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Systemic embolization during TTE
December
1492
Letters
to the Editor
American
atrium and is caused by entrance of the pulmonary veins.3-5 With TEE the transverse sinus can be found,by using a cross-sectional view just above the aortic valve, and it may indeed mimic the left main coronary artery. Jan L. Posma, MD Hans P.M. Hamer, MD Kong I. Lie, MD Department of Cardiology, Thoraxcenter University Hospital Groningen Oostersingel59 9713 EZ Groningen, The Netherlands REFERENCES
REFERENCES
Pitrolo F, Mancuso L, Marchi S, Bondi F, Carmina MG, D’Agostino A, Serio G. Asymptomatic live systemic embolization observed on transesophageal echocardiography. AM HEART J 1993;125:541-3. Narvaez R, Strauss C, Kotler, MN, Maze SS, Greenspan A, Spielman S, Parry WR. Embolization of a large ventricular thrombus during two-dimensional and color flow examination in idiopathic dilated cardiomyopathy. -_ ” Am J Cardiol. 1987; 60:402--3. Visser CA, Kan G, Meltzer RS, Dunning AJ, Roeland TJ, Van Corler M. DeKoning H. Embolic ootential of left ventricular thrombus after miocardial infarction: a two-dimensional echocardiographic study of 119 patients. J Am Co11 Cardiol 1985;5:1276-80.
1. Stoddard
2.
3. 4. 5.
6.
MF, Liddell NE, Longaker RA, Dawkins PR. Transesophageal echocardiography: normal variants andmimickers. AM HEART J 1992;124:1587-98. Seward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW Jr, Edwards WD, Nichols BA, Freeman WK, Tajik AJ. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo Clin Proc 1988;63:649-80. Wilcox BR, Anderson RH. Surgical anatomy of the heart. London: Gower Medical Publishing, 19X%2. Anderson RH, Becker AE. Cardiac-anatomy. London: Gower Medical Publishing, 1980:9. Williams PL, Warwick R, Dyson M, Bannister LH. Gray’s Anatomy. 37th ed. Edinburgh: Churchill Livingstone, 1989:694-6. Hamer JPM. Practical echocardiography in the adult: with Doppler and color Doppler flow imaging. Dordrecht: Kluwer Academic Publishers, 1990:32.
1993
Hear% Journal
4/S/49961
REPLY To the Editor: The description of the transverse sinus as being the oblique sinus in Figs. 21 through 24 of our article1 was incorrect. This area is the transverse sinus, nut the oblique sinus. We appreciate the comments made by Posma et al. Marcus F. Stoddard, MD Division of Cardiology University of Louisville Louisville, KY 40202
418149963
REPLY To the Editor: I thank Dr. Kotler for pointing out his initial observation of a systemic embolization during echocardiographic examination. However, I continue to consider such an observation to be an extremely rare event. Moreover, I would like to take advantage of this letter to underline some peculiar aspects that differentiate our case report from theirs. First, in our report the embolization eame from a left atria1 appendage thrombus not evident on transthoracic examination [TTE] and observed on the transesophageal examination [TEE]. On the contrary, the article of Kotler et al. reported a large ventricular thrombus, and the embolization was observed on TTE. The second important aspect was the absence of signs and symptoms of ischemia that gives rise to an intriguing consideration: people who have heart failure, in our case caused by restrictive cardiomyopathy, even if in sinus rhythm with no clots on TTE and no signs or symptoms of previous ischemia, are not only at risk for cardiac systemic embolization, but they could also have already had an embolism. Thus proper management should be rapidly undertaken in this kind of patient. Francesco Pitrolo, MD Cardiac Department V. Cervello Hospital Palermo, Italy
4/a/49972
SYSTEMIC
EMBOLIZATION
DURING TTE
To the Editor: I read with interest the brief report by Pitrolo et al.,l who state that “to our knowledge ‘live’ systemic embolization has never been rep0rted.l” In 1987 our group reported on a patient with a large ventricular thrombus that embolized during two-dimensional and color flow examination.2 Because iarge thrombi may kmbolize3 at any given time, especially if they are mobile andattached by a thin pedicle, it is not surprising that such thrombi may embolize during an echocardiographic study. Morris N. Kotler, MD Diuision of Cardiovascular Disease Albert Einstein Medical Center 5401 Old York Road Philadelphia, PA 19141-3025
BALLOON DILATION OF AORTIC COARCTATION To the Editor: Although we agree with Johnson et a1.r that surgery offers a more satisfactory alternative to balloon dilatation in the majority of neonates with coarctation of the aorta, we believe that they, like others2 are incorrect to analyze their group data for infants and neonates together. Indeed, it may not be possible to justify this conclusion for older infants on the basis of available data. Our series,a cited by Johnson et al., remains the only prospective eonsecutive series of neonates with coarctation of the aorta. We’coneluded (as cardiologists!) that the results of balloon dilatation in this group are unacceptable. The reason for the widely disparate restenosis rate in the Johnson et al. review ofpublished results for balloon dilatation is explained by similar grouping of neonates and infant&n the other series. Taking the Rao et a1.2 series (which ap-
1492
Letters
to the Editor
American
atrium and is caused by entrance of the pulmonary veins.3-5 With TEE the transverse sinus can be found,by using a cross-sectional view just above the aortic valve, and it may indeed mimic the left main coronary artery. Jan L. Posma, MD Hans P.M. Hamer, MD Kong I. Lie, MD Department of Cardiology, Thoraxcenter University Hospital Groningen Oostersingel59 9713 EZ Groningen, The Netherlands REFERENCES
REFERENCES
Pitrolo F, Mancuso L, Marchi S, Bondi F, Carmina MG, D’Agostino A, Serio G. Asymptomatic live systemic embolization observed on transesophageal echocardiography. AM HEART J 1993;125:541-3. Narvaez R, Strauss C, Kotler, MN, Maze SS, Greenspan A, Spielman S, Parry WR. Embolization of a large ventricular thrombus during two-dimensional and color flow examination in idiopathic dilated cardiomyopathy. -_ ” Am J Cardiol. 1987; 60:402--3. Visser CA, Kan G, Meltzer RS, Dunning AJ, Roeland TJ, Van Corler M. DeKoning H. Embolic ootential of left ventricular thrombus after miocardial infarction: a two-dimensional echocardiographic study of 119 patients. J Am Co11 Cardiol 1985;5:1276-80.
1. Stoddard
2.
3. 4. 5.
6.
MF, Liddell NE, Longaker RA, Dawkins PR. Transesophageal echocardiography: normal variants andmimickers. AM HEART J 1992;124:1587-98. Seward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW Jr, Edwards WD, Nichols BA, Freeman WK, Tajik AJ. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo Clin Proc 1988;63:649-80. Wilcox BR, Anderson RH. Surgical anatomy of the heart. London: Gower Medical Publishing, 19X%2. Anderson RH, Becker AE. Cardiac-anatomy. London: Gower Medical Publishing, 1980:9. Williams PL, Warwick R, Dyson M, Bannister LH. Gray’s Anatomy. 37th ed. Edinburgh: Churchill Livingstone, 1989:694-6. Hamer JPM. Practical echocardiography in the adult: with Doppler and color Doppler flow imaging. Dordrecht: Kluwer Academic Publishers, 1990:32.
1993
Hear% Journal
4/S/49961
REPLY To the Editor: The description of the transverse sinus as being the oblique sinus in Figs. 21 through 24 of our article1 was incorrect. This area is the transverse sinus, nut the oblique sinus. We appreciate the comments made by Posma et al. Marcus F. Stoddard, MD Division of Cardiology University of Louisville Louisville, KY 40202
418149963
REPLY To the Editor: I thank Dr. Kotler for pointing out his initial observation of a systemic embolization during echocardiographic examination. However, I continue to consider such an observation to be an extremely rare event. Moreover, I would like to take advantage of this letter to underline some peculiar aspects that differentiate our case report from theirs. First, in our report the embolization eame from a left atria1 appendage thrombus not evident on transthoracic examination [TTE] and observed on the transesophageal examination [TEE]. On the contrary, the article of Kotler et al. reported a large ventricular thrombus, and the embolization was observed on TTE. The second important aspect was the absence of signs and symptoms of ischemia that gives rise to an intriguing consideration: people who have heart failure, in our case caused by restrictive cardiomyopathy, even if in sinus rhythm with no clots on TTE and no signs or symptoms of previous ischemia, are not only at risk for cardiac systemic embolization, but they could also have already had an embolism. Thus proper management should be rapidly undertaken in this kind of patient. Francesco Pitrolo, MD Cardiac Department V. Cervello Hospital Palermo, Italy
4/a/49972
SYSTEMIC
EMBOLIZATION
DURING TTE
To the Editor: I read with interest the brief report by Pitrolo et al.,l who state that “to our knowledge ‘live’ systemic embolization has never been rep0rted.l” In 1987 our group reported on a patient with a large ventricular thrombus that embolized during two-dimensional and color flow examination.2 Because iarge thrombi may kmbolize3 at any given time, especially if they are mobile andattached by a thin pedicle, it is not surprising that such thrombi may embolize during an echocardiographic study. Morris N. Kotler, MD Diuision of Cardiovascular Disease Albert Einstein Medical Center 5401 Old York Road Philadelphia, PA 19141-3025
BALLOON DILATION OF AORTIC COARCTATION To the Editor: Although we agree with Johnson et a1.r that surgery offers a more satisfactory alternative to balloon dilatation in the majority of neonates with coarctation of the aorta, we believe that they, like others2 are incorrect to analyze their group data for infants and neonates together. Indeed, it may not be possible to justify this conclusion for older infants on the basis of available data. Our series,a cited by Johnson et al., remains the only prospective eonsecutive series of neonates with coarctation of the aorta. We’coneluded (as cardiologists!) that the results of balloon dilatation in this group are unacceptable. The reason for the widely disparate restenosis rate in the Johnson et al. review ofpublished results for balloon dilatation is explained by similar grouping of neonates and infant&n the other series. Taking the Rao et a1.2 series (which ap-