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Uncontrolled pulmonary hypertension may cause worse outcomes after transcatheter aortic valve replacement (TAVR), while hemodynamic monitoring is desirable for risk control. Pulmonary artery pressure (PAP) readings obtained by intracardiac Doppler echocardiography were evaluated.

We analysed the impact of bundle branch block (BBB) and pacemaker (PM) implantation on symptoms and survival after alcohol septal ablation (ASA) in patients with hypertrophic cardiomyopathy (HCM).

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

The current American College of Cardiology Foundation/American Heart Association guidelines on hypertrophic cardiomyopathy state that institutional experience is a key determinant of successful outcomes and lower complication rates of alcohol septal ablation (ASA). The aim of this study was to evaluate the safety and efficacy of ASA according to institutional experience with the procedure.

Because the final myocardial scar might be theoretically associated with an increased risk of sudden cardiac death, the long-term clinical course of patients who undergo alcohol septal ablation (ASA) is still a matter of debate. In this retrospective multicentre study, we report outcomes after ASA, including survival, analysis of causes of deaths, and association between time and cause of death.

Echocardiography has been debated as an adjunct for transcatheter aortic valve replacement (TAVR). The aim of this prospective study was to comparatively evaluate intraprocedural guidance using intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE).

Abstract:Ratio calibration of a digital voltmeter (DVM) is critical for applications such as load cell response for force measurement. The National Institute of Standards and Technology (NIST) DVM ratio service provides ratio voltage measurements that are traceable to the Josephson Voltage Standard (JVS). Previously, the service was supported by NIST JVS systems using manual measurements. The NIST JVS uses a conventional Josephson junction array which often experiences a spontaneous step transition, caused by electromagnetic interference, during its operation. An adjustment is required to obtain a stable voltage step for the ratio calibration. The programmable JVS (PJVS), developed in the last decade, uses an array with non-hysteretic steps to provide a stable voltage. The PJVS was implemented in the DVM ratio calibration service to improve the efficiency and reliability of the service. The new protocol can be executed automatically to reduce the labor cost of the calibration service. The uncertainty of the DVM ratio calibration can be improved by taking automatic multiple measurements. This paper describes the DVM ratio calibration procedure and compares the conventional JVS and PJVS protocols. Results of an actual DVM ratio calibration are presented.

Abstract The use of highly antiretroviral therapy (HAART) significantly reduced morbidity and mortality by inhibition of virus replication. Even though long-term side effects are not fully known, this antiviral strategy has revolutionized the care of HIV-infected patients and is widely used in industrial countries.

Purpose: To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection.Case Report: A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure.Conclusions: Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent “procedure-related” complications.

BackgroundA 25-year-old obese male (BMI 31.9 kg/m2) presented with atypical chest pain of sudden onset that was indistinguishable from acute myocardial infarction. He had tachycardia (104 beats/min) and dyspnea at a low level of exercise. He had no previous cardiac history, but his cardiovascular risk profile included a familial predisposition, smoking and hypertension.

Background:Midazolam is a broadly used drug that can enhance tolerance to transesophageal echocardiography (TEE) in patients with cardiac conditions. Adverse reactions to midazolam have been described previously. We describe central-nervous side effects in 6 of 104 consecutive patients. Methods:One hundred four patients undergoing TEE-diagnostic procedure were investigated. TEE was performed using a SSA 360 Power Vision ultrasound unit (Toshiba, Tokyo, Japan) and a 5- to 6-MHz probe. Indication for TEE was evaluation of cardiac valves (6), search for cardiac embolism (23), patent foramen ovale or atrial septum defect (20), left ventricular dysfunction (11), aortic dissection (7), and other (37). Midazolam and, if necessary, the benzodiazepine antagonist flumazenil (0.25-0.5 mg) were administered intravenously. Results:The mean cumulative dose of midazolam administered in small fractions was 4.8 ± 2 mg. In 6 of 104 patients (5.7%) clinically significant adverse effects to midazolam occurred. The reactions were aggressiveness, euphoria, depression, and intense hiccups (singultus) despite low doses of midazolam. The severest forms of these adverse effects to midazolam could be successfully treated with intravenous infusion of flumazenil (0.25-0.5 mg intravenously). Conclusion:Adverse effects including aggressive, euphoric, or depressive behavior can occur in a significant proportion (6%) of patients with cardiac conditions undergoing TEE after intravenous administration of midazolam. The administration of the benzodiazepine antagonist flumazenil can reverse the adverse effects to midazolam successfully. (J Am Soc Echocardiogr 2002;15:1297-1300.)

BackgroundIn patients with acromegaly, abnormalities of systolic and diastolic left ventricular (LV) performance, mostly associated with hypertension or LV hypertrophy, have been reported. We used 2-dimensional/Doppler echocardiographic methods and tissue Doppler imaging (TDI) to elucidate the impact of disease activity on LV function in patients with acromegaly. MethodsIn a prospective study design, 15 patients with active acromegaly (AA group; mean age-adjusted serum insuline-like growth factor-I [IGF-I] level, 420 ± 170 ng/mL, mean growth hormone nadir during 75-g oral glucose load, 12.3 ± 30.1 μg/L), 18 patients with cured (n = 14, mean IGF-I level 205 ± 115 ng/mL, mean growth hormone nadir during glucose load 0.72 ± 0.34 μg/L) or well-controlled (n = 4, normal age-adjusted ranges of IGF-I levels with medication with somatostatin analogues 354 ± 88 ng/mL) acromegaly (CA group), and 24 control subjects (control group) underwent 2-dimensional/Doppler echocardiographic measurements, including assessment of the Tei index (isovolumic contraction time and isovolumic relaxation time divided by ejection time). Systolic and diastolic mitral annular velocities (peak systolic velocity, peak early diastolic velocity [E′], peak late diastolic velocity [A′], E′/A′ ratio) were derived from pulsed TDI. ResultsNo significant differences between study groups were observed with respect to muscle mass and systolic parameters, such as ejection fraction, fractional shortening, and peak systolic velocity. In patients with AA, E′ and the E′/A′ ratio were lower than in control and CA subjects (AA 6.8 ± 1.7 cm/s, control 10.0 ± 1.7 cm/s, CA 9.1± 3.0 cm/s, P<.01 AA vs control, P<.05 AA versus CA, AA 0.68 ± 0.22, control 0.98 ± 0.16, CA 0.89 ± 0.37, P<.01 AA vs control and CA, respectively). In comparison with control subjects and patients with CA, patients with AA had a reduced mitral peak velocity of early/late filling ratio (AA 0.78 ± 0.22 m/s, control 1.12 ± 0.33 m/s, CA 1.11 ± 0.36 m/s, P<.05 AA vs control and CA) and a prolonged deceleration time (AA 223 ± 41 ms, control 188 ± 26 ms, CA 185 ± 25 ms, P<.05 AA vs control and CA). The Tei index was significantly elevated in patients with AA in comparison with control subjects and patients with CA (AA 0.54 ± 0.13, control 0.40 ± 0.09, CA 0.44 ± 0.10, P<.05 AA vs control and CA). No significant differences were observed between control subjects and patients with CA with respect to mitral flow-derived variables, TDI parameters, and the Tei index. ConclusionDisease activity has a significant impact on LV performance in patients with acromegaly. In subjects with active disease, diastolic dysfunction and beginning impairment of overall LV performance are present. In patients with cured/well-controlled disease, systolic and diastolic function appear normal. (Am Heart J 2002;144:538-43.)

Transthoracic Doppler echocardiography (TTDE) allows noninvasive flow measurement in the distal left anterior descending artery (LAD). The feasibility of detecting coronary flow by contrast-enhanced TTDE with second harmonic technique was assessed, the coronary flow velocity reserve (CFVR) was evaluated in comparison to intracoronary Doppler flow (ICD) analysis and the CFVR after PTCA in LAD was investigated. In 77 (96%) of 80 patients, CFVR was successfully determined with intravenous adenosine infusion. Doppler signal quality was evaluated in the first 46 patients by use of intravenous Levovist infusion and second harmonic technique. The Doppler flow was not visible in 1 patient only. CFVR determined from TTDE (2.77±0.65) was correlated closely with those from ICD (2.88±0.78) measurements (y=0.73x+0.67,r=0.87,P<0.001). In conclusion, TTDE is a feasible method and provides reliable data on CFVR which can be used for followup after PTCA.

Accurate assessment of left ventricular function is of the greatest importance in clinical cardiology for decision making. Diastolic dysfunction is getting more concern as a cause of heart failure while, currently used non-invasive modalities for diagnosing diastolic abnormalities have significant limitations. Dynamic left ventricular volume change was applied for the evaluation of diastolic function by various techniques that have been demonstrated to be of diagnostic value. However, it has not been accepted into clinical practice because existing techniques are either invasive, inaccurate, expensive or time consuming. Real-Time Three-Dimensional Echocardiography:Real-time three-dimensional (3-D) echocardiography is a new ultrasound technique that provides transthoracic volumetric images of the heart in real time. Thereby, the acquired images are ideally suited for the assessment of dynamic left ventricular volume change. Generation and analysis of left ventricular volume-time curves by real-time 3-D echocardiography has been demonstrated to be feasible in normal subjects and patients and accuracy of volume-time curves was good compared to magnetic resonance imaging. We compare the new real-time 3-D echo approach with the advantages and limitations of existing noninvasive and invasive techniques. Eine genaue Beurteilung der linksventrikulären Funktion ist von größter Bedeutung für die kardiologische Diagnostik und Therapie. Besonders diastolische Funktionsstörungen als Ursache für eine diastolische Herzinsuffizienz lassen sich jedoch mit nicht-invasiven Methoden nur eingeschränkt beurteilen. Die Methode der Volumen-Zeit-Kurven-Analyse erlaubt eine detailliertere Beurteilung der diastolischen Funktion. Sie ist jedoch nicht Bestandteil der Routinediagnostik, da die existierenden bildgebenden Verfahren entweder invasiv, ungenau, kostenintensiv oder zeitintensiv sind. Echtzeit-3-D-Echokardiographie:Die Echtzeit-3-D-Echokardiographie, ein neues Verfahren zur Gewinnung von dynamischen Volumendatensätzen des Herzens, ist jedoch besonders beeignet zur Akquisition von linksventrikulären Volumen-Zeit-Kurven. Im direkten Vergleich mit der Magnetresonanztomographie zeigen die Volumen-Zeit-Kurven mittels Echtzeit-3-D-Echokardiographie eine hohe Übereinstimmung bei Untersuchungen an Normalpersonen und Patienten. Die vorliegende Arbeit liefert einen Überblick über die Methode der Volumen-Zeit-Kurven-Analyse mittels Echtzeit-3-D-Echokardiographie sowie den Vorteilen und Limitationen im Vergleich mit anderen Verfahren.

Eine ausschließlich auf standardisierten 2-D-Schnittbildern beruhende Interpretation der morphologischen und funktionellen Pathologie des Herzens kann zu erheblichen Fehlinterpretationen führen. Die Einführung der 3-D-Echokardiographie erlaubt eine räumliche Orientierung und im Gegensatz zur 2-D-Echokardiographie auch eine Aufblickdarstellung kardialer Strukturen. In den letzten Jahren war die Weiterentwicklung der Methode durch die Einführung neuer, einfach handhabbarer und zeitsparender Datenaufnahmetechniken sowie verbesserter Auswertungsmöglichkeiten charakterisiert. Grundsätzlich steht die dynamische 3-D-Echokardiographie, bei der die Datenakquisition von 2-D-Schnittbildern und anschließend offline die Bildrekonstruktion erfolgen, der Echtzeit-3-D-Echokardiographie unter Verwendung von Matrixschallköpfen gegenüber. Gegenwärtig kommt überwiegend die dynamische 3-D-Echokardiographie mittels transösophagealer Sonden mit rotierendem Schallkopf als Akquisitionstechnik zur Anwendung. Basierend auf einer qualitativ-morphologischen oder quantitativen Analyse des 3-D-Datensatzes ergeben sich potentielle klinische Einsatzmöglichkeiten vor chirurgischen Rekonstruktionen der Mitralklappe und bei der präoperativen Planung chirurgischer rekonstruierender Maßnahmen des linken Ventrikels (z. B. Aneurysmektomie). Bei kongenitalen Vitien stellen vor allem die präinterventionelle Diagnostik des Vorhofseptumdefekts und die Therapiekontrolle nach dessen transvenösem Verschluss eine weitere Indikation dar. Due to limitations in transthoracic and occasionally transesophageal 2-D echocardiography with respect to volumetric analysis and morphologic and functional assessment in patients with congenital malformations and valvular heart disease, additional diagnostic tools have been established. In parallel with the rapid evolution in computer technology, 3-D echocardiography has grown into a well-developed technique, such as volume-rendered 3-D reconstruction, capable of displaying dynamic morphology depicting depth of the structures their attachment, and spatial relation to the surrounding tissue. Nevertheless, the complexity of data acquisition and data processing required for adequate dynamic 3-D echocardiographic imaging and volumetric analysis does not allow to use this approach routinely. The commonly used dynamic 3-D echocardiography means off-line computer-assisted image reconstruction from a series of cross-sectional echocardiographic images using currently available transesophageal and transthoracic transducers. Alternatively, real-time 3-D echocardiography based on novel matrix, phased-array transducer technology has been introduced. Although this technique can be easily combined with any routine examination, its clinical use is limited because of a lower image quality in comparison with dynamic 3-D echocardiography. Up to now, there is no transesophageal approach available using real-time 3-D echocardiography. Recently, dynamic 3-D echocardiographic technique has matured noticeably. Beside the well-known sequential scanning, which is characterized by a fixed probe and patient in space and predetermined motion of the transducer, the freehand scanning using an electromagnetic location system has found its way to clinical environment. The main advantage of this technique is that the transducer can be freely moved by the examiner and, thus, the data set acquired within a routine examination. Also 3-D rendering and display have been developed further. In this respect, especially the “real-time rendering mode” allowing the reconstructed 3-D image to be animated and moved in space and to look at it from different perspectives has gained increasing acceptance. In valvular heart disease, reconstructive surgical treatment is aspired. 3-D echocardiographic imaging is the only technique providing “surgical views” prior to opening the heart. It is capable of distinguishing particular destructive substructures of the valves and the valvular apparatus. Especially in mitral valvular reconstruction, it is of clinical importance to achieve optimal surgical results. With respect to volumetric and mass analysis, 3-D echocardiography is more accurate and reproducible in comparison with conventional 2-D analysis. It provides data independent of geometric assumptions, what may considerably influence the results in the presence of wall motion abnormalities, especially in aneurysmatic ventricles. Volumetric analysis of the aneurysmal portion may also be helpful prior to surgical resection. 3-D echocardiography can also be recommended, as a valuable additional approach to atrial septal defect (ASD), corrected transposition of the great arteries, cor triatriatum, and within limits, to ventricular septal defect (VSD) as well. Especially with respect to ASD and VSD, the potential significance of 3-D echocardiography prior to device closure is emphasized. At present, its additional information in decision-making and the increasing number of clinical cases that can be addressed and answered already justify the clinical use of this technique.

Der klinische Nachweis einer Herzinsuffizienz bei normaler Ejektionsfraktion erlaubt die Diagnose einer diastolischen Funktionsstörung des linken Ventrikels. Neben klinischen Zeichen der Herzinsuffizienz und Kriterien anhand der Herzkatheterdiagnostik wie einer abnormalen linksventrikulären Relaxation, Füllung und/oder Dehnbarkeit liefert die Echokardiographie wertvolle Parameter für die Erfassung einer diastolischen Funktionsstörung. Echokardiographische Schweregradeinteilung:Anhand verschiedener Parameter kann die diastolische Funktionsstörung in vier Schweregrade unterschieden werden, die erhebliche prognostische Bedeutung besitzen. Wird mehr als ein echokardiographischer Parameter herangezogen, ist die diastolische Funktionsstörung in nahezu allen Fällen nachweisbar. Herkömmliche Parameter schließen die isovolumetrische Relaxationszeit gemessen mittels gepulster Doppler-Registrierung ein, das Verhältnis von schneller Füllung zur Vorhoffüllung (E/A) und die Dezelerationszeit anhand des schnellen Mitraleinstromsignals sowie das Verhältnis von systolischer zu diastolischer Pulmonalvenenflussgeschwindigkeit. Diese Parameter sind vorlastabhängig. Die intrinsische diastolische Funktion des linken Ventrikels ist schwierig abzuschätzen. Auch bei Vorhofflimmern bestehen verschiedene Möglichkeiten, um den Füllungsdruck des Ventrikels zu berechnen. Neue Methoden:Zwei neue Methoden, der Farb-Doppler-M-Mode des linksventrikulären Einstroms und der Gewebe-Doppler des Mitralrings, sind relativ vorlastunabhängig und erlauben eine direkte Abschätzung der Relaxation und des Füllungsdrucks. Mittels Echtzeit-3-D-Echokardiographie haben wir eine neue Methode entwickelt, um auch die schnelle Füllungsrate (PFR) zu erfassen. Schlussfolgerung:Dieses Spektrum an Untersuchungsmethoden macht die Abklärung einer diastolischen Funktionsstörung zu einer Domäne der Echokardiographie. Left ventricular diastolic dysfunction can be diagnosed if clinical signs of heart failure and normal ejection fraction are found. Beside clinical signs of heart failure and criteria from catheterization studies like abnormal left ventricular relaxation, filling and/or compliance echocardiography provides valuable parameters for the assessment of diastolic dysfunction. Echocardiographic Degrees of Severity:By the use of various parameters diastolic dysfunction can be differentiated into four degrees of severity, which are of great prognostic importance. If more than one echocardiographic parameter is used, sensitivity for the assessment of diastolic dysfunction becomes nearly 100%. Conventional parameters include isovolumetric relaxation time (IVRT) measured by pulsed Doppler, the ratio of rapid filling and atrial filling velocity (E/A), deceleration time of rapid mitral inflow as well as the ratio of systolic and diastolic pulmonary venous flow velocities. In patients with signs of diastolic heart failure and a normal E/A ratio pulmonary venous flow pattern can help to unmask “pseudonormalization” as the transition from abnormal relaxation to restriction. These parameters, however, are preload-dependent and do not provide intrinsic left ventricular properties. Even in atrial fibrillation, left ventricular filling pressure can be assessed. New Methods:Two novel approaches, color Doppler M-mode of left ventricular inflow and tissue Doppler of the mitral annulus, are relatively preload-independent and allow direct estimation of relaxation and filling pressure. By the means of real-time 3-D echocardiography we developed a new method for the non-invasive assessment of rapid filling rate (PFR), thereby completing the echocardiographic approaches to determine diastolic dysfunction. Conclusion:The broad spectrum of approaches available today makes echocardiography the first choice for the assessment of diastolic dysfunction.

OBJECTIVES

Left ventricular diastolic dysfunction (LVDD) is a frequent cause of heart failure. Doppler echocardiography has become the method of choice for the noninvasive evaluation of LVDD. However, pseudonormalization (PN) of the mitral inflow often presents a diagnostic challenge in clinical practice. In this setting, we sought to define the role of tissue Doppler imaging (TDI) of the septal mitral annulus. Echocardiography was performed in 36 consecutive subjects (age 59 ± 10years). Eighteen of these had diagnosed coronary artery disease (CAD) with recent onset of symptoms (within 3 months), 18 had clinical suspicion of CAD, and 15 had symptoms of heart failure (New York Heart Association [NYHA] Class 2.4 ± 0.5). The mitral inflow profile (E, A, E/A) was measured by pulsed Doppler, and the deceleration time (DT) and the isovolumic relaxation time (IVRT) were calculated. Peak diastolic velocities of the septal mitral annulus (ET, AT, ET/AT) and the time interval from Q in the ECG to the onset of ETwere derived from pulsed TDI. Left heart catheterization was performed for direct measurement of left ventricular end‐diastolic pressure (LVEDP). PN defined by an E/A ratio > 1 and an LVEDP ≥ 16 mmHg was found in nine patients. All patients with PN had symptoms of heart failure (NYHA Class 2.8 ± 0.5). Patients with and without PN did not differ with respect to the E/A ratio (1.29 ± 0.44 vs 1.16 ± 0.23, P = ns), DT (182 ± 38 msec vs 205 ± 42 msec, P = ns), and IVRT (88 ± 24 msec vs 92 ± 18 msec, P = ns). In the group with PN, a significant reduction of ET(5.6 ± 1.8 cm/sec vs 8.8 ± 2.9 cm/sec, P < 0.05) and ET/AT(0.5 ± 0.16 vs 0.82 ± 0.37, P < 0.05) was detected. In the PN group, the Q‐ETinterval was prolonged (404 ± 48 msec vs 346 ± 50 msec, P < 0.05). Receiver operating characteristic curve analysis for ETyielded an area under the curve of 0.78 ± 0.06(P = 0.034) for separating patients with versus without PN. When the combination of ET< 7 cm/sec and ET/AT< 1 was used as cutpoint, PN could be identified with a sensitivity of 83% and a specificity of 79%. There was no significant relation between LVEDP and either ET(r = 0.32, P > 0.2) or the Q‐ETinterval (r = 0.14, P > 0.5). In conclusion, ETand the Q‐ETinterval appear to be useful parameters for assessing LV diastolic dysfunction in symptomatic patients with a pseudonormal mitral inflow pattern and elevated filling pressures.

Zusammenfassung: Die Gewebe-Doppler-Echokardiographie ergänzt die konventionelle transthorakale und transösophageale Echokardiographie bei ausgewählten Fragestellungen, wie der Erkennung und Quantifizierung von Wandbewegungsstörungen oder der Lokalisation von akzessorischen Leitungsbahnen. Ein weiteres, klinisch interessantes Anwendungsgebiet hat sich mit der Identifizierung kardialer Zusatzstrukturen herausgebildet. Dabei basiert die Erkennung und Zuordnung der Strukturen in erster Linie auf deren Bewegungsmustern und dem Grad der Synchronität der Bewegung im Vergleich mit der Umgebung. Insbesondere bei endokarditischen Vegetationen wird die Erkennung durch deren inkohärente Bewegung erleichtert. Die Farbkodierung dieses Bewegungstyps demarkiert die Vegetation deutlich vom umgebenden Gewebe. Die Tatsache, daß Vegetationen meist sehr klein und häufig nicht besonders echogen sind, erschwert gewöhnlich ihre Erkennung, fällt jedoch bei der Anwendung der Gewebe-Doppler-Echokardiographie nicht nachteilig ins Gewicht. Von der inkohärenten Bewegung bei frei schwingenden Strukturen kann die kohärente Bewegung mit Phasendifferenz abgegrenzt werden. Typisch ist diese Bewegungsform für solche Zusatzstrukturen, die in ihrer Schwingungsfähigkeit partiell eingeschränkt sind. Als dritte Bewegungsform kann die konkordante Bewegung bei Zusatzstrukturen beobachtet werden, die mit dem umgebenden Gewebe vollständig verwachsen sind. Ihre Bewegung stimmt in Richtung, Geschwindigkeit und Phase mit der Bewegung der Umgebung überein. Neben geweblichen Zusatzstrukturen erleichtert die Gewebe-Doppler-Echokardiographie auch die Erkennung von Spontankontrast im linken Vorhof. Mittels Farbkodierung kann die kreisende Bewegung des Spontankontrasts im linken Vorhof auch dann nachgewiesen werden, wenn deren Echogenität noch gering und der Spontankontrast mittels konventioneller Echokardiographie noch nicht sicher erkennbar ist.

Zusammenfassung: Der physiologische Ablauf von ventrikulärer Füllung und Austreibung wird durch eine regionale, myokardiale Funktionsstörung beeinträchtigt. So kommt es durch die Okklusion eines Koronargefäßes innerhalb kurzer Zeit zu charakteristischen Veränderungen im ischämischen Myokardsegment: Die systolische Wanddickenzunahme ist vermindert (Hypokinesie), fehlt dann völlig (Akinesie) und wird schließlich durch eine paradoxe Auswärtsbewegung ersetzt (Dyskinesie). Das Maximum der Amplitude der Wandexkursion verschiebt sich in die frühe Diastole („post-ejection thickening”). Folge ist eine ventrikuläre Asynchronie, da ischämisches und normoperfundiertes Myokard zeitlich versetzt relaxieren bzw. kontrahieren. Tierexperimentell kann die Asynchronie mit subendo- bzw. subepikardial implantierten Ultraschallkristallen („Sonomikrometrie”) oder durch Analyse der Phasenverschiebung der ersten Fourierschen Schwingung der Wandbewegung von ischämischem und normoperfundiertem Segment nachgewiesen werden. Klinisch ist eine ventrikuläre Asynchronie bei der koronaren Herzerkrankung und der hypertrophen Kardiomyopathie mittels digitalisierter Cineventrikulographie, Radionuklidangiographie oder digitalisierter M-Mode-Echokardiographie faßbar. Wegen des hohen technischen Aufwands fanden diese Methoden allerdings keinen Eingang in die klinische Routinediagnostik. Die Gewebedopplerechokardiographie („tissue Doppler echocardiography” = TDE) erlaubt die Analyse der Wandgeschwindigkeit eines Myokardareals, welches sich auf den Schallkopf zu bewegt, indem niederfrequente, hochamplitudige, vom Myokard emittierte Dopplersignale nach Selektion der Amplitude unter Umgehung des „high pass filters” direkt an den Autokorrelator weitergegeben und farbkodiert dargestellt werden. Räumliche und zeitliche Auflösung der Methode sind hoch und erlauben eine regionale Wandgeschwindigkeitsanalyse zu definierten Zenpunkten des Herzzyklus. Mittels TDE wurden online Synchronie bzw. Asynchronie der ventrikulären Kontraktion und Relaxation zu unterschiedlichen Zeitpunkten des Herzzyklus bei gesunden Probanden, Patienten mit koronarer Herzerkrankung und Patienten mit hypertropher Kardiomyopathie geprüft. Während der isovolumetrischen Relaxationszeit (IVRT) fand sich im apikalen Vier-Kammer-Blick bei gesunden Probanden eine langsame, synchrone Auswärtsbewegung von Septum und Lateralwand (blau-grüne Kodierung). Bei Patienten mit signifikanter RIVA-Stenose und mit hypertropher Kardiomyopathie konnte in dieser Phase des Herzzyklus eine ventrikuläre Asynchronie erkannt werden: Bei Einwärtsbewegung des interventrikulären Septums (rote Farbkodierung) fand sich eine Auswärtsbewegung (blau-grüne Farbkodierung) der lateralen Wand. Mit der Gewebedopplerechokardiographie steht ein einfaches, klinisch praktikables Verfahren zur raschen Erfassung einer ventrikulären Asynchronie zur Verfügung Sensitivität und Spezifität der Methode müssen in nachfolgenden, prospektiv randomisierten Studien geklärt werden.

The aim of the present study was to determine whether quantitative tissue Doppler echocardiography has a role in the assessment of left ventricular hemodynamics. Thirty patients with suspected or known heart disease, but no wall motion abnormalities, took part in the study. Quantitative tissue Doppler echocardiography was performed using new software for digital analysis of the tissue Doppler signal. Average systolic subendocardial (S1), subepicardial (S2), and transmural (S3) wall velocity data were obtained from the inferoposterior wall and compared with the hemodynamics, including high fidelity pressure readings. S1 and S3 rates were found to be most reliable, being directly related to the peak rate of left ventricular pressure rise (dP/dtpeak) and inversely to systemic vascular resistance (SVR) and resistance index (SVRI). The best correlation was between S1, dP/dtpeak, and SVRI (multiple regression analysis: r = 0.76, P < 0.0001; simple regression analysis relating S1 to dP/dtpeak/SVRI: r = 0.77, SEE = 0.25, P < 0.0001). Thus, wall velocity indices as defined in this study have promise to become helpful in guiding the therapeutic modulation of inotropy and afterload in patients with heart failure.

New ultrasonic technology allows noninvasive measurement of the flow in the distal left anterior descending coronary artery. The goal of this study was to validate transthoracic determination of coronary flow velocity with the intracoronary Doppler flow wire technique. In 20 patients with normal coronary arteries, 2 intracoronary and 2 comparative transthoracic Doppler measurements (TTDMs) of the average peak velocity (APV) and the mean systolic and diastolic velocities were performed. The diastolic/systolic ratio was calculated. Blood flow velocity was determined in the distal left anterior descending coronary artery with a Doppler guide wire. Color Doppler and subsequent pulsed wave Doppler readings in an optimal left lateral position were available within 1 hour after completion of the invasive examinations. TTDM were performed during continuous administration of 2.0 g of contrast agent. A modified apical view was obtained from the fourth or fifth intercostal space, and a high-frequency transducer was used (7 MHz for 2-dimensional and 6 MHz for color Doppler imaging; 3.5 MHz for pulsed wave Doppler readings). The Doppler flow signal quality was graded from I to III (I = no flow mapping obtainable, II = poor quality, III = Doppler signals with a well-defined outline). In 13 (65%) patients, 26 TTDMs revealed signal quality of grade III. APV was calculated to be within normal limits (APVecho= 19.96 ± 7.62 cm/s vs APVinvasive= 20.77 ± 7.87 cm/s). APVechocorrelated well with APVinvasive(r= 0.85, y= 0.82x+ 2.85, P< .001). The mean difference between APVechoand APVinvasive(Bias) was -0.81 ± 4.23 cm/s. No correlation was found between invasive and noninvasive measurements of diastolic/systolic velocity ratios (P.05). High-frequency TTDM provides reliable data on APV in the majority of patients. It has the potential to be introduced as a relevant screening test for follow-up of patients after interventional treatment. (J Am Soc Echocardiogr 1999;12:252-6.)

Dynamic three-dimensional echocardiography is a new diagnostic tool for spatial visualisation of cardiac anatomy and volumetric assessment. A computer-controlled probe acquires parallel tomographic slices, from which dynamic three-dimensional images of the heart can be reconstructed. Thirty adult patients with valvular heart diseases, congenital heart diseases, intracardiac masses, heart failure and other cardiac lesions, underwent conventional two-dimensional (n=30), three-dimensional echocardiography (n=30) and thermodilution (n=17). The feasibility, usefulness and possibility of simulating a surgical view of intracardiac anatomy and exact volumetry were determined. The two different morphologic images were compared qualitatively. For quantitative analysis volumetry was performed using standard thermodilution technique and dynamic three-dimensional echocardiography. In more than 80% of the patients additional morphologic information was gained and a strong correlation (r=0.75–0.95) between two volumetry assessments was found. Based on this findings, dynamic three-dimensional echocardiography is an additional and valuable approach in the perioperative and intensive care management in this group of patients.

Doppler echocardiographic assessment of the left and right ventricular function at rest, during and 6 minutes after submaximal exercise was performed in 60 patients with a mean age of 43±11 years suffering from heart failure classified stage I-III according to the NYHA-criteria and 10 volunteers with a mean age of 36±9 years who served as a control group. At mitral (m) and tricuspid (t) valve early diastolic peak-flow velocity (VEm, VEt), atrial peak-flow velocity (VAm, VAt), speed-time integrals (Em, Et, Am, At) and the ratios (VE/VAm, VE/VAt, E/Am, E/At) were determined. The left ventricular end-diastolic diameter (LVEDD) and the right ventricular outflow tract (RVOT) were measured in addition. The left ventricular ejection fraction (LVEF) was decreased to <36% in 9 patients (group 1). In 51 individuals LVEF was found to be >35% but <50% or LVEF was shown to be >50% but VE/VAm-ratio was found to be <1 (group 2). Out of all the determined parameters, VE/VAt, VEt and VAm during exercise were found to be the most sensitive parameters for the detection of early to advanced grade left heart failure.

Surgical treatment of residual shunts after transcatheter occlusion of atrial septal defect or patent foramen ovale is reported in approximately one to two percent of these percutaneous interventions. Minimally invasive surgery on the atrial septum is getting more and more common but little data is available on Amplatzer device explantation through limited access. No completely endoscopic device removal has been described previously. We report a case of a 57-year-old woman in whom an Amplatzer device was removed in a robotic totally endoscopic fashion through ports only using the daVinci telemanipulation system.

Transcatheter aortic valve implantation (TAVI) has been established as a valuable alternative to surgical aortic valve replacement in patients deemed to have high or prohibitive perioperative risk. However, there are several technical constraints and procedural risks inherent to TAVI. These risks include annulus rupture, ventricular perforation, aortic dissection, coronary occlusion, and dislodgement or migration of the valve prosthesis to the aorta or the left ventricle (LV). Other complications may be related to inappropriate valve deployment and subsequent paravalvular leak. Most complications cannot be detected at an early stage without echocardiographic guidance. Although not addressed by current guidelines, some European centres have advocated a ‘minimalist’ approach with exclusively fluoroscopic and angiographic guidance. Transoesophageal echocardiography (TEE), including real-time three-dimensional (RT-3D) imaging, has been established as a standard approach for peri-interventional guidance of TAVI. However, TEE monitoring almost always necessitates general anaesthesia and endotracheal intubation. A potential alternative to TEE is intracardiac echocardiography (ICE) that may provide a solution to a common dilemma: the most important advantage of ICE being the compatibility with monitored anaesthesia care without endotracheal intubation. Other advantages of ICE include uninterrupted monitoring, no fluoroscopic interference, and precise Doppler-based assessment of pulmonary artery pressures. Limitations of ICE include the need for additional venous access, the learning curve associated with a new device, and potentially increased cost.

The interventional closure of interatrial communications requires peri-interventional echocardiographic assessment and guidance to make those treatments as safe as possible. Transoesophageal echocardiography (TEE) including real-time three-dimensional (RT-3D) imaging, later complemented and in part replaced by intracardiac echocardiography (ICE), has become established as the standard approach to prepare for and to guide the interventional treatment of interatrial communications. Accurate imaging of the anatomic features of the particular communication is critical for case selection, planning, and intraprocedural guidance. Especially in the atrial septal defect (ASD) closure, which tends to be more challenging than the patent foramen ovale (PFO) closure, a certain risk of severe complications remains and may result from suboptimal device performance. Other complications may be related to discontinuous use of echocardiographic monitoring. Image fusion and RT-3D ICE are currently under clinical testing and might be suitable to facilitate spatial orientation. Nowadays, two-dimensional ICE is the method of choice for guiding percutaneous device closure, especially of ASDs and ‘complex’ PFOs. Uninterrupted TEE under deep sedation is an alternative. In contrast, the closure of ‘simple’ PFOs will often require nothing but final confirmation of the result, and therefore, short echocardiographic viewing is sufficient in many cases.