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The unique miniature multiplane transesophageal transducer in pediatric cardiology: New development
Journal o f the American Society o f Echocardiography
Abstracts
Vohwne 9 N u m b e r 3
201S
201T
ACOUSTIC BUBBLE DESTRUCTION IS A POSSIBLE MECHANISM FOR TRANSIENT RESPONSE IMAGING Jack G. Mottley, PhD, Maria Giakoumopoulos, Tom Porter, MD, Fe~ Xie, MD, Richard Meltzer, MD, PhD. The University of Rochester, Rochester, NY and the University of Nebraska, Omaha, NB. Several groups have observed that exposing contrast agents to fewer acoustic pulses results in prolonged and increased contrast intensity (Transient Response Imaging). To better understand this phenomenon, we used light transmission through a stirred suspension of contrast agent (Perfluorocarbon Exposed Sonicated Dextrose Albumin (PESDA)) in water as a measure of contrast concentration, and exposed the beaker contents to ultrasonic pulses similar to those produced by diagnostic equipment (2 MHz center frequency, prf 2500 Hz, 5 cycles per toneburst). The amplitude was varied in random order among 6 peak acoustic pressures from 0.08 1o 0.28 MPa (1 MPa(megaPaseal) = 10 Atmospheres) for 3 trials at each pressure. (Pressure was measured with a needle hydrophone in a water tank for equivalent drive voltages). For exposure at less than 0.12 MPa, there was no change in light transmission with time (no bubble destruction). At or above 0.12 MPa, there was a continual increase of light transmission, indicating microbubble destruction, and the rate of decay increased with increasing peak ultrasonic pressure. Peak Applied Pressure Decay Constant S.D. (MPa) (l/s) (N=3) 0.08 0.0007 0.0003 0.12 0.0041 0.0019 0.17 0.0219 0.0098 0.21 0.0598 0.0123 0.25 0.0828 0.0290 0.28 0.1042 0.0207 Aclinical echocardiographic instrument also caused increase in light transmission (bubble destruction). We conclude that a possible mechanism of transient response imaging is acoustic bubble destruction. The phenomenon occurs at surprisingly low peak pressures, well within those generated by diagnostic ultrasound equipment (up 1o 4 MPa, usually in the 1-2 MPa region for echocardiography). This threshold nature of the phenomenon supports transient cavitation as a possible mechanism.
VISUALIZATION AND REGISTRATION OF CORONARy ARTERY FLOW VELOCITY BY TRANSTHORACIC 2D DOPPLER ECHOCARDIOGRAPHY: PRELIMINARYOBSERVATIONS Folkert J. Ten Care, Willem B. Vletter, Marcel M. Koffiard, P.M. FiorettL Thoraxcenter,University Hospital and Erasmus University, Rotterdam, The Netherlands. The diagnostic possibilities of transthoracic two-dimensional Doppler echocardiography (2D Echo) have been increased gradually. However, visualization of coronary artery flow velocity is not possible unless TEE or intracoronary Doppler catheters are used. With the advent of superior transducer technology and imaging software we investigated whether this new technology enables visualization and registration of coronary artery flow velocity using transthoracic 2 Decho. Eleven patients (four male / seven female) with Hypertrophic Cardiomyopathy were investigated. In all visualization of intracoronary flow velocity from the inrel~,entricular septum was possible using Color Doppler, whereas in nine of them a graphic registration of coronary artery flow by pulsed Doppler tracings was performed. A two fold increase in coronary artery flow was observed using Dipyridmnole administration, in one patient, proving that the registrated signal originated from the coronary artery tree. Coronary artery flow has a unique phasic pattern with flow occurring in diastole and has a similar pattern as is known using intracoronary Doppler catheters. Mean diastolic coronary flow velocity was 95 • I 0 cm/sec. 2 Decho
i.c. Doppler
Z7 Conclusion: these preliminary observations in a highly selected group of pts indicate that coronary flow can be visualized and quantitated using routine transthoracic 2 Decho. These findings may obviate the use of intracoronary Doppler catheters for measurements of coronary artery flow in the future.
385
Abstract Poster Session 202 TEE 202A
THE UNIQUE MINIATURE MULTIPLANE TRANSESOPHAGEAL TRANSDUCER IN PEDIATRIC CARDIOLOGY: NEW DEVELOPMENT. AH Cromme- Dijkhuis, MD, KK Djoa, MsC, N Born, MsC, A Vermeulen, MsC, J Hess, MD. Pediatric Cardiology, Sophia Children's Hospital; Experimental Echocardiegraphy, Erasmus University; Rotterdam. OIDelfl, Delft, The Netherlands. The development of a miniature multiplane transesophageal echocardiographic (TEE) transducer for pediatric use represents the latest development in TEE, Horizontal, longitudinal and all possible intermediate oblique planes can be obtained with minimal transducer manipulation, so that cardiac structures continuously are visualized as the imaging plane is steered through a 160 degree arch. This miniature, multiplane TEE transducer has tip dimensions of 27 x 10.6 x 7.9 mm and contains 48 transmitting elements. We evaluated 63 patients with this transducer. Ages ranged from 2 days to 16 years and weights from 3.6 to 67 kilograms. 11 patients had complex heart disease, defined as the presence of at least 3 lesions, 17 patients had abnormal connections and 34 patients only had 1 or 2 lesions In 24 patients prior surgery was performed. 57 patients underwent a cardiac catheterization. To assess the additional value of multiplane TEE above monoplane TEE, the heart defects first were determined in the horizontal plane. Subsequently, continuously steering of longitudinal planes was performed and visualization of defects determined. Validation was done by cardiac catheterization or surgery. In the 63 patients, a total number of 123 abnormalities were observed and jugded. Of this number 95 (77%) were found in the initial horizontal plane. Another 28 (22%) lesions were observed in 27 patients after the rotation of the imaging plane had started. Furthermore, rotation of the plane offered additional information about the abnormal cardiac structure in 81 of the 95 original determined lesions. Information obtained by TEE often influenced the decision making for surgery. MuItiplane TEE with this miniature transducer gave insight in the morphology of right- and left ventricular outflow tract obstructions, atrioventricular valves abnormalities or baffle leakages, especially in more complex heart defects or in hearts with discordant connections. Conclusion: this miniature multiplane transesophageal transducer has enriched the diagnostic possibilities in pediatric cardiology and gives more insight into the morphology of complex head disease. 3- dimensional reconstruction from the esophagus is now possible in young patients.
202B N E W D I A G N O S T I C CRITERIA FOR P R O S T H E T I C VALVE E N D O C A R D I T I S : USING TRANSESOPHAGEAL ECHOCARDIOGRAPHY Christian S. Breburda, MD, Kesavan Shah, MD, Kris Arheart, EdD, Ivan Cakulev, MD, Bruce W.Lytle, M D , Susan Rehm, MD, James D. Thomas MD, William J.Stewart, MD, Cleveland Clinic Foundation Recently, new diagnostic criteria incorporating echocardiography have been validated which provide improved accuracy for native valve endoearditis. We applied similar criteria by performing TEE in 60 pts with suspected prosthetic valve endocarditis (PVE), median age 62 (28-82) years, 45 male. Affected were 40 bioprostheses, 17 mechanical valves and 3 homografts. 42 pts had aortic prostheses, 12 pts mitral and 6 pts had both. Blood cultures were positive in 45 pts (75%). 10 pts had a negative TEE and remained free of PVE for a mean follow up period of 6 months. 50 pts underwent reoperation. PVE was confirmed by surgical inspection (SI) in 39 pts and by histology in 48 pts. TEE findings were classified as proposed Major Criteria: (1) A new oscillating mass, (2) Abscess, (3) Dehiscence or Fistula or as Minor Criteria: (4) New nonoscillating mass and (5) New nodular PV thickening. Endocarditis was rendered 'Certain' (2 major criteria, or 1 major and 2 minor); as "Probable' (1 major or 2 minor) or as "Rejected' (no major or one or less minor). Results: SI confirmed findings of vegetations in 90% of 32 pts with positive TEE findings, abscesy in 88% 0 f 2 5 pts, fistula in 88% of 29 pts, and dehiscence in 86% of 21 pts. By TEE 26 pts (52%) were classified as certain PVE, 19 (38%) as probable, and 15 (30%) were rejected. A 2x2 table o f certain plus probable echo classification versus combined surgical, histologic, and clinical findings (n=60) revealed a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, negative predictive value of 66%, and accuracy 92%. This TEE classification, using the new diagnostic criteria (as certain, probable or rejected in a 2x3 Chiquare) were positively associated with surgical findings (p=0.01). Conclusion: This new classification for the diagnosis of prosthetic valve endocarditis using TEE may be useful to supplement currently used clinical and microbiologic criteria.
Abstracts
Vohwne 9 N u m b e r 3
201S
201T
ACOUSTIC BUBBLE DESTRUCTION IS A POSSIBLE MECHANISM FOR TRANSIENT RESPONSE IMAGING Jack G. Mottley, PhD, Maria Giakoumopoulos, Tom Porter, MD, Fe~ Xie, MD, Richard Meltzer, MD, PhD. The University of Rochester, Rochester, NY and the University of Nebraska, Omaha, NB. Several groups have observed that exposing contrast agents to fewer acoustic pulses results in prolonged and increased contrast intensity (Transient Response Imaging). To better understand this phenomenon, we used light transmission through a stirred suspension of contrast agent (Perfluorocarbon Exposed Sonicated Dextrose Albumin (PESDA)) in water as a measure of contrast concentration, and exposed the beaker contents to ultrasonic pulses similar to those produced by diagnostic equipment (2 MHz center frequency, prf 2500 Hz, 5 cycles per toneburst). The amplitude was varied in random order among 6 peak acoustic pressures from 0.08 1o 0.28 MPa (1 MPa(megaPaseal) = 10 Atmospheres) for 3 trials at each pressure. (Pressure was measured with a needle hydrophone in a water tank for equivalent drive voltages). For exposure at less than 0.12 MPa, there was no change in light transmission with time (no bubble destruction). At or above 0.12 MPa, there was a continual increase of light transmission, indicating microbubble destruction, and the rate of decay increased with increasing peak ultrasonic pressure. Peak Applied Pressure Decay Constant S.D. (MPa) (l/s) (N=3) 0.08 0.0007 0.0003 0.12 0.0041 0.0019 0.17 0.0219 0.0098 0.21 0.0598 0.0123 0.25 0.0828 0.0290 0.28 0.1042 0.0207 Aclinical echocardiographic instrument also caused increase in light transmission (bubble destruction). We conclude that a possible mechanism of transient response imaging is acoustic bubble destruction. The phenomenon occurs at surprisingly low peak pressures, well within those generated by diagnostic ultrasound equipment (up 1o 4 MPa, usually in the 1-2 MPa region for echocardiography). This threshold nature of the phenomenon supports transient cavitation as a possible mechanism.
VISUALIZATION AND REGISTRATION OF CORONARy ARTERY FLOW VELOCITY BY TRANSTHORACIC 2D DOPPLER ECHOCARDIOGRAPHY: PRELIMINARYOBSERVATIONS Folkert J. Ten Care, Willem B. Vletter, Marcel M. Koffiard, P.M. FiorettL Thoraxcenter,University Hospital and Erasmus University, Rotterdam, The Netherlands. The diagnostic possibilities of transthoracic two-dimensional Doppler echocardiography (2D Echo) have been increased gradually. However, visualization of coronary artery flow velocity is not possible unless TEE or intracoronary Doppler catheters are used. With the advent of superior transducer technology and imaging software we investigated whether this new technology enables visualization and registration of coronary artery flow velocity using transthoracic 2 Decho. Eleven patients (four male / seven female) with Hypertrophic Cardiomyopathy were investigated. In all visualization of intracoronary flow velocity from the inrel~,entricular septum was possible using Color Doppler, whereas in nine of them a graphic registration of coronary artery flow by pulsed Doppler tracings was performed. A two fold increase in coronary artery flow was observed using Dipyridmnole administration, in one patient, proving that the registrated signal originated from the coronary artery tree. Coronary artery flow has a unique phasic pattern with flow occurring in diastole and has a similar pattern as is known using intracoronary Doppler catheters. Mean diastolic coronary flow velocity was 95 • I 0 cm/sec. 2 Decho
i.c. Doppler
Z7 Conclusion: these preliminary observations in a highly selected group of pts indicate that coronary flow can be visualized and quantitated using routine transthoracic 2 Decho. These findings may obviate the use of intracoronary Doppler catheters for measurements of coronary artery flow in the future.
385
Abstract Poster Session 202 TEE 202A
THE UNIQUE MINIATURE MULTIPLANE TRANSESOPHAGEAL TRANSDUCER IN PEDIATRIC CARDIOLOGY: NEW DEVELOPMENT. AH Cromme- Dijkhuis, MD, KK Djoa, MsC, N Born, MsC, A Vermeulen, MsC, J Hess, MD. Pediatric Cardiology, Sophia Children's Hospital; Experimental Echocardiegraphy, Erasmus University; Rotterdam. OIDelfl, Delft, The Netherlands. The development of a miniature multiplane transesophageal echocardiographic (TEE) transducer for pediatric use represents the latest development in TEE, Horizontal, longitudinal and all possible intermediate oblique planes can be obtained with minimal transducer manipulation, so that cardiac structures continuously are visualized as the imaging plane is steered through a 160 degree arch. This miniature, multiplane TEE transducer has tip dimensions of 27 x 10.6 x 7.9 mm and contains 48 transmitting elements. We evaluated 63 patients with this transducer. Ages ranged from 2 days to 16 years and weights from 3.6 to 67 kilograms. 11 patients had complex heart disease, defined as the presence of at least 3 lesions, 17 patients had abnormal connections and 34 patients only had 1 or 2 lesions In 24 patients prior surgery was performed. 57 patients underwent a cardiac catheterization. To assess the additional value of multiplane TEE above monoplane TEE, the heart defects first were determined in the horizontal plane. Subsequently, continuously steering of longitudinal planes was performed and visualization of defects determined. Validation was done by cardiac catheterization or surgery. In the 63 patients, a total number of 123 abnormalities were observed and jugded. Of this number 95 (77%) were found in the initial horizontal plane. Another 28 (22%) lesions were observed in 27 patients after the rotation of the imaging plane had started. Furthermore, rotation of the plane offered additional information about the abnormal cardiac structure in 81 of the 95 original determined lesions. Information obtained by TEE often influenced the decision making for surgery. MuItiplane TEE with this miniature transducer gave insight in the morphology of right- and left ventricular outflow tract obstructions, atrioventricular valves abnormalities or baffle leakages, especially in more complex heart defects or in hearts with discordant connections. Conclusion: this miniature multiplane transesophageal transducer has enriched the diagnostic possibilities in pediatric cardiology and gives more insight into the morphology of complex head disease. 3- dimensional reconstruction from the esophagus is now possible in young patients.
202B N E W D I A G N O S T I C CRITERIA FOR P R O S T H E T I C VALVE E N D O C A R D I T I S : USING TRANSESOPHAGEAL ECHOCARDIOGRAPHY Christian S. Breburda, MD, Kesavan Shah, MD, Kris Arheart, EdD, Ivan Cakulev, MD, Bruce W.Lytle, M D , Susan Rehm, MD, James D. Thomas MD, William J.Stewart, MD, Cleveland Clinic Foundation Recently, new diagnostic criteria incorporating echocardiography have been validated which provide improved accuracy for native valve endoearditis. We applied similar criteria by performing TEE in 60 pts with suspected prosthetic valve endocarditis (PVE), median age 62 (28-82) years, 45 male. Affected were 40 bioprostheses, 17 mechanical valves and 3 homografts. 42 pts had aortic prostheses, 12 pts mitral and 6 pts had both. Blood cultures were positive in 45 pts (75%). 10 pts had a negative TEE and remained free of PVE for a mean follow up period of 6 months. 50 pts underwent reoperation. PVE was confirmed by surgical inspection (SI) in 39 pts and by histology in 48 pts. TEE findings were classified as proposed Major Criteria: (1) A new oscillating mass, (2) Abscess, (3) Dehiscence or Fistula or as Minor Criteria: (4) New nonoscillating mass and (5) New nodular PV thickening. Endocarditis was rendered 'Certain' (2 major criteria, or 1 major and 2 minor); as "Probable' (1 major or 2 minor) or as "Rejected' (no major or one or less minor). Results: SI confirmed findings of vegetations in 90% of 32 pts with positive TEE findings, abscesy in 88% 0 f 2 5 pts, fistula in 88% of 29 pts, and dehiscence in 86% of 21 pts. By TEE 26 pts (52%) were classified as certain PVE, 19 (38%) as probable, and 15 (30%) were rejected. A 2x2 table o f certain plus probable echo classification versus combined surgical, histologic, and clinical findings (n=60) revealed a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, negative predictive value of 66%, and accuracy 92%. This TEE classification, using the new diagnostic criteria (as certain, probable or rejected in a 2x3 Chiquare) were positively associated with surgical findings (p=0.01). Conclusion: This new classification for the diagnosis of prosthetic valve endocarditis using TEE may be useful to supplement currently used clinical and microbiologic criteria.