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Ultrasonic tomography of the heart
UIrrumund
in Med.
& Bbl.,
Vol. I, pp
275. 281. Pergamon
Press,
1974. Printed
CLINICAL ULTRASONIC
III Great
Brltaln
NOTE
TOMOGRAPHY
OF THE HEART
A. KRATOCHWIL 11. Universitats-Frauenklinik
Wien, Vorstand
Prof. Dr. H. Husslein.
Spitalgasse
23. 1090 Wien, Austria
C. JANTSCH, H. M~SSLACHER and J. SLANY I. Medizinische
Umversitats-Klinik
Wien, Vorstand Lazarettgasse
Prof. Dr. E. Deutsch,
Kardiologisches
Laboratorium.
14, 1090 Wien, Austria and R. WENCER
II. Medizinische
Abteilung
des Rudolfsspitales,
Boerhaavegasse
(Received 4 January 1973; and injinalform
8, 1030 Wien, Austria
25 April 1973)
Abstract-The report deals with 2 cases of heart tumors in which a commercial ultrasonic diagnostic equipment was used for tomography. In both cases we were successful in demonstrating the lesions. The visualization of subtle diagnostic details is ruled out by the rhythmical movements of the heart which cause blurring and superposition of signals. Key words: Heart,
Echotomography,
Pericardial
cyst, Tumor
IN 1950 Keidel started experiments with the objective of using ultrasound for examinations of the heart. Assuming that ultrasonic impedance depended on the filling phases of the heart, he tried to estimate the heart volume by transsonating cardiac tissues. It was however for Edler and Hertz (1954) to establish this new diagnostic principle in cardiology by applying the pulse echo technique. In many clinics this method, ultrasonic cardiography has meanwhile become an integral part of the diagnostic battery to assess the movements of the atrium, the ventricles, the ventricular septum and above all the valves. The cardiologist’s interest however is not confined to the diagnosis and post-operative control of mitral defects; he also needs diagnostic information on diseases of the tricuspidal valve and the aorta. With increasing experience the diagnosis of pericardial effusion, parietal thrombosis of the atrium and intraauricular tumors became possible. Of special interest is the assessment of myocardial function after infarction. A good correlation was found to exist between left ventricular pressure and reduced movements of the posterior left atria1 wall. In comparison with the numerous publications on onedimensional examinations reports on ultrasonic tomography of the heart are rather rare. Those existing were primarily pubhshed by Japanese teams Tanaka and Kikuchi (1968) who used specially adapted equipment for ultrasonic tomography.
of the right Atrium
We would like to report on two cases in which commercial equipment designed for abdominal diagnostics was successfully applied for tomography of the heart. Our examinations were done with the Austrian Combison system produced by Kretz-Technik. With this machine both ultrasonic display systems can be recorded simultaneously on separate screens, thus allowing a correlation of A and B scanning throughout the entire examination. The system consists of an A and a B scanner with Time motion. DeRection speed is variable, while the height of the stored echo amplitudes can be measured and magnification can be adjusted in 3 steps. The examination was invariably performed with the patient in the supine position. The transducer was 15 mm in dia. the frequency 2 MHz, a thin oil film being used as coupling medium. The scans were performed in the 3rd, 4th and 5th intercostal spaces. Additional scans were made along the longitudinal axis of the heart and parallel to the sternum on either side.
Cow rep0rt.r
No. I : B.J.. 44 yr old, female. Soon after birtha congenital anomaly of her heart was suspected. As a child she could not move as quickly as her peers and easily became breathless. After the onset of puberty the symptoms disappeared completely. 275
216
A. KRATOCHWIL, C. JANTSCH, H. MBSSLACHER. J. SLANY and R. WENGER
At the age of 42 dyspnea recurred following an influenza1 attack. Since January 1971 she has an obstinate cough and precordial pains. The clinical examination showed a heart of normal configuration, somewhat distended on the left. At the apex a loud systolic murmur was recognizable. The first alarming sign was obtained on ECG, which showed distinct right axis deviation as in the rotation of the heart. The chest film (Figs 1 and 2) showed a plump heart rotated to the left with spherical bulging of the left dorsal portion. As this protuberance was not clearly demarcated from the heart wall, X-ray tomography was indicated. It demonstrated a normal-sized left atrium. The posterior heart-wall, however, showed a chicken egg-sized protrusion extending beyond the midline. This was especially noticeable on the lateral tomograms. For differentiation between pericardial cyst, pericardial diverticulum or aneurysm of the heart wall left angiocardiography was performed (Fig. 3). It demonstrated that the protrusion was not connected with the heart wall. As a pericardial cyst was suspected the patient was referred to the ultrasonic laboratory for further clarification. A transverse scan at the level of the 4th intercostal space (Fig. 4) revealed a homogeneous area measuring 9 x 6 cm, which was located between the vertebral column and the left ventricle. On an oblique scan along the presumptive longitudinal axis of the heart the lesion was found to measure 6 x 3.8 cm. Because of its sharp and well defined borders a cystic
Fig. 1. Patient
B.J.. female:
tumor was assumed. This was in good correlation with the findings of the other examinations. Unfortunately the patient refused surgery. A follow-up examination 1 yr later gave the same results. No. 2: F.R., 39 yr old woman who had been well to the age of 37. At that time she began complaining of an inincreasingly annoying cough which eventually was accompanied by vomiting. Without any apparent loss of appetite the patient lost 5 kg within 5 months. Six months prior to admission vertigo and fainting were noted on rapid postural changes. The physical examination showed pronounced dullness over an area of 3 cm from the right sternal border. Heart sounds were normal, cardiac murmurs were absent. The chest film (Fig. 5) and the tomography demonstrated a tumor of approximately 4 cm dia. in the area of the right atrium and the arch. The shaped and calcified structure is found to pulsate and measured irregularly 30 x 50 x 50 mm. For further clarification cardiac catheterization and selective right angiocardiography were ordered. These showed (Fig. 6) narrowing of the right atrium to the point of leaving no more than a sickle-shaped passage for the radiopaque substance. Finally the patient was scheduled for echotomography. On a transverse scan along the 4th intercostal space (Fig. 7a) an irregularly shaped area measuring 4 x 6 cm was visualized. A scan parallel to the right sternal border (Fig. 7b) proved to be more conclusive. It showed the vena cava to be displaced ventrally by a structure cephalad to the diaphragma.
Chest X-ray with pericardial cyst in the antero-posterior indicating the pericardial cyst.
view, the arrow
Ultrasonic
Fig. 2 Patient
B.J., female:
tomography
Chest X-ray in the lateral
Fig 3. Left angiocardiogram
in the lateral
277
of the heart
view, the arrow indicating
view with arrow
indicating
the pericardi al cyst.
the pericardial
cyst
A. KRATOCHWIL,C. JANTSCH,H. M~SSLACHER,J. SLANY and R. WENGER
278
Fig. 4. Transverse ultrasonic section through the fourth ICS with visualization of the pericardial cyst behind the left ventricle (LiVent), R = right, L = left. The picture is taken over a large number of heartbeats so that all heart positions are accumulated.
Fig. 5. Patient
F.R.. female:
Chest X-ray in the antero-posterior the right atrium.
view, the arrow
indicating
the tumor
in
Ultrasonic
tomography
219
of the heart
Fig. 6. Right angiocardiogram shows tumor in the right atrium in the lateral view. Passage of the radiopaque substance through the right atrium is restricted to a lumen of a finger’s width.
Fig. 7(a). Transverse
ultrasonic section through the fourth ICS shows the tumor right atrium (RVO) lateral from the Vena cava (Vca).
(Tu) to lie behind
the
280
A. KRATOCHWIL, C. JANTSCH,H. M~SSLACHER, J. SLANYand R. WENGER
Fig. 7(b). Longitudinal section along the right parasternal border (Cra = cranial, Cou = caudal, Dia = diaphragma, Vca = vena cava, RVo = right atrium, Tu = tumor). The tumor is quite well demarcated and shows central dyshomogeneities. The picture is taken over a large number of heart-beats so that all heart positions are accumulated. This structure is irregularly demarcated and measures 11 cm in length and 5 cm in depth. Inside it echo structures are recognizable which might be comparable with the calcified nodules on the X-ray film. As all examinations performed suggested a tumor of the right atrium the patient was subjected to surgery which confirmed the diagnosis. DISCUSSION The cases reported demonstrate that it may be possible to diagnose gross anatomical changes of the heart using commercial ultrasonic equipment developed for abdominal examinations. In both cases ultrasonic tomography yielded valuable additional information which helped to outline therapeutic procedures. As the heart is in continual motion and surrounded by nearly impenetrable lung and bone tissue, the technique as demonstrated here is as yet far from being ideal. Moreover, the thoracic wall only leaves a small portal for ultrasonic waves to enter; and visualization of subtle diagnostic details is ruled out by the rhythmical movements of the heart, which cause blurring and superposition of signals. The use of fast time-constant circuits as in cardiokineto-ultrasonotomography developed by Tanaka and Kikuchi (1968) should be considered to ensure a phaseoriented visualization of the heart. ECG triggering of the scans may be a possible alternative for improving the results. As Weill (1972) and Winsberg (1972) demonstrated visualization of cardiac pulsations in real time is possible when using suitable instruments. With a special instrument and electronic data processing even the left ventricle can be scanned successfully. And the B-scan Doppler technique used for mapping the big arteries should permit visualization of individual cardiac structures.
For the time being the experienced examiner will, however, draw more and better information from conventional methods of ultrasonic cardiography. REFERENCES Bender, F., Schiirmeyer, E., Gradaus, D. and Reploh, H. D. (1971) Die Diagnose primarer Herztumoren. Dtsch. Med. Wschr. 96, 33.
Bleifeld, W. and Effert, S. (1966) Uber das UltraschallKardiogramm der Tricuspidalklappe. Zschr. Kreislauffschg. 55, 54.
Edler, I. and Hertz, C. H. (1954) The use of ultrasonic reflectoscope for the continuous recordings of the movements of heart walls. Kiinnl. _ Fvsioaraf . _” Stillskaa. Lund Fiirhand. 24,40.
Edler, I. (1955) The diagnostic use of ultrasound in heart disease. Acta med. &and. Suppl. 38, 22. Effert, S., Erkens, H. and Grosse-Brockhoff, F. (1957) Uber die Anwendung des Ultraschall-Echoverfahrens in der Herzdiagnostik. Dtsch. Med. Wschr. 82, 1253. Effert, S. (1959) Der derzeitige Stand der Ultraschallkardiographie. Arch. f Kreislaufl 30, 2 13. Effert, S. and Domanig, E. (1959) Diagnostik intraaurikuliirer Tumoren und grol3er Thromben mit dem Ultraschall-Echoverfahren. Dtsch. Med. Wschr. 84, 6. Effert, S. (1967) Pre- and postoperative evaluation of mitral stenosis by ultrasound. Am. J. Cardiol. 19, 59. Eggleton, R. C., Herrick, J., Townsend, C. and Mitchell, J. H. (1971) Ultrasonic visualization of the left ventricle. Recent Advances in Diagnostic Ultrasound. Charles C. Thomas, Springfield, Illinois.
Ultrasonic
tomography
Ekina, T., Kikuchi, Y., Oko, S., Tanaka, M., Kosaka, S., Uchida, R. and Higiwara, Y. The diagnostic application of ultrasound to the diseases in mediastinal organs. Ultrasonotomography for the Heart and Great Vessels. (First Science Reports of the Research Institute, Tohoku University C12, 199.) Feigenbaum, H., Waldhausen, A. and Hyde, P. (1965) Diagnosis of pericardial effusion. J. Am. Med. Ass. 191, 711. Keidel, W. D. (1950) ijber eine neue Methode zur Registrierung der Volumsgnderungen des Herzens am Menschen. Zschr. f.Kreislaufl 39, 257. Kratochwil, A., Waldtiusl, A. W. and Wewalka, F. (1970) Die Darstellung von LeberverHnderungen im UltraschallSchnittbildverfahren. Zschr.f. Innere Med. 51, 37. Pridie, R. B., Benham, R. and Oakley, C. M. (1971) Echocardiography of the mitral valve in aortic disease. &it. Health J. 33, 296. Rothmann, J., Chase, N. E., Kricheff, S. F., Mayarat, R. and Berenbaum, E. R. (1967) Ultrasonic diagnosis of pericardial effusion. Circulation 35, 358. Schmitt, W. and Braun, H. (1970) Ultraschallkardiographie. G. Thieme-Verlag, Stuttgart. Spencer. W. H., Peter, R. H. and Orgain, E. S. (1971) Detection of a left atrial myxoma by echocardiography. Arch. Int. Med. 128, 787. Tanaka, M., Neyazaki, T., Kosaka, S., Sugi, H., Oka, S., Ebina, T., Terasawa, Y, Unno, K. and Nitta, K. (1971)
of the heart
281
Ultrasonic evaluation of anatomical abnormalities of heart in congenital and acquired heart disease. Brit. Health J. 33, 686. 1 ‘anaka, M., Oka, S., Kikuchi, Y., Okuyama. D., Ebina. T., Kosaka, S., Terasawa, Y., Unno. K., Nitta, K. and Uchida, R. (1968) Cardiac kineto-ultrasonotomography. Ultrasonotomography for the Heart and Great Vessels (9th report) Medical Ultrasonics (The Japan Society of Ultrasonics in Medicine), Vol. 6, p. 79. Tanaka, M., Oka, S., Kikuchi, Y., Gkuyama. D., Kasai, C.. Ebina. T., Kosaka, S., Terasawa, Y. and Unno, K. (1968) Effects of the FTC-circuit on ultrasonotomography. Ultrasonotomography for the Heart and Great Vessels (10th report) Medical Ultrasonics (The Japan Society of Ultrasonics in Medicine), Vol. 6, p, 13 1. Weill, F., Kraehenbuhl, J. R. and Becker, J. C. (1972) M&e en Evidence des Epanchements Pericardiquespar TomoCchoscopie et Tomo&hographie. Coeur et Mt-decme Interne. Vol. XI, p. 389. Wharton. C. F. P., Smithen, C. S. and Sowton, E. (1971) Changes in left ventricular wall movement after acute myocardial infarction measured by reflected Ultrasound. Bit. Med. J. 4, 15. Winsberg. F. and Cole, C. M. (1972) Contmuous ultrasound visualization of the pulsating abdominal aorta. Radiolog) 103. 455. Wolfe, S. B., Popp. R. L. and Feigenbaum. H. (1969) Diagnosis of atrial tumors by ultrasound. Circubtion 39. 615.
in Med.
& Bbl.,
Vol. I, pp
275. 281. Pergamon
Press,
1974. Printed
CLINICAL ULTRASONIC
III Great
Brltaln
NOTE
TOMOGRAPHY
OF THE HEART
A. KRATOCHWIL 11. Universitats-Frauenklinik
Wien, Vorstand
Prof. Dr. H. Husslein.
Spitalgasse
23. 1090 Wien, Austria
C. JANTSCH, H. M~SSLACHER and J. SLANY I. Medizinische
Umversitats-Klinik
Wien, Vorstand Lazarettgasse
Prof. Dr. E. Deutsch,
Kardiologisches
Laboratorium.
14, 1090 Wien, Austria and R. WENCER
II. Medizinische
Abteilung
des Rudolfsspitales,
Boerhaavegasse
(Received 4 January 1973; and injinalform
8, 1030 Wien, Austria
25 April 1973)
Abstract-The report deals with 2 cases of heart tumors in which a commercial ultrasonic diagnostic equipment was used for tomography. In both cases we were successful in demonstrating the lesions. The visualization of subtle diagnostic details is ruled out by the rhythmical movements of the heart which cause blurring and superposition of signals. Key words: Heart,
Echotomography,
Pericardial
cyst, Tumor
IN 1950 Keidel started experiments with the objective of using ultrasound for examinations of the heart. Assuming that ultrasonic impedance depended on the filling phases of the heart, he tried to estimate the heart volume by transsonating cardiac tissues. It was however for Edler and Hertz (1954) to establish this new diagnostic principle in cardiology by applying the pulse echo technique. In many clinics this method, ultrasonic cardiography has meanwhile become an integral part of the diagnostic battery to assess the movements of the atrium, the ventricles, the ventricular septum and above all the valves. The cardiologist’s interest however is not confined to the diagnosis and post-operative control of mitral defects; he also needs diagnostic information on diseases of the tricuspidal valve and the aorta. With increasing experience the diagnosis of pericardial effusion, parietal thrombosis of the atrium and intraauricular tumors became possible. Of special interest is the assessment of myocardial function after infarction. A good correlation was found to exist between left ventricular pressure and reduced movements of the posterior left atria1 wall. In comparison with the numerous publications on onedimensional examinations reports on ultrasonic tomography of the heart are rather rare. Those existing were primarily pubhshed by Japanese teams Tanaka and Kikuchi (1968) who used specially adapted equipment for ultrasonic tomography.
of the right Atrium
We would like to report on two cases in which commercial equipment designed for abdominal diagnostics was successfully applied for tomography of the heart. Our examinations were done with the Austrian Combison system produced by Kretz-Technik. With this machine both ultrasonic display systems can be recorded simultaneously on separate screens, thus allowing a correlation of A and B scanning throughout the entire examination. The system consists of an A and a B scanner with Time motion. DeRection speed is variable, while the height of the stored echo amplitudes can be measured and magnification can be adjusted in 3 steps. The examination was invariably performed with the patient in the supine position. The transducer was 15 mm in dia. the frequency 2 MHz, a thin oil film being used as coupling medium. The scans were performed in the 3rd, 4th and 5th intercostal spaces. Additional scans were made along the longitudinal axis of the heart and parallel to the sternum on either side.
Cow rep0rt.r
No. I : B.J.. 44 yr old, female. Soon after birtha congenital anomaly of her heart was suspected. As a child she could not move as quickly as her peers and easily became breathless. After the onset of puberty the symptoms disappeared completely. 275
216
A. KRATOCHWIL, C. JANTSCH, H. MBSSLACHER. J. SLANY and R. WENGER
At the age of 42 dyspnea recurred following an influenza1 attack. Since January 1971 she has an obstinate cough and precordial pains. The clinical examination showed a heart of normal configuration, somewhat distended on the left. At the apex a loud systolic murmur was recognizable. The first alarming sign was obtained on ECG, which showed distinct right axis deviation as in the rotation of the heart. The chest film (Figs 1 and 2) showed a plump heart rotated to the left with spherical bulging of the left dorsal portion. As this protuberance was not clearly demarcated from the heart wall, X-ray tomography was indicated. It demonstrated a normal-sized left atrium. The posterior heart-wall, however, showed a chicken egg-sized protrusion extending beyond the midline. This was especially noticeable on the lateral tomograms. For differentiation between pericardial cyst, pericardial diverticulum or aneurysm of the heart wall left angiocardiography was performed (Fig. 3). It demonstrated that the protrusion was not connected with the heart wall. As a pericardial cyst was suspected the patient was referred to the ultrasonic laboratory for further clarification. A transverse scan at the level of the 4th intercostal space (Fig. 4) revealed a homogeneous area measuring 9 x 6 cm, which was located between the vertebral column and the left ventricle. On an oblique scan along the presumptive longitudinal axis of the heart the lesion was found to measure 6 x 3.8 cm. Because of its sharp and well defined borders a cystic
Fig. 1. Patient
B.J.. female:
tumor was assumed. This was in good correlation with the findings of the other examinations. Unfortunately the patient refused surgery. A follow-up examination 1 yr later gave the same results. No. 2: F.R., 39 yr old woman who had been well to the age of 37. At that time she began complaining of an inincreasingly annoying cough which eventually was accompanied by vomiting. Without any apparent loss of appetite the patient lost 5 kg within 5 months. Six months prior to admission vertigo and fainting were noted on rapid postural changes. The physical examination showed pronounced dullness over an area of 3 cm from the right sternal border. Heart sounds were normal, cardiac murmurs were absent. The chest film (Fig. 5) and the tomography demonstrated a tumor of approximately 4 cm dia. in the area of the right atrium and the arch. The shaped and calcified structure is found to pulsate and measured irregularly 30 x 50 x 50 mm. For further clarification cardiac catheterization and selective right angiocardiography were ordered. These showed (Fig. 6) narrowing of the right atrium to the point of leaving no more than a sickle-shaped passage for the radiopaque substance. Finally the patient was scheduled for echotomography. On a transverse scan along the 4th intercostal space (Fig. 7a) an irregularly shaped area measuring 4 x 6 cm was visualized. A scan parallel to the right sternal border (Fig. 7b) proved to be more conclusive. It showed the vena cava to be displaced ventrally by a structure cephalad to the diaphragma.
Chest X-ray with pericardial cyst in the antero-posterior indicating the pericardial cyst.
view, the arrow
Ultrasonic
Fig. 2 Patient
B.J., female:
tomography
Chest X-ray in the lateral
Fig 3. Left angiocardiogram
in the lateral
277
of the heart
view, the arrow indicating
view with arrow
indicating
the pericardi al cyst.
the pericardial
cyst
A. KRATOCHWIL,C. JANTSCH,H. M~SSLACHER,J. SLANY and R. WENGER
278
Fig. 4. Transverse ultrasonic section through the fourth ICS with visualization of the pericardial cyst behind the left ventricle (LiVent), R = right, L = left. The picture is taken over a large number of heartbeats so that all heart positions are accumulated.
Fig. 5. Patient
F.R.. female:
Chest X-ray in the antero-posterior the right atrium.
view, the arrow
indicating
the tumor
in
Ultrasonic
tomography
219
of the heart
Fig. 6. Right angiocardiogram shows tumor in the right atrium in the lateral view. Passage of the radiopaque substance through the right atrium is restricted to a lumen of a finger’s width.
Fig. 7(a). Transverse
ultrasonic section through the fourth ICS shows the tumor right atrium (RVO) lateral from the Vena cava (Vca).
(Tu) to lie behind
the
280
A. KRATOCHWIL, C. JANTSCH,H. M~SSLACHER, J. SLANYand R. WENGER
Fig. 7(b). Longitudinal section along the right parasternal border (Cra = cranial, Cou = caudal, Dia = diaphragma, Vca = vena cava, RVo = right atrium, Tu = tumor). The tumor is quite well demarcated and shows central dyshomogeneities. The picture is taken over a large number of heart-beats so that all heart positions are accumulated. This structure is irregularly demarcated and measures 11 cm in length and 5 cm in depth. Inside it echo structures are recognizable which might be comparable with the calcified nodules on the X-ray film. As all examinations performed suggested a tumor of the right atrium the patient was subjected to surgery which confirmed the diagnosis. DISCUSSION The cases reported demonstrate that it may be possible to diagnose gross anatomical changes of the heart using commercial ultrasonic equipment developed for abdominal examinations. In both cases ultrasonic tomography yielded valuable additional information which helped to outline therapeutic procedures. As the heart is in continual motion and surrounded by nearly impenetrable lung and bone tissue, the technique as demonstrated here is as yet far from being ideal. Moreover, the thoracic wall only leaves a small portal for ultrasonic waves to enter; and visualization of subtle diagnostic details is ruled out by the rhythmical movements of the heart, which cause blurring and superposition of signals. The use of fast time-constant circuits as in cardiokineto-ultrasonotomography developed by Tanaka and Kikuchi (1968) should be considered to ensure a phaseoriented visualization of the heart. ECG triggering of the scans may be a possible alternative for improving the results. As Weill (1972) and Winsberg (1972) demonstrated visualization of cardiac pulsations in real time is possible when using suitable instruments. With a special instrument and electronic data processing even the left ventricle can be scanned successfully. And the B-scan Doppler technique used for mapping the big arteries should permit visualization of individual cardiac structures.
For the time being the experienced examiner will, however, draw more and better information from conventional methods of ultrasonic cardiography. REFERENCES Bender, F., Schiirmeyer, E., Gradaus, D. and Reploh, H. D. (1971) Die Diagnose primarer Herztumoren. Dtsch. Med. Wschr. 96, 33.
Bleifeld, W. and Effert, S. (1966) Uber das UltraschallKardiogramm der Tricuspidalklappe. Zschr. Kreislauffschg. 55, 54.
Edler, I. and Hertz, C. H. (1954) The use of ultrasonic reflectoscope for the continuous recordings of the movements of heart walls. Kiinnl. _ Fvsioaraf . _” Stillskaa. Lund Fiirhand. 24,40.
Edler, I. (1955) The diagnostic use of ultrasound in heart disease. Acta med. &and. Suppl. 38, 22. Effert, S., Erkens, H. and Grosse-Brockhoff, F. (1957) Uber die Anwendung des Ultraschall-Echoverfahrens in der Herzdiagnostik. Dtsch. Med. Wschr. 82, 1253. Effert, S. (1959) Der derzeitige Stand der Ultraschallkardiographie. Arch. f Kreislaufl 30, 2 13. Effert, S. and Domanig, E. (1959) Diagnostik intraaurikuliirer Tumoren und grol3er Thromben mit dem Ultraschall-Echoverfahren. Dtsch. Med. Wschr. 84, 6. Effert, S. (1967) Pre- and postoperative evaluation of mitral stenosis by ultrasound. Am. J. Cardiol. 19, 59. Eggleton, R. C., Herrick, J., Townsend, C. and Mitchell, J. H. (1971) Ultrasonic visualization of the left ventricle. Recent Advances in Diagnostic Ultrasound. Charles C. Thomas, Springfield, Illinois.
Ultrasonic
tomography
Ekina, T., Kikuchi, Y., Oko, S., Tanaka, M., Kosaka, S., Uchida, R. and Higiwara, Y. The diagnostic application of ultrasound to the diseases in mediastinal organs. Ultrasonotomography for the Heart and Great Vessels. (First Science Reports of the Research Institute, Tohoku University C12, 199.) Feigenbaum, H., Waldhausen, A. and Hyde, P. (1965) Diagnosis of pericardial effusion. J. Am. Med. Ass. 191, 711. Keidel, W. D. (1950) ijber eine neue Methode zur Registrierung der Volumsgnderungen des Herzens am Menschen. Zschr. f.Kreislaufl 39, 257. Kratochwil, A., Waldtiusl, A. W. and Wewalka, F. (1970) Die Darstellung von LeberverHnderungen im UltraschallSchnittbildverfahren. Zschr.f. Innere Med. 51, 37. Pridie, R. B., Benham, R. and Oakley, C. M. (1971) Echocardiography of the mitral valve in aortic disease. &it. Health J. 33, 296. Rothmann, J., Chase, N. E., Kricheff, S. F., Mayarat, R. and Berenbaum, E. R. (1967) Ultrasonic diagnosis of pericardial effusion. Circulation 35, 358. Schmitt, W. and Braun, H. (1970) Ultraschallkardiographie. G. Thieme-Verlag, Stuttgart. Spencer. W. H., Peter, R. H. and Orgain, E. S. (1971) Detection of a left atrial myxoma by echocardiography. Arch. Int. Med. 128, 787. Tanaka, M., Neyazaki, T., Kosaka, S., Sugi, H., Oka, S., Ebina, T., Terasawa, Y, Unno, K. and Nitta, K. (1971)
of the heart
281
Ultrasonic evaluation of anatomical abnormalities of heart in congenital and acquired heart disease. Brit. Health J. 33, 686. 1 ‘anaka, M., Oka, S., Kikuchi, Y., Okuyama. D., Ebina. T., Kosaka, S., Terasawa, Y., Unno. K., Nitta, K. and Uchida, R. (1968) Cardiac kineto-ultrasonotomography. Ultrasonotomography for the Heart and Great Vessels (9th report) Medical Ultrasonics (The Japan Society of Ultrasonics in Medicine), Vol. 6, p. 79. Tanaka, M., Oka, S., Kikuchi, Y., Gkuyama. D., Kasai, C.. Ebina. T., Kosaka, S., Terasawa, Y. and Unno, K. (1968) Effects of the FTC-circuit on ultrasonotomography. Ultrasonotomography for the Heart and Great Vessels (10th report) Medical Ultrasonics (The Japan Society of Ultrasonics in Medicine), Vol. 6, p, 13 1. Weill, F., Kraehenbuhl, J. R. and Becker, J. C. (1972) M&e en Evidence des Epanchements Pericardiquespar TomoCchoscopie et Tomo&hographie. Coeur et Mt-decme Interne. Vol. XI, p. 389. Wharton. C. F. P., Smithen, C. S. and Sowton, E. (1971) Changes in left ventricular wall movement after acute myocardial infarction measured by reflected Ultrasound. Bit. Med. J. 4, 15. Winsberg. F. and Cole, C. M. (1972) Contmuous ultrasound visualization of the pulsating abdominal aorta. Radiolog) 103. 455. Wolfe, S. B., Popp. R. L. and Feigenbaum. H. (1969) Diagnosis of atrial tumors by ultrasound. Circubtion 39. 615.