Biphasic left ventricular outflow and its mechanism in hypertrophic obstructive cardiomyopathy.

Background: Biphasic systolic velocity in the left ventricular (LV) outflow tract (LVOT) occurs in hypertrophic obstructive cardiomyopathy (HOCM). The cause and importance of this observation remain poorly understood.

Methods: A total of 25 patients with HOCM were matched to 30 control subjects.

Transesophageal echocardiographic (TEE) evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve.

The most important role of TEE in aortic valve disease is in the diagnosis of endocarditis and its complications. Examination of the annulus and subvalvular region is essential in any patient with possible aortic valve endocarditis. Assessment of the severity of aortic stenosis is a useful application of TEE when other data are either inconsistent or unavailable.

Deep venous thrombosis prophylaxis in patients with heart disease.

Therapy to prevent deep venous thrombosis (DVT) and pulmonary embolism remains essential for inpatients, despite short periods of bedrest and hospitalization. Although most available data pertain to surgical patients, subgroups of medical patients are at moderate, high, and very high risk for DVT. These include patients admitted to the medical intensive care unit, those with the acute coronary syndromes, and those with congestive heart failure.

Infective Endocarditis.

Despite improvements in antibiotic regimens, patients with infective endocarditis (IE) have a high risk of valve replacement and death. Effective initial treatment depends on two steps: 1) diagnosis of the infecting organism, enabling specific antibiotic therapy, and 2) complete characterization of the anatomic extent of infection. Identification of the infecting organism requires culturing of blood prior to the initiation of antibiotics.

Echocardiographic predictors of survival in low gradient aortic stenosis.

Echocardiographic predictors of long-term survival for patients with low gradient aortic stenosis who undergo aortic valve replacement have not been previously reported. This study shows that patients with larger pre- and postoperative left ventricular volumes, a lower mean preoperative aortic pressure gradient, and failure of volumes to decrease and ejection fraction to increase postoperatively may have a poor prognosis.

Prevalence and diagnostic value of precordial murmurs for valvular regurgitation in obese patients treated with dexfenfluramine.

Echocardiography is recommended for the detection of valvular regurgitation in asymptomatic users of anorexigens with a heart murmur. To determine the prevalence and diagnostic value of heart murmurs for valvular regurgitation, 223 patients receiving dexfenfluramine therapy for 6.9 months and 189 matched controls underwent history and cardiac auscultation by experienced noncardiologists unaware of echocardiography.

Prevalence and determinants of valvulopathy in patients treated with dexfenfluramine.

Background: Valve regurgitation has been associated with dexfenfluramine, but its prevalence and severity are uncertain. Additional factors that may contribute to valve regurgitation in patients exposed to this drug are poorly understood.

Methods And Results: Echocardiography was performed on subjects recruited from 26 prescribing sites in 15 states.

Evolving Concepts about Aortic Stenosis.

Concepts about the management of aortic stenosis have evolved over the last several years. Concerns about the safety of exercise, positive inotropic drugs, and afterload reduction have been based on the expected exponential relationship of pressure and flow predicted by the Gorlin equation. However, in most patients, even those with severe stenosis, transvalvular pressure gradient increases much less than predicted with increases in cardiac output.

Flow dependence of valve area in aortic stenosis: relation to valve morphology.

Objectives: We sought to develop an index of flow dependence of valve area in aortic valve (AoV) stenosis and to determine whether this index is related to structural characteristics of the diseased valve.

Background: Many studies of AoV stenosis using Gorlin or continuity equation methods have demonstrated flow dependence (an increase in valve area with increased flow). Variation in flow dependence between patients despite similar flow rates remains unexplained.

Valve excrescences: prevalence, evolution and risk for cardioembolism.

Objectives: We sought to determine prospectively the prevalence, evolution and embolic risk of valve excrescences in normal subjects and patients with and without suspected cardioembolism.

Background: Valve excrescences detected by transesophageal echocardiography (TEE) have been considered a cardioembolic substrate in selected patients.

Methods: Ninety healthy volunteers (Group I) and 88 patients without suspected cardioembolism and a normal TEE (Group II) were studied and followed up clinically for 58 +/- 21 and 48 +/- 20 months, respectively.

An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus.

Background: Valvular heart disease is the most important cardiac manifestation of systemic lupus erythematosus. We performed a study to determine the relation of valvular disease to other clinical features of lupus, whether or not the valve disease progresses, and the associated morbidity and mortality.

Methods: We performed transesophageal echocardiography and rheumatologic evaluations in 69 patients with systemic lupus erythematosus.

Value of the cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects.

To determine the accuracy of the cardiovascular physical examination for the diagnosis of asymptomatic valvular heart disease (VHD), we prospectively studied 143 subjects, 68 apparent normal subjects and 75 patients with diseases known to produce VHD. All subjects underwent a complete physical examination with dynamic cardiac auscultation by a physician blinded to clinical data and compared with the results of transesophageal color Doppler echocardiography (TEE). By TEE, 33 subjects (23%), and by physical examination, 25 subjects (17%) had at least 1 form of VHD.

Regional left atrial stasis during atrial fibrillation and flutter: determinants and relation to stroke.

Objectives: This study sought to 1) determine the location of left atrial stasis during atrial arrhythmia; 2) define the degree of stasis associated with significant risk of stroke; and 3) identify clinical or transthoracic echocardiographic data useful for predicting left atrial stasis.

Background: Prior studies suggest that stroke during atrial arrhythmia is related to stasis in either the body of the left atrium or the appendage. Recent data indicate that appendage stasis is associated with appendage thrombus formation, but stroke during atrial arrhythmia occurs frequently in the absence of appendage stasis.

Osteogenesis imperfecta and cardiovascular diseases.

Aortic and mitral valvular insufficiency in patients with osteogenesis imperfecta result from an underlying defect in connective tissue formation. The surgical cases reported in the literature have included mechanical and bioprosthetic valve replacement as well as attempts at repair and reconstruction. Despite complications related to bleeding and tissue friability, acceptable results have been obtained.

Caring for patients with acute intermittent porphyria.

The porphyrias are a group of metabolic disorders of heme biosynthesis genetically determined defects. Acute intermittent porphyria is the most common form of porphyria found in the United States. It is caused by a genetic defect in chromosome 11, where one of two genes for porphobilinogen deaminase is defective.

Transesophageal echocardiography in endocarditis.

TEE plays a central role in the diagnosis and management of infective endocarditis. In experienced hands this technique is probably over 90% sensitive and specific for the detection of intracardiac lesions associated with endocarditis. TEE should be performed as soon as possible once endocarditis is suspected.

Pulmonary vein thrombosis.

Pulmonary vein thrombosis is difficult to diagnose clinically and requires a combination of conventional diagnostic modalities. Transesophageal echocardiography was used in the present case to readily diagnose this entity and follow thrombus regression on anticoagulant therapy. This limited experience suggests that transesophageal echocardiography may be the initial diagnostic study of choice for pulmonary vein thrombosis.

Transesophageal echocardiography in the diagnosis of aortic disease.

Transesophageal echocardiography (TEE) has recently become a major diagnostic tool in aortic disease. By far the most important role of TEE is in the rapid diagnosis of acute aortic dissection. In this disease the sensitivity and specificity of TEE are both well more than 90%, patient risk is minimal, and the test can (and should) be done in the emergency department.

Systemic lupus erythematosus valve disease by transesophageal echocardiography and the role of antiphospholipid antibodies.

Objectives: The aims of this study were to better characterize valve disease in systemic lupus erythematosus and to determine its association with antiphospholipid antibodies.

Background: Estimates of the prevalence of valve disease in systemic lupus erythematosus have been higher in autopsy series than in clinical studies using transthoracic echocardiography. Antiphospholipid antibodies have been suggested to be a primary pathogenetic factor.

The two-view radionuclide ventriculogram. Advantages of the LPO view.

This report is a prospective study of 33 male patients who underwent both contrast ventriculography (CVG) and radionuclide ventriculography (RVG) within a 24-hour period. Expert, blinded observers graded the left ventricle's regional wall motion (RWM) in the left anterior descending (LAD), left circumflex (LCx), and posterior descending arterial (PDA) distributions on right anterior oblique (RAO), and left anterior oblique (LAO) CVGs, and on anterior (ANT), LAO, 70 degrees left anterior oblique (LAO70), and left posterior oblique (LPO) RVGs. When statistically compared with CVG RWM standard data, RVG studies composed of LAO and LPO views were equal to the RVG studies composed of ANT, LAO, and LAO70 views in assessment of the LAD and LCx distributions.

Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis.

To compare the diagnostic value of transesophageal and transthoracic echocardiography in infective endocarditis, paired transesophageal and transthoracic echocardiograms were obtained prospectively for 66 episodes of suspected endocarditis in 62 patients. Echocardiographic results were compared with the presence or absence of endocarditis determined by pathologic or nonechocardiographic data from the subsequent clinical course. All echocardiograms were interpreted by an observer told only that the studies were from patients in whom the diagnosis of endocarditis was suspected.

Anomalous papillary muscle producing dynamic left ventricular outflow tract obstruction.

A patient with a dynamic left ventricular outflow murmur was shown to have an anomalous anterolateral papillary muscle by transthoracic and transesophageal two-dimensional Doppler echocardiography. High late systolic outflow velocity and systolic anterior motion were demonstrated in the lateral outflow tract near the anomalous muscle, suggesting a role for the Venturi effect. This is the first confirmation by Doppler echocardiography of an anomalous papillary muscle contributing to abnormal left ventricular hemodynamics.