- Email: [email protected]
Spontaneous echocardiographic contrast with the carbomedics mitral valve prosthesis
adrenernic activitv. Am J Cordial 1989:64:1379-1382 13. Marraccini P, Levantesi D, Michelassi C, Dalle Vacche M, L’Abbate A. 7. Korncr PI. Circulatory adaptation in hypoxia. Physioi Reu 1959;39:687-730. Individual variability in symptoms,ischemicthreshold and cardiovascular efli8. StenbergJ, Ekblom B, MeasinR. Hemodynamicresponseto work at simulated ciency during exercise testing in patients with effort angina. Can J Cardiol 1989;5:222-228. altitude, 4$00 m. .I Appl Physiof 1966;2111589-1594. 9. Push LGCE. Cardiac outout in muscular exercise at 5.800 m (19ooo ft1. J 14. Savonitto S, Cardelliio G, Sardina M, Chebat E, Baldi G, Beun-GarbeD, ~ Appl >hysiol 1964;19:431-4&. Be.vilacquaM, Norbiato G. Effects of a cable car trip on blood pressureand 10. Balke B. Cardiac performance at high altitude. Am J Curdiol 196414: cardiovascularhormonesin lowlander and highlandernormotensives.Cardiologia 796-810. 1991;36:42-47. 15. Palatini P, Guvardi G, Penzo M, Dorigatti F, Anaclerio M, PcssinaAC. Il. Vogel JA, Harris CW. Cardiopulmonary responsesof resting man during Effect of low and high altitude exposureon the bloodpressureresponseto exercise. early exposure to high altitude. J Appl Physiol 1967;22:1124-1128. 12. D’Este D, Mantovan R, Martin0 A, D’Este F, Artusi L, Alllbardi P, Frances- Cardiologia 1991;36:853-859. chi M, Zerio C, Pas&to P. Blood pressurechangesat rest and during effort in 16. Richalet JP, Mehdioui H, Rathat C. Acute hypoxia decreasescardiac renormotensiveand hypertensivesubjectsin responseto altitude acute hypoxia. G sponse to catecholaminesin exercising humans. Int J Sports Med 1988;9: Itol Cardiol 1991~21~643-649. 157-162.
Spontaneous Echocardiigraphic Mitral Vahfe Prosthesis
Contrast with the Carbomedics
Shimon A. Reisner, MD, Diana Rinkevich, MD, Walter Markiewicz, MD, Zvi Adler, MD, and Simcha Mile, MD pontaneous echocardiographic contrast is a wellknown, although poorly understood, phenomenon S that has been occasionally noticed in patients with low flow states such as the echoesseenin the left atrium in patients with mitral valve di~ease,~in the left ventricle in severeleft ventricular systolic dysfunction2or in the infe rior vena cava of patients with constrictive pericarditix3 There are rare reports on spontaneouscontrast in patients with mechanical prosthetic mitral valves.4-6Compared with the more common“smoke-like” contrast observedin low flow states,spontaneousechoesin patients with mechanical mitral prosthetic valves are bright and high velocity but scanty. BetweenJanuary and Decemberof 1990,17 patients (7 females and 6 males, aged 9 to 71 years) had mitral valve replacementat the Rambam Medical Center using the Carbomedics bileaflet mechanical prosthetic valve. Postoperative echocardiographic study was available in 13 of the 17 patients (76%). Sevenconsecutivepatients who had mitral valve replacement using the Sorin prosthesis (Sorin Biomedica, Saluggia, Italy) were usedas a control group: 5 female and 2 male patients aged 28 to 50 years. All patients were ambulatory and treated with oral anticoagulant medications; noneweretreated intravenously at the time the echocardiographic study was performed. No patient had clinical congestiveheartfailure or was in a low output state. None had clear evidence of prosthesis dysfunction. Two-dimensional and pulsed-Doppler echocardiographic images were acquired using a Hewlett-Packard 7702OA ultrasound imager equipped with a 2.5 MHz phased-array transducer. Continuous-waveDoppler was obtained with a 1.9 MHz nonimaging transducer. Standard 2-dimensional, M-mode and Doppler echocardiographic recordings wereobtained in the parasternal, apiFrom the Departments of Cardiology and Cardiac Surgery, P.O. Box
9602, Rambam Medical Center, Technion Institute of Technology, Haifa 31096, Israel. This work was supported in part by Grant 8% 00177 from the United States-Israel Biitional Science Foundation, Jerusalem, Israel. Manuscript received April 14, 1992; revised manuscript received June 15,1992, and accepted June 17.
cal and subcostal viewsand recordedon a l/2 inch videotape with VHS format. Spontaneouscontrast was defined as intense mobile echoesmouing in the left ventricular cavity and noticed during multiple cardiac cycles. The intensity of spontaneouscontrast was divided into 3 groups: (1) no spontaneous echoesdetected, (2) mild contrast - defined as definite but sparse echoes,and (3) intense spontaneous contrast - defined as numerous echoesseenin the left ventricular cavity. Analysis of recorded videotapesfor detecting and grading spontaneous contrast was performed by 2 independentobserversunaware of clinical data. Echocardiographic measurements were performed according to the American Society of Echocardiography recommendations.7Ejection fraction was calculated from the I-chamber view using the area-length method8 and the softwarepackageon the Hewlett-Packard ultrasound machine. The ejectionfraction was averagedfrom 2 measurementsin patients with normal sinus rhythm andfrom 5 cardiac cyclesinpatients with atrialfibrillation. The extent of the systolicjet into the left atrium was evaluated to assessmitral regurgitation.9 Pressuregradients werecalculatedfrom velocities using the modified Bernoulli equation.lo Mitral valve area was measured using the pressure halftime method.” Pulmonary pressure was calculated whenever tricuspid regurgitation was recordedby adding the systolic transtricuspid pressure gradient to the proximate right atria1 pressure.12 Hemodynamic and echocardiographic data of patients with the Carbomedicsprosthesis were compared with data of patients with the Sorin prosthesis using the Student’s t testfor unpaired data or the chi-square test. Data of patients with the Carbomedicsvalve with and without spontaneouscontrast were compared using the Student’s t testfor unpaired data or the chi-square test. Statistical significance was assumedat p 50.05. Demographic,clinical and echocardiographicdata of all patients are summarized in Table 1. Calculation of the ejectionfraction was impossible in 2 patients because of a poor visualization of left ventricular endocardial BRIEF REPORTS 1497
TABLE I Demographic, Clinical and Echocardiographic Carbomedics and Sorin Prosthetic Valves Age (yr) Pt.
Size
& Sex
Time
Rhythm
MR (O-3+)
LA
Characteristics of Patients with the
LV
EF
MVA
MG
AVR
Cont.
2.2 3.5 2.9 2.8 2.5 2.0 2.8 2.5 2.6 2.1 2.0 3.0 3.8
4 3 5 4 4 3 3 3 6 2 4 2 3
+
++ ++ + + + + ++ ++ ++ -
2.4 2.0 2.7 2.7 2.2 2.3 2.6
4 4 2 4 5 2 4
Carbomedics 1 2 3 4 5 6 7 8 9 10
11 12 13
9F 47F 47F 46M 58F 43M 66M 51F 36F 72M 37M 51F 63M
27 31 29 31 27 31 33 31 29 31 27 27 31
1 16 4
10 6 5
1 7 7 12 9 2 4
NSR AF AF NSR AF NSR NSR AF AF AF AF AF NSR
0 0 + 0 + 0 0 0 + 0 0 0 +
43 55 55 36 79 51 45 45 49 49 53 59 38
42 47 55 58 42 62 72 40 65 64 52
37 64 60 52 61 47 29 48 34 37 57
46
48
52 42 41 57 54 47 32
52 40 50 58 42 48 46
52 54 58 54
+ +
Sorin
1 2 3 4 5 6 7
50F 48F 29M 39M 29F 39F 44F
29 29 29 29 31 29 27
1 6
1 2 1 3
1
AF AF AF AF AF NSR NSR
0 + + 0 0 0 0
57 61
+ +
-
+
-
See text for rading of spontaneous contrast intensity. AF = atrial 8.bnllabon; AVR = aorticvalve replacement; Cont. = spontaneous contrast: EF = ejection fraction (96); IA = left atrium (mm); LV = left ventricle (mm); MG = mean gradient (mm Hg); MR = mitral regurgitation; WA = mitral valve area km2); NSR = normal sinus rhythm; Size = manufacturers size of prosthesls (mm); Time = time from surgery to echocardiography (months).
TABLE II Clinical and Echocardiographic the Carbomedics and Sorin Prostheses
Age (year) Time from surgery to echo (mos) Prosthesis size (mm) Left atrial size (mm) Left ventricular size (mm) Ejection fraction (%) Mean gradient (mm Hg) Prosthesis area (cm*) Systolic pulmonary pressure (mm Hg) Atrial fibrillation (%I Mitral regurgitation No (%I Mild (%) Spontaneous contrast No (%) Mild (%) Intense (%) *p <0.05. Wifference not significant $Difference not significant
Data of Patients with
Carbomedics (n = 13)
Sorin (n = 7)
48 f 16 6.4 + 4.2
39 k 8t 2 f 2*
29.6 51.2 54.8 47.8 3.6 2.7 27.0
2 2.1
29.0 2 1.2t
+ 11.1
46.4 48.0 56.0 3.6 2.4 32.5
+ f 2 f f
10.4 12.1 1.3 0.6 4.8
k 8.77
f 6.lt + 3.3t
+ l.lt + 0.3t
2 16.2t
8/ 13 (60)
517 (70)
9/13 (70) 4/13 (30)
517 (70)$ 217 (30)$
4/ 13 (30) 4/13 (30) 5113 (40)
717 (100) o/7 (0) o/7 (0)
by unpaired Student’s by chi-square test.
t test.
borders. There was no statistically significant difference betweenpatients with the Carbomedicsadpatients with the Sorin prostheses regarding age, echocardiographic measurements,size andfunction of the prosthetic valve, prevalenceof combined mitral and aortic valve replacement, or the existence of atria1 fibrillation (Table Il). The time from surgery to the echocardiographic study was shorter in the Sorin group. 1498
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
TABLE Ill Clinical and Echocardiographic Data of Patients with the Carbomedics Prosthesis With and Without Spontaneous Contrast With Contrast (n = 9) Age (year) Time from surgery to echo (mos) Prosthesis size (mm) Leti atrial size (mm) Left ventricular size (mm) Ejection fraction (%I Mean gradient (mm Hg) Prosthesis area (cm*) Atrial fibrillation (%) Mitral regurgitation (%I 0 + *Difference tDifference
not significant not significant
Without Contrast (n = 4)
48k 13 6.2 f 4.3 29.8 ? 2.0 51.8 2 12.6 55.1 f 11.3 48.0 + 12.5 4.0 + 1.1 2.7 f 0.5 619
47.0 + 14.1* 2.7 f 1.2* 2.7 + 0.8* 3/4t
619 319
3/4t 1/4t
by unpaired Student’s by chi-square test.
t test.
47 + 14* 6.8 -t 4.6* 29.0 rt 2.3*
49.7 + a.a* 54.0 k 9.1*
1
Looking at sameparameters in the group with the Carbomedicsprosthesis, we noted no statistically sign+ icant differencebetweenpatients with and without spontaneous contrast (Table ZZI). No spontaneouscontrast wasobservedin any of the 7 patients with the Sorin valve. In 9 of 13patients with the Carbomedicsvalve (70%) definite spontaneouscontrast was observedby 2 independentobservers.In 5 of these9 patients the contrast was intense.In all 9 patients spontaneouscontrast wasfound on 2-dimensional echocardiography performedfrom the apical window using the 4or 2-chamberview (Figure 1). Spontaneouscontrast was noticed immediately after the valve was opened, and DECEMBER 1, 1992
individual echoes could be followed by a frame-byframe analysisfrom the valve level almost to the apex of the ventricle. Some echoescould be seendirected to the left ventricular outflow tract during late diastole. No systolic echoeswere observed. M-mode echocardiographyfacilitated the evaluation of the exact timing of the echoesand emphasizedtheir high velocity (Figure 2). Two types of spontaneouscontrast may exist6 (1) smoke-like spontaneouscontrast, typical for low output states.ld3 (This type of contrast is believedto result from red blood cell aggregation13); and (2) bright and high velocity spontaneouscontrast, which hasbeensporadically reported in patients with mitral prostheses.(This is probably causedby any kind of microparticles or microbubbles.) Schuchmanet al4 proposedthat the contrast he observedresulted from echogenicparticles, like platelets or particles from the cloth covering of the Starr-Edwards valve. Preis et al5 found that patients with the Beall prosthetic valve who demonstrated a spontaneouscontrast had a significant increasein serumlactic dehydroge naselevels,and therefore he suggestedthat microcavitations and the releaseof gasesfrom hemolyzing red blood cells are the origin of the phenomenon.In vitro studies indicate that spontaneouscontrast may result from microbubbles of gas generated in the blood as a result of high flow and turbulence causing stable cavitation.14 Taylor and Chan6 noticed systolic left atria1 spontaneous contrast in several types of normally functioning mechanical mitral prostheses.In this study a transesophageal echocardiographic 5 MHz high-resolution transducer was used. Sigel et all3 detectedspontaneouscontrast by a 7.5 MHz transducer but not with a lower frequency 3.5 MHz transducer. In intraoperative studies
using an epicardial high-frequency 5 MHz transducer it is commonto notice spontaneouscontrast before passing on the heart lung machine. This may result from normal red blood cells causingscatterof ultrasound waves.Theoretically, as newer echo machineswith higher sensitivity and higher frequency transducersare used,the visualization of spontaneouscontrast could becomea commonand normal phenomenon. Smoke-likespontaneouscontrast is an indicator for an increasedthromboembolicrisk. 1 The clinical significance of spontaneouscontrast in patients with prosthetic mitral valvesis not clear. The particles causing theseechoesare probably too small to causeclinically recognizedemboli, but the long-term effect associatedwith their presenceis unclear. It is alsouncertain whether spontaneouscontrast indicates prosthesisdysfunction. The available information is insufficient and basedon an M-mode echocardiographicstudy from 19754 and 2 abstracts.5v6Compared with the bileaflet new Carbomedics valve used in our patients, the prosthetic valves involved in the aforementioned studies were the older generationvalveswith poorer hemodynamicsthat are no longer in use in most centers. We observedspontaneouscontrast in most patients who receivedthe Carbomedicsbileaflet mechanicalprosthesis in the mitral position by a routine transthoracic echocardiographyusing a 2.5 MHz transducer. We did not observethis phenomenonin other mechanical mitral prosthesesthat we use. We therefore conclude that this phenomenon is related to the Carbomedics prosthetic valve itself, although the mechanism for its production and the clinical significance are unknown. 1. Daniel WG, NellessenU, SchroderE, Nonnast-Daniel B, BednarskiP, Nikatta P, Lichtlen PR. Left atrial spontaneousechocontrast in mitral valve disease:an indicator for an increasedthromboembolic risk. J Am Cdl Cardid 1988;ll: 1204-1211. 2 Mike11FL, Asinger RS, EkspergarKJ, Anderson WR, Hodges M. Regional stasisof blood in the dysfunctionalleft ventricle. Echocardiographicdetectionand differentiation from early thrombosis.Circulation 1982;66:755-763. 3. Meltzex RS, Klig V, Viir C, Teichholz LE. Spontaneousechocardiographic contrast in the inferior vena cava. Am Heart J 1985;110:826-830. 4. SchuchmanH, FeigenbaumH, Dillon JC, Chang S. Intracavitary echoesin patients with prosthetic valves. J Chin Ultrasound 1975;3:107-110. 5. Preis LK, HessJP, Austin JL, Craddock GB, McGuire LB, Martin RP. Left BRIEF REPORTS 1499
ventricularmicrocavitations in patientswith Beall valves (abstr). Am J Cardiol 1980;45:402. 6. Taylor D, Chan KL. Tra-phageal echocardiographicidentification of two types of left atria1 spontaneouscontrast in patientswith mitral mechanicalprosthetic valves (abstr). Circulation 1991;84(supplII):II-161. 7. Feigenbaum H. Echocardiographic measurementsand normal values. In: Echocardiography.4th ed. Philadelphia: Lea & Febiger, 1986:621-639. L Carr KW, Engler RL, ForsytheJR, JohnsonAD, Gosink B. Measurementof left ventricular ejection fraction by mechanicalcross-sectionalechocardiography. Circulation 1979;59:1196-1206. 9. Abbasi AS, Allen MW, DiCristofaro D, Ungar I. Detection and estimationof the degreeof mitral regurgitation by range-gatedpulsedDoppler echocardiography. Circulation 1980;61:143-147.
10. Holen J, Aaslid R, Landmark L, SimonsenS. Determination of prasure gradient in mitral stenosiswith noninvasiveultrasound Doppler technique.Acra Med &and 1976;199:455-460. Il. Hatle L, AngelsenB, TromsdalA. Noninvasiveassessment ofatrioventricular pressurehalf-time by Doppler ultrasound. Circulation 1979;60:1096-1104. 12. Eerger M, Haimowitz A, Van Tosh A, B&off RL, Goldberg E. Quantitative assessmentof pulmonary hypertension in patients with tricuspid regurgitation usingcontinuouswave Doppler ultrasound.J Am Co11Cardiol 1985;6:359-365. 13. Sigel B, C&ho JCU, Spigot DG, Flangian DP, Schuler JJ, Kasprisin DO, Nyhus LM, Capek V. Ultrasonography of blood during stasisand coagulation. Inuest Radio1 1981;16:71-76. 14. Kort A, Kronzon I. Microbubble formation: in vitro andin viva observation.J Clin Ultrasound 1982;10:117-120.
Frequency of Left Atrial Thrombi by Transesophageal Echocardiigraphy in Idiopathic and in lschemic Dilated Cardiomyopathy Carlo Vigna, MD, Aldo Russo, MD, Vincenzo De Rito, MD, GianPiero Perna, MD, Alessandro Villella, MD, Marco Testa, MD, Vito Sollazzo, MD, Raffaele Fanelli, MD, and Francesco Loperfido, MD ystemic emboli occur in dilated cardiomyopathy (DC) at an annual rate of about 4%.’ Left ventricular S thrombus is often considered the source for embolic eventsin DC.2 A relation betweenleft ventricular thrombi and rate of embolic events, however, has not been found in a recent study.3Left atria1 thrombi may constitute an alternative sourcefor systemicembolismin DC.4 We examined 80 consecutivepatients with DC (46 men and 34 women,meanage61 f 8 years) by transthoracic (TTE) and transesophageal(TEE) echocardiography betweenMay 1990 and December 1991. DC was diagnosedon the basisof clinical and TTEjMings, and was of unknown etiology in 42 patients (52.5%) and ischemic in 38 (47.5%). Systemic embolism had previously occurred in 12patients (I 5%) (in peripheral arteries in 5, in central nervoussystemin 5, and in kidneys in 2), as revealedby history and clinicalfindings (including computed tomography scans).In 8 of these I2 patients, the episodeof embolism was recent (<3 months before the study). At the moment of the study, lpatients (2%), all with atria1 fibrillation, were receiving chronic oral anticoagulant therapy. Of these4 patients, 3 had had a previous embolism.Reasonsfor nonutilization of anticoagulants in the remaining 8 patients wereundetermined. Thirteen patients (16%) (4 with previous embolism) were receiving treatment with antiplatelet agents.New York Heart Association classification was class ZZin 53 patients (66%) and class ZZZor IV in 27 (34%). Atria1 ftbrillation waspresent in 22 patients (27.5%) and normal sinus rhythm in 58 (72.5%). The status of atria1 fibrillation was chronic in I8 patients and unknown in 4. No patient complained of recentepisodesof palpitation. Weperformed TTE and TEE studies with an Aloka SDS 870 system,using a 2.5 or 3.5 MHz probefor TTE, and a biplane 5 MHz probe for TEE. Left ventricular thrombi, left ventricular end-diastolic internal dimenFrom the Department of Cardiology, Casa Sollievo SofferenzaHospital, Istituto di Ricerca e Cum a Carattere Scientika, S. Giovanni Rotondo (FG); and the Institute of Cardiology, Catholic University, Large A. Gemelli 8,00168 Rome, Italy. Manuscript receivedApril 13, 1992;revisedmanuscriptreceivedJune 17,1992,and accepted June 22. 1500
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
sion and ejection fraction, left atria1 area and mitral regurgitation grade (I-point scale by color Doppler mapping of the regurghant jet area into the left atrium) wereassessedby TTE. Also the Herzog’sprojectioti was used to detect atria1 thrombus by TTE. The standard techniquewas usedfor TEE, being careful to image the left atria1 appendagein everypatient. Left atria1 thrombus was diagnosedby the presenceof a clearly defined echo-densemass,acoustically distinct from endocardiurn and left atria1 appendagepectinate muscles.Biplane imaging of the left ventricle was performed in every patient to detect left ventricular thrombus. Gain settings wereregulated in order to image left atria1 spontaneous echo contrast.6 Statistical analysis was performed using the chisquare or Fisher’s exact test, when appropriate. A p value of X0.05 was consideredstatistically significant. Left ventricular thrombi at TTE or TEE, or both, and left atria1 thrombi at TEE werefound in 14 (I 7.5%) and 18 (22.5%) patients, respectively (p = not sign@ cant). Left ventricular thrombi by TTE were confirmed by TEE in everypatient. No patient had left ventricular thrombus only at TEE. All left ventricular thrombi were flat. A left atria1 body thrombus was neverfound. Both left ventricular and atria1 thrombi were present in 4 patients. Of the 4 patients taking anticoagulation therapy at the time of the study, 2 had atria1 thrombus and none had left ventricular thrombus. No thrombus (ventricular or atrial) was found in 52 patients (65%). In patients with embolism (Table I), a thrombus was more TABLE I Left Ventricular and Atrial Thrombi in Patients With and Without Embolism Thrombus None Left atrium* Left ventricle *Twopatients
Embolism (n = 12)
No Embolism (ll = 68)
p Value
1 (8%) 10 (83%)
51(75%) 8 (12%) 11 (16%)
3 (25%)
with embolism
atrial thrombus. NS = not significant.
DECEMBER 1, 1992
and 2 without
embolism
had either left ventricular
or
Spontaneous Echocardiigraphic Mitral Vahfe Prosthesis
Contrast with the Carbomedics
Shimon A. Reisner, MD, Diana Rinkevich, MD, Walter Markiewicz, MD, Zvi Adler, MD, and Simcha Mile, MD pontaneous echocardiographic contrast is a wellknown, although poorly understood, phenomenon S that has been occasionally noticed in patients with low flow states such as the echoesseenin the left atrium in patients with mitral valve di~ease,~in the left ventricle in severeleft ventricular systolic dysfunction2or in the infe rior vena cava of patients with constrictive pericarditix3 There are rare reports on spontaneouscontrast in patients with mechanical prosthetic mitral valves.4-6Compared with the more common“smoke-like” contrast observedin low flow states,spontaneousechoesin patients with mechanical mitral prosthetic valves are bright and high velocity but scanty. BetweenJanuary and Decemberof 1990,17 patients (7 females and 6 males, aged 9 to 71 years) had mitral valve replacementat the Rambam Medical Center using the Carbomedics bileaflet mechanical prosthetic valve. Postoperative echocardiographic study was available in 13 of the 17 patients (76%). Sevenconsecutivepatients who had mitral valve replacement using the Sorin prosthesis (Sorin Biomedica, Saluggia, Italy) were usedas a control group: 5 female and 2 male patients aged 28 to 50 years. All patients were ambulatory and treated with oral anticoagulant medications; noneweretreated intravenously at the time the echocardiographic study was performed. No patient had clinical congestiveheartfailure or was in a low output state. None had clear evidence of prosthesis dysfunction. Two-dimensional and pulsed-Doppler echocardiographic images were acquired using a Hewlett-Packard 7702OA ultrasound imager equipped with a 2.5 MHz phased-array transducer. Continuous-waveDoppler was obtained with a 1.9 MHz nonimaging transducer. Standard 2-dimensional, M-mode and Doppler echocardiographic recordings wereobtained in the parasternal, apiFrom the Departments of Cardiology and Cardiac Surgery, P.O. Box
9602, Rambam Medical Center, Technion Institute of Technology, Haifa 31096, Israel. This work was supported in part by Grant 8% 00177 from the United States-Israel Biitional Science Foundation, Jerusalem, Israel. Manuscript received April 14, 1992; revised manuscript received June 15,1992, and accepted June 17.
cal and subcostal viewsand recordedon a l/2 inch videotape with VHS format. Spontaneouscontrast was defined as intense mobile echoesmouing in the left ventricular cavity and noticed during multiple cardiac cycles. The intensity of spontaneouscontrast was divided into 3 groups: (1) no spontaneous echoesdetected, (2) mild contrast - defined as definite but sparse echoes,and (3) intense spontaneous contrast - defined as numerous echoesseenin the left ventricular cavity. Analysis of recorded videotapesfor detecting and grading spontaneous contrast was performed by 2 independentobserversunaware of clinical data. Echocardiographic measurements were performed according to the American Society of Echocardiography recommendations.7Ejection fraction was calculated from the I-chamber view using the area-length method8 and the softwarepackageon the Hewlett-Packard ultrasound machine. The ejectionfraction was averagedfrom 2 measurementsin patients with normal sinus rhythm andfrom 5 cardiac cyclesinpatients with atrialfibrillation. The extent of the systolicjet into the left atrium was evaluated to assessmitral regurgitation.9 Pressuregradients werecalculatedfrom velocities using the modified Bernoulli equation.lo Mitral valve area was measured using the pressure halftime method.” Pulmonary pressure was calculated whenever tricuspid regurgitation was recordedby adding the systolic transtricuspid pressure gradient to the proximate right atria1 pressure.12 Hemodynamic and echocardiographic data of patients with the Carbomedicsprosthesis were compared with data of patients with the Sorin prosthesis using the Student’s t testfor unpaired data or the chi-square test. Data of patients with the Carbomedicsvalve with and without spontaneouscontrast were compared using the Student’s t testfor unpaired data or the chi-square test. Statistical significance was assumedat p 50.05. Demographic,clinical and echocardiographicdata of all patients are summarized in Table 1. Calculation of the ejectionfraction was impossible in 2 patients because of a poor visualization of left ventricular endocardial BRIEF REPORTS 1497
TABLE I Demographic, Clinical and Echocardiographic Carbomedics and Sorin Prosthetic Valves Age (yr) Pt.
Size
& Sex
Time
Rhythm
MR (O-3+)
LA
Characteristics of Patients with the
LV
EF
MVA
MG
AVR
Cont.
2.2 3.5 2.9 2.8 2.5 2.0 2.8 2.5 2.6 2.1 2.0 3.0 3.8
4 3 5 4 4 3 3 3 6 2 4 2 3
+
++ ++ + + + + ++ ++ ++ -
2.4 2.0 2.7 2.7 2.2 2.3 2.6
4 4 2 4 5 2 4
Carbomedics 1 2 3 4 5 6 7 8 9 10
11 12 13
9F 47F 47F 46M 58F 43M 66M 51F 36F 72M 37M 51F 63M
27 31 29 31 27 31 33 31 29 31 27 27 31
1 16 4
10 6 5
1 7 7 12 9 2 4
NSR AF AF NSR AF NSR NSR AF AF AF AF AF NSR
0 0 + 0 + 0 0 0 + 0 0 0 +
43 55 55 36 79 51 45 45 49 49 53 59 38
42 47 55 58 42 62 72 40 65 64 52
37 64 60 52 61 47 29 48 34 37 57
46
48
52 42 41 57 54 47 32
52 40 50 58 42 48 46
52 54 58 54
+ +
Sorin
1 2 3 4 5 6 7
50F 48F 29M 39M 29F 39F 44F
29 29 29 29 31 29 27
1 6
1 2 1 3
1
AF AF AF AF AF NSR NSR
0 + + 0 0 0 0
57 61
+ +
-
+
-
See text for rading of spontaneous contrast intensity. AF = atrial 8.bnllabon; AVR = aorticvalve replacement; Cont. = spontaneous contrast: EF = ejection fraction (96); IA = left atrium (mm); LV = left ventricle (mm); MG = mean gradient (mm Hg); MR = mitral regurgitation; WA = mitral valve area km2); NSR = normal sinus rhythm; Size = manufacturers size of prosthesls (mm); Time = time from surgery to echocardiography (months).
TABLE II Clinical and Echocardiographic the Carbomedics and Sorin Prostheses
Age (year) Time from surgery to echo (mos) Prosthesis size (mm) Left atrial size (mm) Left ventricular size (mm) Ejection fraction (%) Mean gradient (mm Hg) Prosthesis area (cm*) Systolic pulmonary pressure (mm Hg) Atrial fibrillation (%I Mitral regurgitation No (%I Mild (%) Spontaneous contrast No (%) Mild (%) Intense (%) *p <0.05. Wifference not significant $Difference not significant
Data of Patients with
Carbomedics (n = 13)
Sorin (n = 7)
48 f 16 6.4 + 4.2
39 k 8t 2 f 2*
29.6 51.2 54.8 47.8 3.6 2.7 27.0
2 2.1
29.0 2 1.2t
+ 11.1
46.4 48.0 56.0 3.6 2.4 32.5
+ f 2 f f
10.4 12.1 1.3 0.6 4.8
k 8.77
f 6.lt + 3.3t
+ l.lt + 0.3t
2 16.2t
8/ 13 (60)
517 (70)
9/13 (70) 4/13 (30)
517 (70)$ 217 (30)$
4/ 13 (30) 4/13 (30) 5113 (40)
717 (100) o/7 (0) o/7 (0)
by unpaired Student’s by chi-square test.
t test.
borders. There was no statistically significant difference betweenpatients with the Carbomedicsadpatients with the Sorin prostheses regarding age, echocardiographic measurements,size andfunction of the prosthetic valve, prevalenceof combined mitral and aortic valve replacement, or the existence of atria1 fibrillation (Table Il). The time from surgery to the echocardiographic study was shorter in the Sorin group. 1498
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
TABLE Ill Clinical and Echocardiographic Data of Patients with the Carbomedics Prosthesis With and Without Spontaneous Contrast With Contrast (n = 9) Age (year) Time from surgery to echo (mos) Prosthesis size (mm) Leti atrial size (mm) Left ventricular size (mm) Ejection fraction (%I Mean gradient (mm Hg) Prosthesis area (cm*) Atrial fibrillation (%) Mitral regurgitation (%I 0 + *Difference tDifference
not significant not significant
Without Contrast (n = 4)
48k 13 6.2 f 4.3 29.8 ? 2.0 51.8 2 12.6 55.1 f 11.3 48.0 + 12.5 4.0 + 1.1 2.7 f 0.5 619
47.0 + 14.1* 2.7 f 1.2* 2.7 + 0.8* 3/4t
619 319
3/4t 1/4t
by unpaired Student’s by chi-square test.
t test.
47 + 14* 6.8 -t 4.6* 29.0 rt 2.3*
49.7 + a.a* 54.0 k 9.1*
1
Looking at sameparameters in the group with the Carbomedicsprosthesis, we noted no statistically sign+ icant differencebetweenpatients with and without spontaneous contrast (Table ZZI). No spontaneouscontrast wasobservedin any of the 7 patients with the Sorin valve. In 9 of 13patients with the Carbomedicsvalve (70%) definite spontaneouscontrast was observedby 2 independentobservers.In 5 of these9 patients the contrast was intense.In all 9 patients spontaneouscontrast wasfound on 2-dimensional echocardiography performedfrom the apical window using the 4or 2-chamberview (Figure 1). Spontaneouscontrast was noticed immediately after the valve was opened, and DECEMBER 1, 1992
individual echoes could be followed by a frame-byframe analysisfrom the valve level almost to the apex of the ventricle. Some echoescould be seendirected to the left ventricular outflow tract during late diastole. No systolic echoeswere observed. M-mode echocardiographyfacilitated the evaluation of the exact timing of the echoesand emphasizedtheir high velocity (Figure 2). Two types of spontaneouscontrast may exist6 (1) smoke-like spontaneouscontrast, typical for low output states.ld3 (This type of contrast is believedto result from red blood cell aggregation13); and (2) bright and high velocity spontaneouscontrast, which hasbeensporadically reported in patients with mitral prostheses.(This is probably causedby any kind of microparticles or microbubbles.) Schuchmanet al4 proposedthat the contrast he observedresulted from echogenicparticles, like platelets or particles from the cloth covering of the Starr-Edwards valve. Preis et al5 found that patients with the Beall prosthetic valve who demonstrated a spontaneouscontrast had a significant increasein serumlactic dehydroge naselevels,and therefore he suggestedthat microcavitations and the releaseof gasesfrom hemolyzing red blood cells are the origin of the phenomenon.In vitro studies indicate that spontaneouscontrast may result from microbubbles of gas generated in the blood as a result of high flow and turbulence causing stable cavitation.14 Taylor and Chan6 noticed systolic left atria1 spontaneous contrast in several types of normally functioning mechanical mitral prostheses.In this study a transesophageal echocardiographic 5 MHz high-resolution transducer was used. Sigel et all3 detectedspontaneouscontrast by a 7.5 MHz transducer but not with a lower frequency 3.5 MHz transducer. In intraoperative studies
using an epicardial high-frequency 5 MHz transducer it is commonto notice spontaneouscontrast before passing on the heart lung machine. This may result from normal red blood cells causingscatterof ultrasound waves.Theoretically, as newer echo machineswith higher sensitivity and higher frequency transducersare used,the visualization of spontaneouscontrast could becomea commonand normal phenomenon. Smoke-likespontaneouscontrast is an indicator for an increasedthromboembolicrisk. 1 The clinical significance of spontaneouscontrast in patients with prosthetic mitral valvesis not clear. The particles causing theseechoesare probably too small to causeclinically recognizedemboli, but the long-term effect associatedwith their presenceis unclear. It is alsouncertain whether spontaneouscontrast indicates prosthesisdysfunction. The available information is insufficient and basedon an M-mode echocardiographicstudy from 19754 and 2 abstracts.5v6Compared with the bileaflet new Carbomedics valve used in our patients, the prosthetic valves involved in the aforementioned studies were the older generationvalveswith poorer hemodynamicsthat are no longer in use in most centers. We observedspontaneouscontrast in most patients who receivedthe Carbomedicsbileaflet mechanicalprosthesis in the mitral position by a routine transthoracic echocardiographyusing a 2.5 MHz transducer. We did not observethis phenomenonin other mechanical mitral prosthesesthat we use. We therefore conclude that this phenomenon is related to the Carbomedics prosthetic valve itself, although the mechanism for its production and the clinical significance are unknown. 1. Daniel WG, NellessenU, SchroderE, Nonnast-Daniel B, BednarskiP, Nikatta P, Lichtlen PR. Left atrial spontaneousechocontrast in mitral valve disease:an indicator for an increasedthromboembolic risk. J Am Cdl Cardid 1988;ll: 1204-1211. 2 Mike11FL, Asinger RS, EkspergarKJ, Anderson WR, Hodges M. Regional stasisof blood in the dysfunctionalleft ventricle. Echocardiographicdetectionand differentiation from early thrombosis.Circulation 1982;66:755-763. 3. Meltzex RS, Klig V, Viir C, Teichholz LE. Spontaneousechocardiographic contrast in the inferior vena cava. Am Heart J 1985;110:826-830. 4. SchuchmanH, FeigenbaumH, Dillon JC, Chang S. Intracavitary echoesin patients with prosthetic valves. J Chin Ultrasound 1975;3:107-110. 5. Preis LK, HessJP, Austin JL, Craddock GB, McGuire LB, Martin RP. Left BRIEF REPORTS 1499
ventricularmicrocavitations in patientswith Beall valves (abstr). Am J Cardiol 1980;45:402. 6. Taylor D, Chan KL. Tra-phageal echocardiographicidentification of two types of left atria1 spontaneouscontrast in patientswith mitral mechanicalprosthetic valves (abstr). Circulation 1991;84(supplII):II-161. 7. Feigenbaum H. Echocardiographic measurementsand normal values. In: Echocardiography.4th ed. Philadelphia: Lea & Febiger, 1986:621-639. L Carr KW, Engler RL, ForsytheJR, JohnsonAD, Gosink B. Measurementof left ventricular ejection fraction by mechanicalcross-sectionalechocardiography. Circulation 1979;59:1196-1206. 9. Abbasi AS, Allen MW, DiCristofaro D, Ungar I. Detection and estimationof the degreeof mitral regurgitation by range-gatedpulsedDoppler echocardiography. Circulation 1980;61:143-147.
10. Holen J, Aaslid R, Landmark L, SimonsenS. Determination of prasure gradient in mitral stenosiswith noninvasiveultrasound Doppler technique.Acra Med &and 1976;199:455-460. Il. Hatle L, AngelsenB, TromsdalA. Noninvasiveassessment ofatrioventricular pressurehalf-time by Doppler ultrasound. Circulation 1979;60:1096-1104. 12. Eerger M, Haimowitz A, Van Tosh A, B&off RL, Goldberg E. Quantitative assessmentof pulmonary hypertension in patients with tricuspid regurgitation usingcontinuouswave Doppler ultrasound.J Am Co11Cardiol 1985;6:359-365. 13. Sigel B, C&ho JCU, Spigot DG, Flangian DP, Schuler JJ, Kasprisin DO, Nyhus LM, Capek V. Ultrasonography of blood during stasisand coagulation. Inuest Radio1 1981;16:71-76. 14. Kort A, Kronzon I. Microbubble formation: in vitro andin viva observation.J Clin Ultrasound 1982;10:117-120.
Frequency of Left Atrial Thrombi by Transesophageal Echocardiigraphy in Idiopathic and in lschemic Dilated Cardiomyopathy Carlo Vigna, MD, Aldo Russo, MD, Vincenzo De Rito, MD, GianPiero Perna, MD, Alessandro Villella, MD, Marco Testa, MD, Vito Sollazzo, MD, Raffaele Fanelli, MD, and Francesco Loperfido, MD ystemic emboli occur in dilated cardiomyopathy (DC) at an annual rate of about 4%.’ Left ventricular S thrombus is often considered the source for embolic eventsin DC.2 A relation betweenleft ventricular thrombi and rate of embolic events, however, has not been found in a recent study.3Left atria1 thrombi may constitute an alternative sourcefor systemicembolismin DC.4 We examined 80 consecutivepatients with DC (46 men and 34 women,meanage61 f 8 years) by transthoracic (TTE) and transesophageal(TEE) echocardiography betweenMay 1990 and December 1991. DC was diagnosedon the basisof clinical and TTEjMings, and was of unknown etiology in 42 patients (52.5%) and ischemic in 38 (47.5%). Systemic embolism had previously occurred in 12patients (I 5%) (in peripheral arteries in 5, in central nervoussystemin 5, and in kidneys in 2), as revealedby history and clinicalfindings (including computed tomography scans).In 8 of these I2 patients, the episodeof embolism was recent (<3 months before the study). At the moment of the study, lpatients (2%), all with atria1 fibrillation, were receiving chronic oral anticoagulant therapy. Of these4 patients, 3 had had a previous embolism.Reasonsfor nonutilization of anticoagulants in the remaining 8 patients wereundetermined. Thirteen patients (16%) (4 with previous embolism) were receiving treatment with antiplatelet agents.New York Heart Association classification was class ZZin 53 patients (66%) and class ZZZor IV in 27 (34%). Atria1 ftbrillation waspresent in 22 patients (27.5%) and normal sinus rhythm in 58 (72.5%). The status of atria1 fibrillation was chronic in I8 patients and unknown in 4. No patient complained of recentepisodesof palpitation. Weperformed TTE and TEE studies with an Aloka SDS 870 system,using a 2.5 or 3.5 MHz probefor TTE, and a biplane 5 MHz probe for TEE. Left ventricular thrombi, left ventricular end-diastolic internal dimenFrom the Department of Cardiology, Casa Sollievo SofferenzaHospital, Istituto di Ricerca e Cum a Carattere Scientika, S. Giovanni Rotondo (FG); and the Institute of Cardiology, Catholic University, Large A. Gemelli 8,00168 Rome, Italy. Manuscript receivedApril 13, 1992;revisedmanuscriptreceivedJune 17,1992,and accepted June 22. 1500
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
sion and ejection fraction, left atria1 area and mitral regurgitation grade (I-point scale by color Doppler mapping of the regurghant jet area into the left atrium) wereassessedby TTE. Also the Herzog’sprojectioti was used to detect atria1 thrombus by TTE. The standard techniquewas usedfor TEE, being careful to image the left atria1 appendagein everypatient. Left atria1 thrombus was diagnosedby the presenceof a clearly defined echo-densemass,acoustically distinct from endocardiurn and left atria1 appendagepectinate muscles.Biplane imaging of the left ventricle was performed in every patient to detect left ventricular thrombus. Gain settings wereregulated in order to image left atria1 spontaneous echo contrast.6 Statistical analysis was performed using the chisquare or Fisher’s exact test, when appropriate. A p value of X0.05 was consideredstatistically significant. Left ventricular thrombi at TTE or TEE, or both, and left atria1 thrombi at TEE werefound in 14 (I 7.5%) and 18 (22.5%) patients, respectively (p = not sign@ cant). Left ventricular thrombi by TTE were confirmed by TEE in everypatient. No patient had left ventricular thrombus only at TEE. All left ventricular thrombi were flat. A left atria1 body thrombus was neverfound. Both left ventricular and atria1 thrombi were present in 4 patients. Of the 4 patients taking anticoagulation therapy at the time of the study, 2 had atria1 thrombus and none had left ventricular thrombus. No thrombus (ventricular or atrial) was found in 52 patients (65%). In patients with embolism (Table I), a thrombus was more TABLE I Left Ventricular and Atrial Thrombi in Patients With and Without Embolism Thrombus None Left atrium* Left ventricle *Twopatients
Embolism (n = 12)
No Embolism (ll = 68)
p Value
1 (8%) 10 (83%)
51(75%) 8 (12%) 11 (16%)
3 (25%)
with embolism
atrial thrombus. NS = not significant.
DECEMBER 1, 1992
and 2 without
embolism
had either left ventricular
or