226

Brief Communications

Fig.

2.

American

A large thrombus

is seen in the lumen

suspected cardiac source of emboli. Although this is a small series, all of the TTEs failed to reveal cardiac sources of emboli, except in one patient who had a left ventricular thrombus. However, since the thrombus was laminated and immobile, it was unlikely to have caused the embolic event.7 The addition of TEE confirmed the findings on TTE in our patients, and allowed visualization of the aorta as the likely source of emboli in all eight patients. Aortography has been used in evaluating patients with peripheral emboli. The risk of emboli caused by the guiding wire using the transfemoral technique is 0.10 % in all patients undergoing contrast aortography. However, the risk of emboli in patients with intraortic debris is 27 % .8, g Aortography may be undesirable for several reasons: (1) The sensitivity and specificity of the test are unknown. (2) The test is an invasive procedure that may place patients at risk for further emboli as a result of the intraaortic catheterization. (3) The test cannot detect the mobile atheromatous material necessary for the diagnosis. The combined use of TTE and TEE presents a somewhat noninvasive diagnostic method of investigating both the heart and the aorta in patients presenting with peripheral emboli, as well as cerebral vascular disease thought to be secondary to emboli originating in the aortic arch.6 Not only does this combination of tests permit diagnosis, but in those patients in whom intravascular manipulation, aortic surgery, or even contrast aortography is planned, TEE will provide the angiographers and surgeons with information that is essential in assessing the risk of peripheral emboli prior to performing procedures. Accurate diagnosis can lead to clinical trials for therapy, a better understanding of the disease, and prospective studies comparing the relatively low risk TEE with contrast aortography.

JC Jr. Cholesterol to clinical entity.

emboCircula-

aorta (Ao)

of patient

No. 6.

2. Fisher DF, Clagett GP, Brigham RA, et al. Dilemmas in dealing with the blue toe syndrome: aortic vs peripheral source. Am J Surg 1984;148:836-9. 3. Ramirez G, O’Neill W, Lambert R, Bloomer HA. Cholesterol embolization: a complication of angiography. Arch Intern Med 1978;138:1430-2. 4. Smith MC, Ghose MK, Henry AR. The clinical snectrum of renal cholesterol embolization. Am J Med 1981;71:174-80. 5. Fine MJ. Kanoor W. Falanaa V. Cholesterol embolization: a review of 22icases in the English literature. Angiology 1987; 38~769-84. 6. Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new AM HEART finding seen by transesophageal echocardiography. J 1990;120:658-60. 7. Haugland JM, Asinger AW, Mike11 FL, et al. Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography. Circulation 1984;70:588-98. 8. Hessel SJ, Adams DF, Abrams HL. Complications of angioa- I raphy. Radiology 198I;138:273-81. 9. Karalis DG, Chandrasekaran K, Victor MF, et al. Recognition and embolic potential of intraortic atherosclerotic debris. J Am Co11 Cardiol 1991;17:73-8.

Transesophageal echocardiographic features of left ventricular pseudoaneurysm resulting after mitral valve replacement surgery Mohsin Alam, MD, Cathy Glick, MD, Remigio Garcia, MD, and Joseph W. Lewis, Jr., MD. Detroit, Mich. Early diagnoses pseudoaneurysm From

REFERENCES

1. Moldveen-Geronimus M, Merriam lization: from pathologic curiosity tion 1967;35:946-53.

of the descending

January 1992 Heart Journal

the Heart

of left ventricular (LV) false aneurysm or are important because of the potential

and Vascular

Institute,

Henry

Ford

Hospital.

Reprint requests: Mohsin Alam, MD, Division of Cardiovascular K-14, Henry Ford Hospital, 2799 West Grand Blvd., Detroit

4/4/33487

MedicineMI 48202.

Volume Number

123 1

Brief Communications

227

Fig. 1. Transesophageal Z-D echocardiogram of a patient with a pseudoaneurysm of the left ventricle. Note the narrow orifice (arrow) of the aneurysm communicating with the left ventricle. AN, Pseudoaneurysm; BV, bioprosthetic mitral valve; LA, left atrium; LV, left ventricle.

Fig. 2. Transesophageal2-D echocardiogram of the second patient with a pseudoaneurysm of the left ventricle. Note the narrow neck (arrow) of the aneurysm contiguous with the left ventricle. A, Aortic valve; other abbreviations as in legend to Fig. 1.

risk for rupture. l, s These aneurysms are bounded only by fibrous tissue and pericardium and are amenable to surgical repair, which is invariably indicated. Transthoracic echocardiography and color flow Doppler are of value in diagnosing this entity. 3-5 In this report, transesophageal echocardiographic features of LV pseudoaneurysm heretofore unreported are presented. Transthoracic and transesophageal two-dimensional (2-D) echocardiography and color flow Doppler studies were performed using standard equipment and techniques in two patients. Both patients had bioprosthetic cardiac valves implanted for severe mitral regurgitation. In one patient, mitral regurgitation resulted from infective endocarditis, and in the other patient endocarditis occurred after valve replacement surgery. In both patients the echocardiograms were performed because of postoperative congestive heart failure, failure to thrive and, in one instance, postoperative infective endocarditis. Transthoracic 2-D echocardiography revealed an echo-free space with a narrow orifice communicating with the posterolatera1 wall of the left ventricle. Color flow Doppler demonstrated systolic flow from the left ventricle into the aneurysm. Transesophageal2-D echocardiography revealed an echo-free space posterolaterally, which was evident both from the transgastric (Fig. 1) as well as the transesophageal views (Fig. 2) of the left ventricle. The bioprosthetic mitral valves were within normal limits. The diagnosis was subsequently confirmed in one patient by left ventriculography and surgery. The second patient has so far refused surgery. True aneurysms of the left ventricle are more common than pseudoaneurysms.l The echocardiographic differentiation between the two is based on the presence of a nar-

row orifice associated with the pseudoaneurysm and a wide neck associated with true aneurysms. In both our patients .the pseudoaneurysms were better demonstrated and delineated by the transesophageal as opposed to the transthoracic study. This is because these aneurysms are usually located posteriorly and lend themselves to better imaging by a high frequency, high resolution ultrasound probe in the esophagus. As both patients had suffered from infective endocarditis perioperatively, it is not quite clear whether the pseudoaneurysms resulted from complications of endocarditis3 or mitral valve replacement surgery,2y 6 or both. Roberts et al6 previously reported necropsy findings in 10 patients who developed LV lacerations and/or aneurysm formation between the mitral anulus and the papillary muscle stump after mitral valve replacement surgery. They postulated an inadvertent incision of the LV free wall during excision of the mitral valve as the probable cause of the aneurysm formation in their patients. The submitral location of the LV aneurysms in our patients suggests that they may have occurred in a similar manner. In conclusion, transesophageal2-D echocardiography and color flow Doppler can accurately diagnose pseudoaneurysms of the left ventricle. This test should be considered when the transthoracic imaging is equivocal or suboptimal to diagnose these patients. REFERENCES

1. Van Tassel RA, Edwards JE. Rupture of the heart complicating myocardial infarction: analysis of 40 cases including nine examples of left ventricular false aneurysm. Chest 1972;61:10416. 2. Littler WA, Meade JB, Hamilton DI. Ventricular aneurysms after cardiac surgery. Br Heart J 1971;33:962-9.

228

Brief Communications

American

January 1992 Heart Journal

Kessler KM, Kieval J, Saksena S, Sanderson TL, Myerburg RL. Echographic features of oosterior left ventricular wall coli endocarditis. AM pseudoa&urysm due to Eschkrichia HEART J 1982;103:139-42. 4. Carlson EB, Wolfe WG, Kisslo J. Subvalvular left ventricle pseudoaneurysm after mitral valve replacement: two-dimensional echocardiographic findings. J Am Co11 Cardiol 1985;6: 1164-6. 5. Roelandt JRTC, Sutherland GR, Yoshida K, Hoshikawa J. Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler flow imaging. J Am Co11 Cardiol 1988;12:807-11. 6. Roberts WC, Ianer JM, Virmani R. Left ventricular incision midway between the mitral anulus and the stumps of the papillary muscles during mitral valve excision with or without rupture or aneurysmal formation: analysis of 10 necropsy patients. AM HEART J 1982;104:1278-87. 3.

Role of transesophageal echocardiography in sinus of Valsalva aneurysm Patrice A. McKenney, and Susan E. Wiegers,

MD, Richard MD. Boston,

J. Shemin, Mass.

MD,

Sinus of Valsalva aneurysms are often complicated by rupture. Although the right atrium and ventricle are the most frequent sites, rupture can occur into the left ventricle, pulmonary artery, or pericardium.i Successful surgical management requires precise determination of the location and hemodynamic consequences of the lesion. We present a patient in whom transesophageal echocardiography was superior to transthoracic echocardiography in the assessment and management of a ruptured sinus of Valsalva aneurysm. s A Z&year-old woman was noted to have a heart murmur in 1983, thought to be a patent ductus arteriosus. She was asymptomatic and did not seek further medical care until November 1989, when she presented with increasing dyspnea on exertion and fatigue. A gated blood pool scan with flow study revealed a 3:l pulmonary-to-systemic flow ratio and an ejection fraction of 78%. In late December 1989, dental work was performed with prophylactic antibiotic administration before but not after the procedure. One month later the patient presented with fever, chills, and multiple blood cultures positive for Actinobacillus actinomycetemcomitans. The patient was treated for 4 weeks with intravenous antibiotics with resolution of fever; however, there was persistent dyspnea that manifested after she had climbed one flight of stairs. She was then referred From the Evans Memorial Department of Cardiothoracic and the Cardiology Section, Hospital. Reprint versity 4/4/33406

requests: Hospital,

Department of Clinical Research and the Surgery, Boston University Medical Center; Thorndike Memorial Laboratory of Boston City

Patrice A. McKenney, MD, Division of Cardiology, 88 E. Newton St., Boston, MA 02118.

Uni-

Fig. 1. Ruptured sinus of Valsalva aneurysm photographed underwater to show the classic “wind sock” appearance. The main orifice of the aneurysm measures 1 cm in diameter, with several smaller holes representing multiple sites of rupture. White arrow indicates the origin of the aneurysm in the noncoronary sinus of Valsalva. Black arrow indicates the site of rupture into the right atrium.

to this institution for further evaluation. The temperature was 98.6O F, the blood pressure was 120/30 mm Hg, and the heart rate was 80 beats/min. There was no jugular venous distension. The carotid pulses were bounding. The point of maximal impulse was in the fifth intercostal space, 1 cm lateral to the midclavicular line. A right ventricular lift was present. The first and second heart sounds were palpable. A grade 416 continuous murmur was heard over the entire precordium. Neither third nor fourth heart sounds were heard. The lungs were clear. There was no hepatomegaly, peripheral edema, or evidence of cutaneous emboli. The chest radiograph showed normal heart size and pulmonary markings. The electrocardiogram revealed normal sinus rhythm with evidence of left ventricular hypertrophy. Transthoracic echocardiography was notable for a dilated left ventricle with normal systolic function, and a fistula between the noncoronary sinus of Valsalva and the right atrium. Significant flow through the fistula occurred during both systole and diastole. Because of turbulent flow in that area, it was unclear whether aortic insufficiency was present. The patient was taken to the operative suite where intraoperative transesophageal echocardiography was performed. This study showed a ruptured noncoronary sinus of Valsalva aneurysm resulting in a fistula into the right atrium (Figs. 1 and 2). Clarification of the question of aortic insufficiency was required to assess the need for valve repair or replacement. In contrast to the transthoracic echocardiogram, the aortic valve was well visualized and

Transesophageal echocardiographic features of left ventricular pseudoaneurysm resulting after mitral valve replacement surgery.

226 Brief Communications Fig. 2. American A large thrombus is seen in the lumen suspected cardiac source of emboli. Although this is a small se...
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