YAG ns laser. The ps laser cut of an anterior capsule was assessed by scanning electron microscopy (SEM). RESULTS: Open, well defined iridectomies (mean total energy 4028 mJ, mean diameter 724 microns), were achieved at first attempt in 92% of the cases. In 64% an iris bleeding and in 21% an IOP increase of > 10 mm Hg occurred. All capsulotomies were performed successfully (mean energy 690 mJ/mm cutting length) but with a high incidence of intraocular lens damage. The attempted vitreoretinal applications remained unsuccessful as a result of optical aberrations of the eye and contact lens. Although ps laser capsulotomies and iridectomies required much higher total energy than ns procedures, the resulting tissue effects of the ps pulses were more clearly defined. SEM examination of a ps incision of the anterior lens capsule demonstrated, nevertheless, that the cut was more irregular than the edge of a continuous curvilinear capsulorhexis. CONCLUSION: Series of ps pulses applied in computer controlled patterns can be used effectively for laser surgery in the anterior segment and are considerably less disruptive than ns pulses. The ps laser is well suited for laser iridectomies while the ns laser is preferable for posterior capsulotomies. As vitreoretinal applications remained unsuccessful, the range of indications for intraocular photodisruption could not be extended by the ps laser.     

The usefulness of transesophageal echocardiography in the diagnosis of atypical aortic coarctation

We report the case of a 20-year-old woman with severe hypertension diagnosed two months previously. The symptoms and physical examination suggested the diagnosis of coarctation of the aorta, but a transthoracic echocardiogram and a thoracic CT scan were normal. Nevertheless, a severe stenosis of the thoracoabdominal aorta was demonstrated by transesophageal echocardiography. The usefulness of transesophageal echocardiography for the diagnosis of atypical coarctation of the aorta is discussed.     

Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection

A 43-year-old woman, whose physical findings were consistent with Marfan's syndrome, presented with acute chest pain. Transthoracic two-dimensional echocardiography demonstrated dilated ascending aorta with a circular shape intimal flap at the root level. Subsequently, the patient required transesophageal echocardiography (TEE), but during esophageal intubation, the patient developed acute pericardial tamponade which resulted in death in spite of cardiopulmonary resuscitation. Although, some investigators recommend TEE as the first choice of diagnostic method of aortic dissection, hemodynamic stability is very important during TEE study. Therefore, aggressive sedation may be required in the case of circumferential dissection of the ascending aorta to prevent the increases of the blood pressure and the heart rate which suggested an extensive tear of the aortic intima during TEE procedure.     

Cor triatriatum in a 70-year-old woman: role of transesophageal echocardiography and dynamic three-dimensional echocardiography in diagnostic assessment

In this report we describe a 70-year-old woman with unrecognized nonobstructive cor triatriatum (CT). She had concomitant mitral regurgitation and coronary artery disease. Diagnosis of CT and its hemodynamic assessment were accomplished by transesophageal echocardiography. Dynamic three-dimensional echocardiography demonstrated multiple fenestrations in the left atrial membrane. Intraoperative findings confirmed the diagnostic accuracy of three-dimensional echocardiography. To our knowledge, this is the first case of CT that has anatomic correlation with three-dimensional echocardiography.