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Identification of left ventricular thrombi by cross-sectional echocardiography
ABSTRACTS
THE ASSESSMENT OF THE RIGHT ATRIUM USING APEX-SECTOR ECHOCARDIOGRAPHY Fredrick G. Kushner, MD; Wilfred Lam, MD; Patricia Klunder, BS; Joel Morganroth, MD, FACC, University of Pennsylvania School of Medicine, Philadelphia, Pa. Using an apex view with the cross sectional SKF Echosector (ASE), right atria1 (RA) and left atria1 (LA) dimensions were evaluated in 25 patients (pts)(l3 males, age 17-76 yrs) and compared to the LA, left ventricular (LV) and right ventricular (RV) dimensions as measured Data were obtained in using the M-mode echocardiogram. the following groups: secundum (2") and primum (1") atria1 septal defects (ASD), congestive cardiomyopathy (CCM), idiopathic hypertrophic subaortic stenosis (IHSS), valvular aortic stenosis (AS) and normals (NL): M-Mode (in mm) ASE (range in mm) RV LA iA RA iv 14-26 30-39 23-36 NL 30-39 40-49 17-18 33-50 26-58 40-45 AS 31-47 32-50 32-40 14-19 40-45 IHSS 40-50 13-19 40-55 30-49 54-73 CCM 48-60 34-53 11-34 40-60 31-51 1" AS0 50-60 24-45 32-40 29-32 35-42 2" AS0 50-60 Although the M-mode RV dimensions were normal in all pts with IHSS and CCM, the ASE-RA dimensions were abnormal in all cases. Similarly, in pts with RV volume overload (ASDS) the M-mode RV size may be normal in some cases, There whereas the ASE-RA size was abnormal in all cases. was a poor correlation between ASE and M-mode LA size. In conclusion, ASE is a valuable tool to evaluate RA dimension, and appears to be more sensitive than the Mmode echocardiogram in detecting right heart disease. In addition, ASE may provide a more complete evaluation of LA abnormalities.
IDENTIFICATION OF LEFT VENTRICULAR THROMBI BY CROSS-SECTIONAL ECHOCARDIOGRAPHY Alexander Neumann; William Bommer, MD; Lynn Weinert; Todd Grehl, MO, FACC; Dean T. Mason, MD, FACC; Ezra A. Amsterdam, MD, FACC; Anthony N. DeMaria, MD, FACC; University of California, Davis, California. The detection of left ventricular thrombi (LVT) following myocardial infarction remains a difficult problem. Thus, we studied 15 consecutive infarction patients (pts) by M-mode and two-dimensional (2-D) echocardiography to assess the value of these techniques in the recognition of LVT. All pts had anterior infarctions and large antero-apical dyskinetic segments on cineangiography (tine). Three pts exhibited evidence of LVT consisting of recurrent systemic emboli (EMB). Two EMB pts showed apical filling defects on tine. The third EMB pt had a levophase tine which failed to demonstrate a defect, but was found to have a 2-3 cm apical LVT at surgery. No non-EMB pt had tine evidence of LVT. Z-D echo images were obtained along the long (LA) and short axes (SA) of the left ventricle with the transducer at the left sternal border; and in a hemiaxial (HA) projection with the transducer at the cardiac apex. Although the LA and SA views confirmed the presence of dyskinesis, they did not provide sufficient imaging of the apex to delineate an abnormal mass. However, in all 3 EMB pts intense echoes from a distinct apical mass were visualized with the HA view. No evidence of LVT was observed on Z-D exam in any of the non-EMB pts. M-mode echoes revealed apical akinesis in all pts, however despite multiple M-mode scans, no consistent echo producing mass could be visualized. Thus, although M-mode visualization of thrombi is unreliable in most pts, Z-D in the hemiaxial view provides clear demonstration of these masses and may obviate the need for angiography.
392
February 1978
The American Journal of CARDIOLOGY
USEFULNESS 0~ THE TIME INTERVAL HISTOGRAM (TIH) OF THE RANGE-GATED PULSED DOPPLER (RGPD) FOR DETECTING LEFT-TORIGHT ATRIAL SHUNTS (LRAS) Stanley J. Goldberg, MD, FACC; Jose C. Areias, MD; Folkert de Villeneuve, MD; Silia Spitaels, MD; U. of AZ., Tucson, and Erasmus U., Rotterdam. The purpose of this investigation was to determine if children with LRAS could be separated noninvasively from those with other cardiac lesions exclusively by examination of the TIH of the RGPD. The RGPD allows Doppler sampling within a 2X4mm sample volume defined in location by the M-mode echocardiogram. TIH is a graphic frequency-time histogram created at a sampling rate of 4,00O/sec., on which a frequency dispersion indicates nonlaminar flow. TIH dispersion in 96 instances of normal flow was less than 1 cm amplitude and thus, 1 cm was used as the upper normal limit. The study population consisted of 15 experimental children with LBAS and 43 acyanotic controls. The criterion for recognition of LRAS was diastolic TIH dispersion >l cm amplitude with the range gate in the right atria1 outflow tract. Observer bias was diminished because they 1) were unfamiliar with the children, 2) were blind to their diagnoses, 3) were protected from casual remarks by language barrier, 4) reported results by analyzing pooled, unmarked records independently by reference only to a code number. Under these circumstances, one examiner detected all instances of LRAS and the other detected 14/ 15 instances (pc.01). No false positives occurred for controls. An important difference between this and prior RGPD studies is that the present one evaluated only graphic TIH output whereas others relied principally on audible output for all judgements. TIH technique is more objective than the audible one and results can be evaluated by others without special audio equipment. This investigation demonstrates the clinical utility of graphic TIH output of the RGPD.
DIAGNOSIS OF VENTRICULAR SEPTAL DEFECT BY PULSED DOPPLER ECHOCARDIOGRAPHY - SENSITIVITY, SPECIFICITY, LIMITATIONS J.G. Stevenson, MD.: I. Kawabori, MO.; T.K. Dooley, BS.; and W.G. Guntheroth, MD.; University of Washington Hospital, Seattle The M-mode echocardiographic findings of ventricular septal defect (VSD) are usually non-specific. A VSD is suspected when turbulent blood flow is detected in the right ventricle by pulsed Doppler echocardiography (PDE), and a specific PDE diagnosis of VSD can be made by following the turbulent VSD jet through the septum. In order to assess the sensitivity, specificity and limitations of PDE diagnosis of VSD, 105 children undergoing cardiac catheterization were examined by PDE. Catheterization diagnoses included VSD in 51 (isolated in 31, with transposition of the great arteries (TGA) in 3, tetralogy 7, A-V canal 5, truncus arteriosus 5). The PDE diagnosis of VSD was made in 46/5i = 90%. There was one false positive diagnosis of VSD in a youngster with left ventricle to right atria1 shunt but no clear VSD, yielding a specificity of YR%. Five had VSD jets which could not be followed through the septum: 1 in unusual (apical) location, 1 in TGA with shunt from anatomic RV to LV (unusual flow direction) 3 in youngsters with large VSD and elevations of pulmonary resistance ranging from 8.9 to 13.3 units (little VSD turbulence, no discrete jet to follow). The presence of additional shunts (atrial, ductal) did not compromise our ability to diagnose VSD by PDE. The PDE detection of isolated, or complicated VSD with overall sensitivity of 90% and specificity of 98% has obvious clinical utility. The PDE diagnosis of VSD may be more difficult however in cases with unusual VSD location or flow direction, or with elevated pulmonary resistance.
Volume 41
THE ASSESSMENT OF THE RIGHT ATRIUM USING APEX-SECTOR ECHOCARDIOGRAPHY Fredrick G. Kushner, MD; Wilfred Lam, MD; Patricia Klunder, BS; Joel Morganroth, MD, FACC, University of Pennsylvania School of Medicine, Philadelphia, Pa. Using an apex view with the cross sectional SKF Echosector (ASE), right atria1 (RA) and left atria1 (LA) dimensions were evaluated in 25 patients (pts)(l3 males, age 17-76 yrs) and compared to the LA, left ventricular (LV) and right ventricular (RV) dimensions as measured Data were obtained in using the M-mode echocardiogram. the following groups: secundum (2") and primum (1") atria1 septal defects (ASD), congestive cardiomyopathy (CCM), idiopathic hypertrophic subaortic stenosis (IHSS), valvular aortic stenosis (AS) and normals (NL): M-Mode (in mm) ASE (range in mm) RV LA iA RA iv 14-26 30-39 23-36 NL 30-39 40-49 17-18 33-50 26-58 40-45 AS 31-47 32-50 32-40 14-19 40-45 IHSS 40-50 13-19 40-55 30-49 54-73 CCM 48-60 34-53 11-34 40-60 31-51 1" AS0 50-60 24-45 32-40 29-32 35-42 2" AS0 50-60 Although the M-mode RV dimensions were normal in all pts with IHSS and CCM, the ASE-RA dimensions were abnormal in all cases. Similarly, in pts with RV volume overload (ASDS) the M-mode RV size may be normal in some cases, There whereas the ASE-RA size was abnormal in all cases. was a poor correlation between ASE and M-mode LA size. In conclusion, ASE is a valuable tool to evaluate RA dimension, and appears to be more sensitive than the Mmode echocardiogram in detecting right heart disease. In addition, ASE may provide a more complete evaluation of LA abnormalities.
IDENTIFICATION OF LEFT VENTRICULAR THROMBI BY CROSS-SECTIONAL ECHOCARDIOGRAPHY Alexander Neumann; William Bommer, MD; Lynn Weinert; Todd Grehl, MO, FACC; Dean T. Mason, MD, FACC; Ezra A. Amsterdam, MD, FACC; Anthony N. DeMaria, MD, FACC; University of California, Davis, California. The detection of left ventricular thrombi (LVT) following myocardial infarction remains a difficult problem. Thus, we studied 15 consecutive infarction patients (pts) by M-mode and two-dimensional (2-D) echocardiography to assess the value of these techniques in the recognition of LVT. All pts had anterior infarctions and large antero-apical dyskinetic segments on cineangiography (tine). Three pts exhibited evidence of LVT consisting of recurrent systemic emboli (EMB). Two EMB pts showed apical filling defects on tine. The third EMB pt had a levophase tine which failed to demonstrate a defect, but was found to have a 2-3 cm apical LVT at surgery. No non-EMB pt had tine evidence of LVT. Z-D echo images were obtained along the long (LA) and short axes (SA) of the left ventricle with the transducer at the left sternal border; and in a hemiaxial (HA) projection with the transducer at the cardiac apex. Although the LA and SA views confirmed the presence of dyskinesis, they did not provide sufficient imaging of the apex to delineate an abnormal mass. However, in all 3 EMB pts intense echoes from a distinct apical mass were visualized with the HA view. No evidence of LVT was observed on Z-D exam in any of the non-EMB pts. M-mode echoes revealed apical akinesis in all pts, however despite multiple M-mode scans, no consistent echo producing mass could be visualized. Thus, although M-mode visualization of thrombi is unreliable in most pts, Z-D in the hemiaxial view provides clear demonstration of these masses and may obviate the need for angiography.
392
February 1978
The American Journal of CARDIOLOGY
USEFULNESS 0~ THE TIME INTERVAL HISTOGRAM (TIH) OF THE RANGE-GATED PULSED DOPPLER (RGPD) FOR DETECTING LEFT-TORIGHT ATRIAL SHUNTS (LRAS) Stanley J. Goldberg, MD, FACC; Jose C. Areias, MD; Folkert de Villeneuve, MD; Silia Spitaels, MD; U. of AZ., Tucson, and Erasmus U., Rotterdam. The purpose of this investigation was to determine if children with LRAS could be separated noninvasively from those with other cardiac lesions exclusively by examination of the TIH of the RGPD. The RGPD allows Doppler sampling within a 2X4mm sample volume defined in location by the M-mode echocardiogram. TIH is a graphic frequency-time histogram created at a sampling rate of 4,00O/sec., on which a frequency dispersion indicates nonlaminar flow. TIH dispersion in 96 instances of normal flow was less than 1 cm amplitude and thus, 1 cm was used as the upper normal limit. The study population consisted of 15 experimental children with LBAS and 43 acyanotic controls. The criterion for recognition of LRAS was diastolic TIH dispersion >l cm amplitude with the range gate in the right atria1 outflow tract. Observer bias was diminished because they 1) were unfamiliar with the children, 2) were blind to their diagnoses, 3) were protected from casual remarks by language barrier, 4) reported results by analyzing pooled, unmarked records independently by reference only to a code number. Under these circumstances, one examiner detected all instances of LRAS and the other detected 14/ 15 instances (pc.01). No false positives occurred for controls. An important difference between this and prior RGPD studies is that the present one evaluated only graphic TIH output whereas others relied principally on audible output for all judgements. TIH technique is more objective than the audible one and results can be evaluated by others without special audio equipment. This investigation demonstrates the clinical utility of graphic TIH output of the RGPD.
DIAGNOSIS OF VENTRICULAR SEPTAL DEFECT BY PULSED DOPPLER ECHOCARDIOGRAPHY - SENSITIVITY, SPECIFICITY, LIMITATIONS J.G. Stevenson, MD.: I. Kawabori, MO.; T.K. Dooley, BS.; and W.G. Guntheroth, MD.; University of Washington Hospital, Seattle The M-mode echocardiographic findings of ventricular septal defect (VSD) are usually non-specific. A VSD is suspected when turbulent blood flow is detected in the right ventricle by pulsed Doppler echocardiography (PDE), and a specific PDE diagnosis of VSD can be made by following the turbulent VSD jet through the septum. In order to assess the sensitivity, specificity and limitations of PDE diagnosis of VSD, 105 children undergoing cardiac catheterization were examined by PDE. Catheterization diagnoses included VSD in 51 (isolated in 31, with transposition of the great arteries (TGA) in 3, tetralogy 7, A-V canal 5, truncus arteriosus 5). The PDE diagnosis of VSD was made in 46/5i = 90%. There was one false positive diagnosis of VSD in a youngster with left ventricle to right atria1 shunt but no clear VSD, yielding a specificity of YR%. Five had VSD jets which could not be followed through the septum: 1 in unusual (apical) location, 1 in TGA with shunt from anatomic RV to LV (unusual flow direction) 3 in youngsters with large VSD and elevations of pulmonary resistance ranging from 8.9 to 13.3 units (little VSD turbulence, no discrete jet to follow). The presence of additional shunts (atrial, ductal) did not compromise our ability to diagnose VSD by PDE. The PDE detection of isolated, or complicated VSD with overall sensitivity of 90% and specificity of 98% has obvious clinical utility. The PDE diagnosis of VSD may be more difficult however in cases with unusual VSD location or flow direction, or with elevated pulmonary resistance.
Volume 41