- Email: [email protected]
Doppler echocardiographic evaluation of pseudoaneurysms complicating composite grafts of the ascending aorta
372
21B
Journal of the American Societyof Echocardiography May-June 1995
Abstracts
A Prospective, Randomized, Blinded Comparison of Multiplane and Biplane Transesophageal Echocardiography. James G. Warner, Jr., M.D., Ed.D., Mohammed Salim, M.D., AbdelMohsen Nomeir, M.D., Dalane W. Kitzman, M.D., The Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC
23B
Although muttiplane transesophagealechocardiography (TEE) is becoming an accepted diagnostic technique, there has been no prospective, randomized, blinded study comparing its ability to visualize intracardiac structures to biplane TEE. Therefore, we performed dual multiplane and biplane TEE exams using a single intubation with a multiplane probe on 50 patients (100 total studies). The order of the techniques and or 2 independent expedenced examiners was randomly assigned. One independent examiner was only allowed to use 0~ and 90~ sector planes (biplane technique), while the other examiner used all planes from 0~ to 180~ (multiplane technique). Images of 29 prospectively selected cardiac structures and valvular function parameters were scored as follows: 0=not visualized, 1=visualized enough to identify, 2=diagnostic quality, 3=exceptional quality. Studies were presented for scoring in random sequence to an experienced reviewer blinded to the technique. Intraobserver reliability was high (1=0.86). Correlation between 2 independent reviewers on 25 studieswas also good (r=0.77). Results: M e a n total structure visualization quality score, the predetermined primary outcome measurement, was significantly higher for the multiplane technique (49.2+6.7) than the biplane technique (45.1+_6.8)(p=0.0001). Several individual structures were significantly better visualized by the multiplane technique: ascending aorta (p=0.0002), left upper pulmonary vein (p=0.02), fossa ovalis (p=0.02), and left main coronary artery (p=0.03). Several other structures showed a strong trend (p<0.07) toward better visualization with the multiplane technique, including the dght upper pulmonary vein, mitral valve subvalvular apparatus, fight coronary artery, pulmonic valve apparatus, main pulmonary artery, and aortic valve function. A separate subjective score of overall adequacy of the study for addressing the clinical indication showed a strong trend (p=0.06) in favor of the multiplane technique with higher scores in 11/50 multiplane studies versus 3/50 biplane studies. Conclusion: Multiplane TEE provides superior overall visualization of intracardiac structures when compared to biplane, padicutady for the ascending aorta, left upper pulmonary vein, fossa ovalis, and left main coronary artery.
22B
DOPPLER ECHOCARDIOGRAPHIC EVALUATION OF PSEUDOANEURYSMS COMPLICATING COMPOSITE GRA?TS OF THE ASCENDING AORTA Kenji Nakamura MD, Naoko Ishizuka ~ , Kiyomi Niki MD, Youko Fujita t~, Akimasa Hashimoto MD, Hitoshi Koyanagi ~fD, Saichi Hosoda ~D. The Heart Institute of Japan, Tokyo Women's Medical College, Tokyo. Japan Composite graft replacement of the ascending aorta and aortic valve has become the procedure of choice for the treatment of ascending aortic aneurysm with associated aortic valvular regurgitation. Among complications of composite grafts is the development of pseudoaneurysm (PA) of the ascending aorta secondary to dehiscence of the suture line at the aortic annulus, coronary ostia, or distal graft anastomosis. We have examined 45 patients(pts) with composite aortic grafts using transthoracic(TTDE) and transesophageal (TEDE) Doppler echocardiography and assessed the usefulness of Doppler techniques in identifying the serious complication. In the 9 pts with PA (dehiscence of coronary ostia 7 and distal anastomosis 2) confirmed at surgery, PA was diagnosed as an enlarged ascending aorta with an echofree space of 2 cm or more between the aortic graft and the native aortic wall, along with the demonstration of abnormal flow into the echo-free space, and localization of its site of origin using TTDE(6/9) and TEDE (9/9). In 36 pts in whom aortography did not indicate PA, the maximal diameter of the ascending aorta averaged 3.6 • 0.3 cm (3.0-4.1 cm) and both left(34/36) and ri~it(32/36) coronary ostium and coronary flow were identified using TEDE. In the 12 pts with no PA, periductal thrombus between the conduit wall and the native wrapped aorta was detected, but good coronary flow was identified in all pts by TEDE. Yhus, TEDE may be a sensitive non-invasive tool to detect thrombus and abnormal blood flow in PA, and may identify the groups for developing late complications.
Transesophageal versus Transthoracic E c h o c a r d i o g r a p h y in t h e E v a l u a t i o n of Right Atrial Tumors Gila Leibowitz MD, Norma Keller MD, Werner G. Daniel MD, Robin S. Freedberg MD, Paul A. Tunick MD, Christoph Stottmeister MD, Itzhak Kronzon MD. NYU Medical Center, NY, NY, and Hannover Medical School, Hannover, Germany
This study compared the relative yield of transesophageal echo (TEE) and transthoracic echo (TTE) in the evaluation of right atrial tumors (RAT). 23 pts with RAT had TTE and TEE. 6 pts had primary RAT (3 myxoma, 1 fibroelastoma, 1 fibrosarcoma, 1 rhabdomyosarcoma). In 10 pts the tumors r e a c h e d t h e RA v i a t h e i n f e r i o r v e n a c a v a (6 hypernephroma, 3 intravenous l e J o m y o m a t o s J s , 1 stromomyoma). 7 pts had malignant secondary tumors (1 melanoma, 1 liposarcoma, 1 osteogenie sarcoma, 1 l e i o m y o s a r c o m a , 1 b r o n c h i a l c a r c i n o m a , 1 small cell carcinoma, 1 sarcoma). TEE demonstrated 3 tumors net detected by TTE. TEE provided 16 additional findings net seen on TTE: regarding size in 6, site of attachment in 1, involver~ent of great vessels in 3, extension to adjacent tissues in 2, external atrial compression by tumor in 1, extension to the right ventricle in 1, mobile component in 1, and additional masses in 1. Conclusions: 1. TEE is superior to TTE in the evaluation of right atrial tumors. 2. TEE should be considered in pts with RAT even when RAT has been demonstrated with TTE.
24B
COMPARISON OF LEFT VENTRICULAR MASS BY TRANSESOPHAGEALTO TRANSTHORACIC ECHO John Jue MD, Ken Gin MD, Brad Munt MD. Vancouver Hospital and Health Sciences Center, UBC, Vancouver, BC, Canada Backaround: Although M mode derived mass has been proven to have prognostic significance in population studies, 2D transthoraeic echo (TTE) derived mass has been recommended by the American Society of Echocardiegraphy for individual patients to detect serial changes. Transesophageal echo (TEE) has the potential for greater accuracy in measuring mass but its correlation to 2D TTE mass is unknown. We hypothesize that 2D mass may be different by TEE compared to TTE due to slightly dissimilar imaging planes obtained. Methods: Patients referred for TEE for clinical indications who also had technically adequate l-rE images during the same setting were studied. Area length (AL) and truncated ellipsoid (TE) formulae were used to calculate mass from the TEE gastric short axis and longitudinal views. Mean wall thickness (MWT) and left ventricular (LV) length (L) were recorded "FI-E mass was also calculated independently by these same formulae by observers blinded to the TEE results. Results: massAL (g) massTE (g) MWT (mm) L (cm) n=26 rEE ~14+35* 104_+24* 8.2_+1.8 7.42+_07I * *p
/
/ y=~3x+3o , / / .
o o Oj~eo
TEETEE
~
I
TE ss
~1y=.93x+27/
| 6
2:~[0
260
6 0 ~ ~ ~ o. _T_.E=: 40
o
. 240
Conclusions: TEE underestimates 2D derived LV mass compared to TTE. This underscores the fact that the views used in TEE are not completely synonomous with those during "FI'E. In the calculation of LV 2D mass, the discrepancy appears to be due predominantly to foreshortening of the long axis dimension by TEE. Mean wall thickness by these two lechniques did not differ.
21B
Journal of the American Societyof Echocardiography May-June 1995
Abstracts
A Prospective, Randomized, Blinded Comparison of Multiplane and Biplane Transesophageal Echocardiography. James G. Warner, Jr., M.D., Ed.D., Mohammed Salim, M.D., AbdelMohsen Nomeir, M.D., Dalane W. Kitzman, M.D., The Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC
23B
Although muttiplane transesophagealechocardiography (TEE) is becoming an accepted diagnostic technique, there has been no prospective, randomized, blinded study comparing its ability to visualize intracardiac structures to biplane TEE. Therefore, we performed dual multiplane and biplane TEE exams using a single intubation with a multiplane probe on 50 patients (100 total studies). The order of the techniques and or 2 independent expedenced examiners was randomly assigned. One independent examiner was only allowed to use 0~ and 90~ sector planes (biplane technique), while the other examiner used all planes from 0~ to 180~ (multiplane technique). Images of 29 prospectively selected cardiac structures and valvular function parameters were scored as follows: 0=not visualized, 1=visualized enough to identify, 2=diagnostic quality, 3=exceptional quality. Studies were presented for scoring in random sequence to an experienced reviewer blinded to the technique. Intraobserver reliability was high (1=0.86). Correlation between 2 independent reviewers on 25 studieswas also good (r=0.77). Results: M e a n total structure visualization quality score, the predetermined primary outcome measurement, was significantly higher for the multiplane technique (49.2+6.7) than the biplane technique (45.1+_6.8)(p=0.0001). Several individual structures were significantly better visualized by the multiplane technique: ascending aorta (p=0.0002), left upper pulmonary vein (p=0.02), fossa ovalis (p=0.02), and left main coronary artery (p=0.03). Several other structures showed a strong trend (p<0.07) toward better visualization with the multiplane technique, including the dght upper pulmonary vein, mitral valve subvalvular apparatus, fight coronary artery, pulmonic valve apparatus, main pulmonary artery, and aortic valve function. A separate subjective score of overall adequacy of the study for addressing the clinical indication showed a strong trend (p=0.06) in favor of the multiplane technique with higher scores in 11/50 multiplane studies versus 3/50 biplane studies. Conclusion: Multiplane TEE provides superior overall visualization of intracardiac structures when compared to biplane, padicutady for the ascending aorta, left upper pulmonary vein, fossa ovalis, and left main coronary artery.
22B
DOPPLER ECHOCARDIOGRAPHIC EVALUATION OF PSEUDOANEURYSMS COMPLICATING COMPOSITE GRA?TS OF THE ASCENDING AORTA Kenji Nakamura MD, Naoko Ishizuka ~ , Kiyomi Niki MD, Youko Fujita t~, Akimasa Hashimoto MD, Hitoshi Koyanagi ~fD, Saichi Hosoda ~D. The Heart Institute of Japan, Tokyo Women's Medical College, Tokyo. Japan Composite graft replacement of the ascending aorta and aortic valve has become the procedure of choice for the treatment of ascending aortic aneurysm with associated aortic valvular regurgitation. Among complications of composite grafts is the development of pseudoaneurysm (PA) of the ascending aorta secondary to dehiscence of the suture line at the aortic annulus, coronary ostia, or distal graft anastomosis. We have examined 45 patients(pts) with composite aortic grafts using transthoracic(TTDE) and transesophageal (TEDE) Doppler echocardiography and assessed the usefulness of Doppler techniques in identifying the serious complication. In the 9 pts with PA (dehiscence of coronary ostia 7 and distal anastomosis 2) confirmed at surgery, PA was diagnosed as an enlarged ascending aorta with an echofree space of 2 cm or more between the aortic graft and the native aortic wall, along with the demonstration of abnormal flow into the echo-free space, and localization of its site of origin using TTDE(6/9) and TEDE (9/9). In 36 pts in whom aortography did not indicate PA, the maximal diameter of the ascending aorta averaged 3.6 • 0.3 cm (3.0-4.1 cm) and both left(34/36) and ri~it(32/36) coronary ostium and coronary flow were identified using TEDE. In the 12 pts with no PA, periductal thrombus between the conduit wall and the native wrapped aorta was detected, but good coronary flow was identified in all pts by TEDE. Yhus, TEDE may be a sensitive non-invasive tool to detect thrombus and abnormal blood flow in PA, and may identify the groups for developing late complications.
Transesophageal versus Transthoracic E c h o c a r d i o g r a p h y in t h e E v a l u a t i o n of Right Atrial Tumors Gila Leibowitz MD, Norma Keller MD, Werner G. Daniel MD, Robin S. Freedberg MD, Paul A. Tunick MD, Christoph Stottmeister MD, Itzhak Kronzon MD. NYU Medical Center, NY, NY, and Hannover Medical School, Hannover, Germany
This study compared the relative yield of transesophageal echo (TEE) and transthoracic echo (TTE) in the evaluation of right atrial tumors (RAT). 23 pts with RAT had TTE and TEE. 6 pts had primary RAT (3 myxoma, 1 fibroelastoma, 1 fibrosarcoma, 1 rhabdomyosarcoma). In 10 pts the tumors r e a c h e d t h e RA v i a t h e i n f e r i o r v e n a c a v a (6 hypernephroma, 3 intravenous l e J o m y o m a t o s J s , 1 stromomyoma). 7 pts had malignant secondary tumors (1 melanoma, 1 liposarcoma, 1 osteogenie sarcoma, 1 l e i o m y o s a r c o m a , 1 b r o n c h i a l c a r c i n o m a , 1 small cell carcinoma, 1 sarcoma). TEE demonstrated 3 tumors net detected by TTE. TEE provided 16 additional findings net seen on TTE: regarding size in 6, site of attachment in 1, involver~ent of great vessels in 3, extension to adjacent tissues in 2, external atrial compression by tumor in 1, extension to the right ventricle in 1, mobile component in 1, and additional masses in 1. Conclusions: 1. TEE is superior to TTE in the evaluation of right atrial tumors. 2. TEE should be considered in pts with RAT even when RAT has been demonstrated with TTE.
24B
COMPARISON OF LEFT VENTRICULAR MASS BY TRANSESOPHAGEALTO TRANSTHORACIC ECHO John Jue MD, Ken Gin MD, Brad Munt MD. Vancouver Hospital and Health Sciences Center, UBC, Vancouver, BC, Canada Backaround: Although M mode derived mass has been proven to have prognostic significance in population studies, 2D transthoraeic echo (TTE) derived mass has been recommended by the American Society of Echocardiegraphy for individual patients to detect serial changes. Transesophageal echo (TEE) has the potential for greater accuracy in measuring mass but its correlation to 2D TTE mass is unknown. We hypothesize that 2D mass may be different by TEE compared to TTE due to slightly dissimilar imaging planes obtained. Methods: Patients referred for TEE for clinical indications who also had technically adequate l-rE images during the same setting were studied. Area length (AL) and truncated ellipsoid (TE) formulae were used to calculate mass from the TEE gastric short axis and longitudinal views. Mean wall thickness (MWT) and left ventricular (LV) length (L) were recorded "FI-E mass was also calculated independently by these same formulae by observers blinded to the TEE results. Results: massAL (g) massTE (g) MWT (mm) L (cm) n=26 rEE ~14+35* 104_+24* 8.2_+1.8 7.42+_07I * *p
/
/ y=~3x+3o , / / .
o o Oj~eo
TEETEE
~
I
TE ss
~1y=.93x+27/
| 6
2:~[0
260
6 0 ~ ~ ~ o. _T_.E=: 40
o
. 240
Conclusions: TEE underestimates 2D derived LV mass compared to TTE. This underscores the fact that the views used in TEE are not completely synonomous with those during "FI'E. In the calculation of LV 2D mass, the discrepancy appears to be due predominantly to foreshortening of the long axis dimension by TEE. Mean wall thickness by these two lechniques did not differ.