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Background The noninvasive assessment of superior vena cava (SVC), crista terminalis (CT), and the right atrial appendage (RAA) has clinical implications in determining the right atrium (RA) pressure in adult patients in whom the inferior vena cava cannot be imaged, in planning electrophysiological procedures and for evaluation of thrombi in RA/RAA. It is difficult to image these structures using standard two-dimensional transthoracic echocardiography (2DTTE), but the right parasternal approach has shown promise in the very few studies published so far. Aim The aim of this study was to show the feasibility of this approach and its usefulness in qualitative and quantitative assessments of these structures by both 2D and three (3D) TTE in patients with and without known cardiac pathologies. Material and methods The study consisted of 38 adult patients, 17 of whom had cardiac pathologies (Group 1) while the remainder (Group 2) had no evidence of heart disease clinically or by echocardiography. Results and conclusion Both SVC and RAA could be imaged by 2DTTE and 3DTTE in 53% of 40 patients (two separate groups of 20 consecutive patients) studied demonstrating the technical feasibility of this approach. SVC size and collapsibility, CT and RAA size, and RAA fractional shortening were evaluated in both groups by both 2D and 3DTTE. 3DTTE provided incremental value over 2DTTE by its ability to view en face the SVC in short axis and the base of RAA and RAA volumes resulting in more comprehensive assessment of their size and function.

Ascending aortic pseudoaneurysms (AO PSAs), if left untreated, are complicated by a high rate of rupture resulting in significant morbidity and mortality. New transcatheter modalities have emerged as acceptable surgical alternatives for their management. We present a case of an ascending aortic PSA in which intraoperative two- and three-dimensional transesophageal echocardiography (2DTEE and 3DTEE) provided a comprehensive assessment of the PSA in pre- and postclosure settings.

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto-ostial left main coronary artery PCI, in which three-dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two-dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.

BACKGROUND The ascending aorta (AA) has not been well studied using two-dimensional right parasternal transthoracic echocardiographic examination (2DRPE). AIM The aim of the present study was to assess the incremental value of 2DRPE over two-dimensional left parasternal transthoracic echocardiographic examination (2DLPE) in evaluating the size of AA in adult patients (pts) and, secondly, to determine whether live/real time three-dimensional (3D) RPE provided any additional benefit over 2DRPE. MATERIALS AND METHODS The AA was successfully imaged by 2DLPE, 2DRPE, and 3D RPE in 87 of 141 (61.7%) pts which comprised of two groups of consecutive pts separated by an interval of 2 weeks. RESULTS The maximum length of AA visualized by 2DRPE (4.98 ± 0.89) was larger than 2DLPE in 76/87(87%) pts (P < 0.001). Both the maximum systolic AA inner luminal width and leading edge-to-leading edge width by 2DRPE were greater than 2DLPE (P < 0.001). Similar to other noninvasive imaging modalities where mid-AA width is taken at level of right pulmonary artery, mid-AA width could also be taken at this level by 2DRPE in 79/87(91%) pts since this landmark was visualized during 2DRPE. However, this vessel could be visualized in only 2/87 (2%) pts with 2DLPE. 3DRPE conferred additional benefit over 2DRPE. The maximal AA length by 3DRPE was larger than 2DRPE in 60/87(69%) pts, and the maximal inner lumen and leading edge to leading edge widths were larger in 54/87(62%) and 66/87(76%) pts, respectively. CONCLUSION Our preliminary study demonstrates significant incremental value of 2DRPE over 2DLPE in the assessment of AA. 3DRPE confers an additional advantage over 2DRPE.

We demonstrate the incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional modality in the identification of all three cusps of the pulmonary valve in patients in whom only two leaflets could be detected by the latter technique. This was because of the ability of 3DTTE to view the cusps enface permitting assessment of relationship to one another and the surrounding cardiac structures. In addition, 3DTTE showed not only the potential errors that can occur in pulmonary valve cusp identification when the two-dimensional modality is used alone but also how some of these errors can be avoided by paying attention to the surrounding structures.

Depression is a disease that can dramatically lower quality of life. Symptoms of depression can range from temporary sadness to suicide. Embarrassment, shyness, and the stigma of depression are some of the factors preventing people from getting help for their problems. Contemporary social media technologies like Internet forums or micro-blogs give people the opportunity to talk about their feelings in a confidential anonymous environment. However, many participants in such networks may not recognize the severity of their depression and their need for professional help. Our approach is to develop a method that detects symptoms of depression in free text, such as posts in Internet forums, chat rooms and the like. This could help people appreciate the significance of their depression and realize they need to seek help. In this work Natural Language Processing methods are used to break the textual information into its grammatical units. Further analysis involves detection of depression symptoms and their frequency with the help of words known as indicators of depression and their synonyms. Finally, similar to common paper-based depression scales, e.g., the CES-D, that information is incorporated into a single depression score. In this evaluation study, our depressive mood detection system, DepreSD (Depression Symptom Detection), had an average precision of 0.84 (range 0.72-1.0 depending on the specific measure) and an average F measure of 0.79 (range 0.72-0.9).

Mitral and aortic valves are coupled via fibrous tissue. This coupling is considered to be important for cardiac function before and after mitral valve surgery. The relationship between mitral–aortic coupling and different types of mitral regurgitation (MR) is not completely understood. Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) was performed in 133 subjects: 30 normal subjects, 15 patients with Carpentier type I MR (annular dilatation and congenital cleft), 40 type II (mitral valve prolapse), 20 type IIIa (rheumatic) and 28 type IIIb (ischemic mitral regurgitation). Custom software was used to track mitral (MA) and aortic annuli (AoA) in 3D space throughout cardiac cycle, allowing measurement of changes in mitral and aortic valve morphology. Normal mitral–aortic coupling is characterized by reciprocal changes in the annular areas throughout cardiac cycle, with systolic reduction of the angle between the two annular planes. In Carpentier type II patients, not only MA but also AoA areas were increased (P

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two-dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two-dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two-dimensional views only, and a greater breadth of information is instead available through the use of three-dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three-dimensional transesophageal echocardiography offered incremental benefits over two-dimensional imaging alone.

Internet Support Groups (ISGs) offer people easy access to information regarding depression as well as support from others who are either currently suffering from depression or have previously suffered from depression. The safety and efficacy of ISGs for people with depression have not been thoroughly studied.The safety and helpfulness of a depression ISG were assessed by analyzing pre- and postintervention depressive symptoms, other psychological outcomes, and participant ratings of helpfulness.Participants were recruited through self-referral from six primary care offices. Participants were given access to a depression ISG and participated in an ISG for 6 weeks.Thirty-four (n = 34) participants enrolled in the study (mean age = 32.53, standard deviation [SD] = 16.10). Depressive symptoms approached significance for decreasing over time and self-efficacy increased over time. No self-harm occurred over the course of the study, but two participants developed self-harm ideation. Ratings of ISG helpfulness were mixed.Primary care patients participating in depression ISGs reported few adverse experiences directly related to the ISG. Depressive symptoms and self-efficacy have beneficial findings while ratings of helpfulness were mixed.Primary care patients can benefit from the use of an ISG. This could be particularly pertinent to people in rural settings where mental health resources are not as available. An ISG offers a low-cost and easily accessible resource for primary care patients with depression.

We describe 2 patients with significant aortic paraprosthetic regurgitation who underwent percutaneous closure where live/real time three-dimensional transesophageal echocardiography provided incremental value over two-dimensional transesophageal echocardiography.

The study evaluated the safety of reclaimed water using health risk assessment and biotoxicity tests. The reclaimed water was produced from reverse osmosis and used in industrial and miscellaneous purposes. The health risk assessment was conducted based on the concentrations of detectable pollutants in reclaimed water in a hypothetical scenario. The estimated carcinogenic and non-carcinogenic risks are lower than the generally accepted level. Biotoxicity evaluation included three genotoxicity tests, a chronic toxicity test using medaka fishes, and a subchronic toxicity test using mice. The reclaimed water is not genetically toxic, and does not cause significant chronic effects on these model organisms. These results confirm the safety of using reclaimed water from municipal wastewater treatment plants.

BACKGROUND Ascending aortic pseudoaneurysm (PsA) is an uncommon but surgically challenging problem with high morbidity and mortality. Herein we describe the efficacy and safety of the different approaches to transcatheter intervention for repair of ascending PsA and assess the selection of occluder devices using real-time 3-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE).METHODS AND RESULTS: Three patients with complex ascending PsA after cardiac or aortic root surgery were treated with transcatheter intervention due to high risk for redo surgery. Perioperative RT 3D-TEE combined with fluoroscopy was used for monitoring. All ascending PsA were successfully occluded with different devices using the transcatheter technique either with the transapical, transarterial approach, or transvenous combined with hybrid process depending on lesion anatomy. CONCLUSIONS Treatment of complex ascending PsA with transcatheter or combined hybrid intervention with cautious planning based on patient presentation and well-coordinated teamwork was successful. RT 3D color Doppler TEE provided precise information for the selection of appropriate occluder device, and also facilitated the procedure by guiding the catheter through difficult anatomy.

We present two cases in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two-dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.

Background The anatomy of septal defects can be complex and morphologically unpredictable. Balloon sizing of such defects may not be feasible, and an appropriately sized commercial occluder may not be available. Therefore, percutaneous transcatheter closure of such defects can be challenging because of an increased risk of complications. In this study, we have described the efficacy and safety of transcatheter closure of complex septal defects using Amplatzer cribriform occluder devices, assessed by real time three-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE). Methods and Results Four complex septal defects were involved in this investigation: (1) reimplanted multiple atrial septal defects (ASD) with one device embolization; (2) postinfarction ventricular septal defect; (3) long tunnel patent foramen ovale; and (4) postoperative residual ASD. All patients underwent percutaneous transcatheter interventions due to the high risk of surgical complications, and one of the three available cribriform ASD device sizes (18 mm, 25 mm, or 35 mm) was implanted. Perioperative RT 3D TEE combined with fluoroscopy was used for monitoring during the procedure. All defects were successfully occluded by cribriform septal occluder devices using the transcatheter technique. Conclusion Our patients with complex septal defects were successfully treated by transcatheter closure using an Amplazter cribriform septal occluder device with careful planning based on patient presentation and close interdisciplinary collaboration. RT 3D color Doppler TEE provided precise information for the selection of the appropriate occluder device and facilitated the procedure by guiding the catheter through the often challenging patient anatomy.

Background Perioperative monitoring of mitral valve (MV) anatomy, function, and pathology is essential for surgical management of different MV disease. Aims To overcome the several potential pitfalls of two-dimensional transesophageal echocardiography (2D TEE) and offline 3D TEE. Methods Live 3D TEE was used to assess 73 patients (44 men and 29 women) with Carpentier type II MV regurgitation undergoing MV surgery perioperatively. Results The isolated segment most frequently involved was A2/P2, but A1or P1 rarely was involved in an isolated lesion or combined lesions. The agreement between 3D TEE finding and surgery was 88% (64/73). In nine patients, the live 3D TEE images revealed more segments or scallops with prolapse than the surgeon noted intraoperatively. Conclusions Live 3D TEE allows more sensitivity and was feasible identification of prolapse or flail of individual segments of MV leaflets during surgery. We conclude that live 3D TEE should be regarded as an important adjunct to the standard 2D TEE examination in making decisions about MV surgery.

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left-sided (LASP) or right-sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three-dimensional transesophageal echocardiography (3DTEE) and who had a two-dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.

Objectives -This hospital-based study was conducted to determine the survival rates of patients after coronary artery bypass grafting (CABG) surgery and the associated prognostic factors related to all-cause mortality during a 7-year follow-up in Taiwan. Methods and results - Between January 1997 and December 2003, the medical records of 1877 patients who underwent primary, isolated CABG surgery were studied. The Kaplan-Meier method was used to estimate survival. Multiple Cox regression was used to investigate the independence of prognostic factors associated with all-cause mortality. Of the 1877 patients who underwent CABG surgery, 192 expired during the 7-year study period. The overall patient survival rate was 85.96% (95% Cl: 83.74-88.16). Using multiple Cox regression analysis, in addition to female gender, older age at surgery, pulmonary oedema, longer ischaemic time, longer cardiopulmonary bypass time, and poorer postoperative left ventricular ejection fraction were significant factors associated with all-cause mortality for both men and women. Associated prognostic factors varied by gender. For men, smoking (RR = 2.82, 95% Cl: 1.06-4.16), respiratory failure (RR = 6.88, 95% Cl: 3.29-14.40) and cardiogenic shock (RR = 4.04, 95% Cl: 2.13-7.67) were significantly related to all-cause mortality, but not for women. Sepsis (RR = 8.97,95% Cl: 1. 19-19.81) and ICU stay (RR = 1.03,95% Cl: 1.01 -1.05) were significantly related to all-cause mortality among female patients only. Conclusions - Several gender-related differences were noted pertaining to all-cause mortality and the relationships between smoking, sepsis, respiratory failure, cardiogenic shock, and ICU stay.

Currently, tricuspid valve infective endocarditis (TVIE) is encountered in daily clinical practice more frequently due to the increasing prevalence of illicit intravenous drug use and the implantation of intracardiac devices. In this study, we compared findings from intra-operative live/real time three-dimensional transesophageal echocardiograms (3DTEE) and two-dimensional transesophageal echocardiograms (2DTEE) of 10 patients who underwent surgery for native tricuspid valve (TV) endocarditis. Unlike 2DTEE, 3DTEE allowed en face visualization of the 3 TV leaflets from both, atrial and ventricular aspects, in 9 of the 10 cases. In the remaining patient, in whom 3DTEE could not identify all 3 leaflets en face, the TV was found essentially destroyed at surgery. Using 3DTEE, the number of vegetations was accurately reported when compared with the surgical record. Furthermore, the orientation of each vegetation was the same as noted in the surgical findings. 2DTEE missed the identification of vegetations in 5 patients. The attachment site of vegetations to the TV were also not characterized by 2DTEE in 5 patients. In all 10 cases, 3DTEE characterized the vegetations more accurately with larger dimensions, including those in the azimuthal axis, and volumes. In addition, a perivalvular abscess that lead to surgical intervention was identified by 3DTEE, however, missed by 2DTEE. In conclusion, 3DTEE allows en face visualization of the TV apparatus permitting accurate description of the number and dimensions of vegetations identified by our surgical standard, which ultimately informs patients' prognosis and dictates the timing and planning for surgical intervention. Its use should be in conjunction with 2DTEE when evaluating TVIE.

A 2.5-year-old boy presented with frequent hospitalizations due to recurrent respiratory tract infections with dyspnea. A fibromuscular membrane dividing the left atrium with obstruction of left atrial inflow to the left ventricle was documented by two-dimensional transthoracic echocardiography (2DTTE). Live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over 2DTTE by providing en face views of the 2 obstructing orifices in the membrane enabling accurate assessment of their position, shape and size. 3DTTE also showed clearly the location of the membrane superior and proximal to the left atrial appendage which was not well delineated by 2DTTE. In addition, 3DTTE demonstrated the full extent of the left atrial appendage and careful sequential cropping of the 3D dataset showed it to have 2 distinct lobes and no thrombus. These findings provided comprehensive assessment of the lesion and were helpful in surgical decision making and planning.

article i nfo Introduction:Infunctionalmitralregurgitation(FMR),effectiveregurgitantorificearea(EROA)displaysadynam- ic pattern. The impact of dynamic changes of annulus dysfunction and leaflets tenting on phasic EROA was ex- plored with real-time three-dimensional transesophageal echocardiography (RT3D-TEE). Methods: RT3D-TEE was performed in 52 FMR patients and 30 controls. Mitral annulus dimensions and leaflets tenting were measured throughout systole (TomTec, Germany). Phasic EROA was measured by proximal isovelocity surface area (PISA) method. Results: Mitral annulus had the minimal area and an oval shape with saddle configuration during early systole in controls, which enlarged and became round and flattened towards mid and late systole (P b 0.05). In contrast, annulus in FMR was significantly larger, rounder and flatter (P b 0.001), which further dilated and became more flattened at late systole (P b 0.05 vs control). Leaflet tenting height in FMR decreased in mid systole and remains unchanged towards late systole. The leaflet tenting volume peaked at early and late systole with a mid-systolic trough in both FMR and controls. But tenting volume of patients with FMR was significantly larger than that of controls (all P b 0.001 vs control in whole systole). Further analysis demonstrated that early tenting volume (β value = 0.053, P b 0.05) was a predictor of early EROA, whereas late tenting volume (β value = 0.031, P b 0.05) and late annular displacement velocity were predictors of late EROA. Conclusions: The early and late peak EROAs of FMR was primarily contributed by tenting volume at early systole and late systole respectively. These findings would beof value toconsiderin interventions aimed atreducing the severity of FMR.

Background Paravalvular leaks (PVLs) are a common complication of prosthetic valve replacement. Use of the transcatheter intervention technique is a suitable alternative in high-risk patients who may not tolerate repeat surgery. Common reasons for failure of this demanding intervention include poor imaging quality and unsuitable anatomy. The purpose of this study was to assess the usefulness and the incremental value of real-time three-dimensional (RT 3D) transesophageal echocardiography (TEE) over two-dimensional (2D) TEE findings in the evaluation of the geometry and track of mitral PVLs during transcatheter closure. Methods Five patients with six mitral PVLs at high risk for repeat surgery underwent transcatheter leak closure. Intraoperative RT 3DTEE was used to assess the location, shape, number, and size of the defects. Transapical approaches were used in all cases with fluoroscopic and RT 3D TEE guidance of the wire and catheter, device positioning, and assessment of residual leak after the procedure. Results In all of the cases, defects with irregular crescent shapes and distorted tracks were clearly delineated by RT 3D TEE. This was compared to those results obtained through 2D TEE, which was unable to characterize the defects. Three cases showed small leaks, which were completely occluded with a patent ductus arteriosus (PDA) device in two cases, and a muscular ventricular septal defect (mVSD) occluder combined with coil devices in one case. One case involved a large leak and early device embolization of the muscular VSD occluder, which was removed surgically, and demonstrated a crescent–shaped defect. One patient had two releaks 2 months subsequent to the procedure due to two new extended leaks at the tails of the crescent–shaped defect. Conclusion RT 3D TEE can clearly delineate the geometries of defects in their entirety, including shape, size, and location of the defect and track canal. It would also appear that RT 3D TEE is superior to 2D TEE in the process of guiding the wire through the difficult canal anatomy, facilitating the overall procedure. The small mitral PVLs can be completely occluded, but subsequent complications occurred with large defect closures because of embolization or releak. Therefore, transcatheter closure of PVLs seems to be an attractive alternative for these patients, but newer occluder designs that better conform to leak geometry will be required to improve outcomes.

Objectives: This study assessed the ability of live/real time three-dimensional transesophageal echocardiography (3DTEE) in measuring (1) atrial septal defect (ASD) maximum dimension, area, and adjacent rim size, (2) ASD occluder left and right atrial disk size, (3) length of contact between the left atrial (LA) disk and the aorta, and in (4) assessing device related complications such as residual shunt, device embolization, and device encroachment upon adjacent cardiac structures. Materials and Methods: 3DTEE images acquired during percutaneous ASD closure by the Amplatzer Septal Occluder in 15 adult patients were retrospectively analyzed. Offline analysis was done using both the Philips 5500 ultrasound system and Philips QLAB software. 3D color flow Doppler images were used to assess residual ASD shunting. Results: The Philips 5500 and Philips QLAB measurements correlated well for ASD maximum dimension and area measurements. The Philips QLAB 3DTEE disk size measurements also correlated well with the manufacturer obtained sizes. The aortic rim was deficient in 7 of the 15 patients, and the mean ASD occluder device size was 4 mm greater than the mean ASD maximum dimension. The LA occluder disk was in contact with the aorta throughout the cardiac cycle in 12 of the 15 patients, and the LA occluder disk size correlated significantly with the contact length with the aorta. Conclusion: Most of the patients demonstrated contact between the LA occluder disk and the aorta throughout the cardiac cycle. 3DTEE may be useful in identifying patients at greater risk for aortic erosion. (Echocardiography 2013;30:345-353)

Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three-dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.

Background: Two-dimensional transesophageal echocardiography (2D TEE) Doppler color flow imaging is the gold standard for assessing the severity of mitral regurgitation (MR). Severe MR with very eccentric jet may involve more than one mitral leaflet lesion and can be missed by 2D TEE. The purpose of this study was to assess the usefulness and the incremental value of real-time three-dimensional (RT 3D) TEE over 2D TEE findings in the evaluation of patients suffering eccentric MR with more than one mitral leaflet lesion. Methods: Intraoperative 2D TEE and RT 3D TEE examinations were performed on 168 patients with Carpenter II MR who underwent surgery. MR was defined as either central, free-standing eccentric jet or very eccentric jet. 2D TEE and RT 3D TEE finding were compared with surgical findings. Results: Of these 168 MR patients, 25 patients (14.9%) had central jets and 143 patients (85.1%) had eccentric jets. Among 143 patients with eccentric jets, 47 patients (32.9%) had free-standing eccentric MR jets, and 96 (67.1%) patients had very eccentric jets. 3D TEE diagnosed the severity and location of MR lesions correctly in all patients; this was not the case with 2D TEE, which had significant diagnostic misses in nine patients (9.4%, p

We compared findings from intraoperative live/real time three-dimensional transesophageal echocardiography (3DTEE) and two-dimensional transesophageal echocardiography (2DTEE) with surgery in 67 patients having aortic aneurysm and/or aortic dissection. Of these, 20 patients had aortic aneurysm without dissection, 21 aortic aneurysm and dissection, and 26 aortic dissection without aneurysm. 3DTEE diagnosed the type and location of aneurysm correctly in all patients unlike 2DTEE, which missed an aneurysm in one case. There were four cases of aortic aneurysm rupture. Three of them were diagnosed by 3DTEE but only one by 2DTEE, and one missed by both techniques. The mouth of saccular aneurysm, site of aortic aneurysm rupture, and communication sites between perfusing and nonperfusing lumens of aortic dissection could be viewed en face only with 3DTEE, enabling comprehensive measurements of their area and dimensions as well as increasing the confidence level of their diagnosis. In all patients with aortic dissection, 3DTEE enabled a more confident diagnosis of dissection because the dissection flap when viewed en face presented as a sheet of tissue rather than a linear echo seen on 2DTEE which can be confused with an artifact. 2DTEE missed dissection in one patient. In six cases the dissection flap involved the right coronary artery orifice by 3DTEE and surgery. These were missed by 2DTEE. Aortic regurgitation severity was more comprehensively assessed by 3DTEE than 2DTEE. Aneurysm size by 3DTEE correlated well with 2DTEE and surgery/computed tomography scan. In conclusion, 3DTEE provides incremental information over 2DTEE in patients with aortic aneurysm and dissection.

We report an adult with a right coronary artery to right atrial fistula in whom live/real time three-dimensional transesophageal echocardiography with its ability to trace the entire course and obtain en face views of the fistula connections, was able to provide significant incremental information over two-dimensional transesophageal echocardiography.

Aorto-left ventricular tunnel (ALVT) is a rare congenital malformation. We report an unusual case of ALVT with a large interventricular septal aneurysm causing severe aortic regurgitation and left ventricular outflow obstruction diagnosed with real time three-dimensional transesophageal echocardiography (3D TEE). Real time 3D TEE allows for assessment and novel views of complex cardiac abnormalities and can aid in perioperative monitoring.

Endovascular stent grafts have become increasingly used in the management of arterial trauma, chronic vascular occlusive diseases, and deep vein thrombosis (DVT). Here, we describe a case of stent migration to the right heart due to a motor vehicle accident in a patient with iliac venous stent implanted for venous stenosis. Computed tomography (CT) scan imaging identification of a metallic stent was superior to the standard two-dimensional transesophageal echocardiography (TEE) techniques without imaging artifact from reverberation. However, real time three-dimensional (3D) TEE can precisely defined a metallic stent in right heart oriented with shape and direction without consuming time compared to that of CT scanning. The use of 3DTEE can facilitate identification of intracardiac metallic foreign bodies perioperatively in a patient with accident and emergent unstable condition. (Echocardiography 2010;27:587-589).

We studied 19 patients with pericardial disease using two-dimensional and three-dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE a more comprehensive assessment of pericardial effusion can be made and both the parietal and visceral layers of the pericardium can be visualized en face and examined for pathologies and fibrin deposits. In our series of patients, 3DTTE was superior to 2DTTE in uncovering mass lesions involving the pericardium such as tuberculous granulomas and metastatic disease. Furthermore, it provided a better assessment of the nature of pericardial lesions, such as pericardial and mediastinal hematomas, pericardial cysts, and metastatic disease to the pericardium by sequential cropping of the 3D data sets and visualizing the interior of the lesions in a manner not possible with 2DTTE. It was also valuable in determining the extent of pericardial calcification in pericardial constriction and in measuring the size of pericardial masses. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of pericardial diseases and that it provides incremental knowledge to the echocardiographer.

BACKGROUND Transcatheter Amplatzer septal occluder (ASO) device closure of atrial septal defects (ASDs) has traditionally been guided by two-dimensional transesophageal echocardiography (2D-TEE) and intracardiac echocardiography (ICE) modalities. Real time three-dimensional transthoracic echocardiography (RT3D-TTE) provides rotating images to define ASD and adjacent structures with potential as an alternative to 2D-TEE or ICE for guiding the device closure of ASD. Our aim was to assess the feasibility and effectiveness of RT3D-TTE in parasternal four-chamber views to guide ASO device closure of ASD. METHODS AND RESULTS From July 2004 to August 2005, 59 patients underwent transcatheter ASO device closure of ASD. The first 30 patients underwent 2D-TEE guidance under general anesthesia and the remaining 29 patients underwent RT3D-TTE guidance with local anesthesia. All interventions were successfully completed without complications. The clinical characteristics and transcatheter closure variables of RT3D-TTE and 2D-TEE were compared. Echocardiographic visualization of ASD and ASO deployment was found to be adequate when using either methods. Catheterization laboratory time (39.1 +/- 5.4 vs 78.8 +/- 14.1 minutes, P < 0.001) and interventional procedure length (7.6 +/- 4.2 vs 15.3 +/- 2.9 minutes, P < 0.001) were shortened by using RT3D-TTE as compared with 2DE-TEE. There was no difference in the rate of closure following either method, assessed after a 6-month follow-up. The maximal diameter measured by RT3D-TTE and 2D-TEE was correlated well with a balloon-stretched ASD size (y = 0.985x + 0.628, r = 0.924 vs y = 0.93x + 2.08, r = 0.885, respectively). CONCLUSION RT3D-TTE may be a feasible, safe, and effective alternative to the standard practice of using 2D-TEE to guide ASO deployment.

We studied the reliability and validity of the World Health Organization quality of life (WHOQOL) assessment instrument in patients with human immunodeficiency virus (HIV) infection. WHOQOL-BREF was used to assess 136 HIV-infected outpatients. The results were analyzed and compared with data from 213 healthy persons. The Cronbach's alpha for internal consistency ranged from 0.74 to 0.85 across domains in HIV-infected patients. The test-retest reliability ranged from 0.64 to 0.79 across domains at average 4-week retest interval. Factor analysis identified four major factors: social, psychological, environment, and physical, consistent with the four domains of the instrument. The scores of all four domains correlated positively with self-evaluated health status and happiness (r range: 0.52-0.60 and 0.55-0.73 across domains, respectively), and correlated negatively with the number and severity of symptoms (r range: -0.40 to -0.47 and -0.41 to -0.52, respectively). The scores of physical, psychological and social domains, but not the environment domain, discriminated between healthy persons and HIV-infected patients (all p0.01). We conclude that the WHOQOL-BREF can be a useful quality-of-life instrument in patients with HIV infection.

The purposes of this study were to explore Taiwanese nurses' beliefs, attitudes, and values about sexuality and to determine the extent to which these variables influence their attitudes toward taking a sexual history. A total of 391 nurses voluntarily participated in this study. The results of this study revealed that Taiwanese nurses hold moderate positive beliefs and slight positive attitudes and values about sexuality. They also expressed slight positive attitudes about taking a sexual history. The use of a regression analysis revealed that these nurses' beliefs, attitudes, and values about sexuality accounted for 9% of the variance in attitudes about taking a sexual history. Only beliefs and attitudes about sexuality were significant predictors of attitudes towards taking a sexual history. Strategies to change Taiwanese nurses' beliefs and attitudes about sexuality should be an essential nursing issue in practice and education.

Research on attribution theory has focused on a number of different social contexts. Close personal relationships and marriage in particular have been investigated widely. Cross-cultural differences in attribution patterns have also been explored, although mostly in relation to academic achievement or employment. This article focused on cross-cultural variations in marital attributions. Thirty-six couples from the People's Republic of China (P.R.C.) and 32 couples from the United States (U.S.) were included. Marital attributions were correlated with marital distress for both groups. However, the P.R.C. spouses tended to report more relationship-enhancing causal attributions than did U.S. spouses. There were also some differences in attributions of responsibility and blame across cultures. These findings are discussed in relationship to current marital attribution theory.

A large proportion of antibiotics used in hospitals is for surgical prophylaxis. We determined the prevailing practices and factors associated with the misuse of surgical antibiotic prophylaxis in hospitals in Taiwan.In a systematic survey of the medical records of 629 patients from 14 hospitals who underwent clean or clean-contaminated surgery from September 1998 through March 1999, data on the timing and duration of, and reasons for, antibiotic use were collected and analyzed.Overall, 578 (92%) patients received antibiotics perioperatively; in 499 (79%) cases, antibiotics were used for surgical prophylaxis. Only 302 (61%) patients received prophylaxis within 1 hour before surgery. More than 70% of patients received more than 3 days of postoperative antibiotic prophylaxis. The most commonly used antibiotics were first-generation cephalosporins and aminoglycosides. Factors independently associated with inappropriately timed prophylaxis included surgery performed at a hospital with a greater proportion of intensive care unit beds (conditional odds ratio [OR] = 1.14 per 1% increase, 95% confidence interval [CI95%] 1.06-1.23; p0.01), surgery duration of at least 1 hour (OR = 0.40, CI95% 0.24-0.67; p0.01), orthopedic surgery (OR = 0.59, CI95% 0.36-0.98; p = 0.041), and cardiothoracic surgery (OR = 2.07, CI95% 1.14-3.77; p = 0.02). Risk factors for more than 3 days of prophylaxis included surgical placement of prosthetic material (OR = 2.26, CI95% 1.10-4.64; p = 0.03), the number of antibiotics used (OR = 1.99 per antibiotic, CI95% 1.26-3.13; p0.01), surgery duration of at least 1 hour (OR = 3.07, CI95% 1.45-6.51; p0.01), neurosurgery (OR = 4.57, CI95% 2.24-9.31; p0.01), and the use of oral antibiotics together with intravenous drugs (OR = 20.72, CI95% 10.72-40.07; p0.01).The results of this survey indicate that inappropriate use of surgical antibiotic prophylaxis is common in hospitals in Taiwan. Our results identify several problem areas, including incorrect timing, duration, and use of oral antibiotics for surgical prophylaxis, that require targeted physician education and public health interventions.

With the prospect of increasing numbers of patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), healthcare professionals (professionals) need to be better informed about patients' perspectives in order to provide efficacious, compassionate, and efficient care to patients. In Taiwan, the biomedical research and healthcare professionals' perspectives have dominated research related to HIV/AIDS. The purpose of the study was to investigate the stressors experienced by patients which have, thus far, been under-explored. This study used a phenomenological approach to gain insight into the patients' experience. In-depth, open-ended interviews were used to collect data. Interviews were tape recorded and transcribed verbatim to maintain data integrity and to reduce perceptual bias. The open coding procedure was used to analyze the interview transcripts. Study participants were 14 male patients with an average age of 35.71 year-old, who had known their positive HIV status for an average of 24.9 months. Patients experienced multiple stressors because of having the life threatening illness of HIV/AIDS. Their stressors were identified as follows: being confronted with the diagnosis, fear of disclosure, unpredictability of their physical condition, hypervigilance toward physical symptoms, emotional upheaval, and constrained life planning. The findings of this study form the basis for professionals to design services particularly addressed to patients' needs, for example, informed testing, and pre- and post-counseling. Further efforts could focus on developing systemic intervention programs to help patients better cope with the challenges of living with HIV/AIDS.

The Wang tube was modified to improve in vitro semen manipulation, by adding another two racks to the anterior (posterior) wall of the low component of the Wang tube and supplying another four convex lenses symmetrical to those on the bottom wall. The former provides a slanted position leading to a complete real-time sperm separation image and benefiting low-quality sperm preparation when the modified Wang tube is turned on its side. The latter converses the microscope's light better and gives a clearer objective image.

Various sperm preparation techniques, swim-up and Percoll gradient, and the newly developed Wang's tube system, were evaluated for their ability to recover normal-chromatin sperm. Twenty human semen samples, collected by masturbation, were studied simultaneously with the three methods. Analysis by Acridine orange fluorescence test was performed on all samples. Pretreated semen contains 58 +/- 22% green sperm (fertile/normal). Treatment with Wang's tube system resulted in 99 +/- 1.0% green sperm; Percoll gradient, 78 +/- 11%; and swim-up technique, 72 +/- 15%. It would appear that Wang's tube system yields a high-quality sperm preparation with enough concentration, very active forward progression, and greatly improved sperm morphology, while containing normal-chromatin, double-stranded DNA.

Transesophageal echocardiography has been increasingly used in addition to the transthoracic approach. It not only allows an unobstructed window for viewing the left atrium, but also provides high-quality imaging to improve diagnosis of prosthetic valve dysfunction. To determine the value of transesophageal echocardiography in detection of dysfunctioning mitral prosthetic regurgitation, 11 patients clinically suspected of dysfunctioning mitral prosthesis were studies by transthoracic, transesophageal echocardiography and was documented by a left ventricular angiography. There were 7 biological tissue valves and 4 metallic Bjork-Shiley valves. Compared with a left ventricular angiography, the transthoracic approach to 8 patients made an underestimation of the grade of regurgitation. The angiographic grading confirmed the transesophageal approach in all patients except one who was graded as mild regurgitation by left ventricular angiography, moderate regurgitation by transesophageal echocardiography, but no regurgitation by transthoracic echocardiography. Our results indicated that in patients with suspected mitral prosthetic dysfunction, a transesophageal echocardiography is more sensitive than a transthoracic echocardiography in detecting mitral regurgitation.

We evaluated 147 patients with adequate color Doppler and angiographic studies for mitral regurgitation. Sixty-five patients had no mitral regurgitation by both color Doppler and angiography and 82 patients had mitral regurgitation by both techniques. Thus the sensitivity and specificity of color Doppler for the detection of mitral regurgitation was 100%. Three two-dimensional echocardiographic planes (parasternal long and short axis, apical four-chamber view) were used to analyze variables of the mitral regurgitant jet signals in the left atrium. The best correlation with angiography was obtained when the regurgitant jet area (RJA) (maximum or average from three planes) expressed as a percentage of the left atrial area (LAA) obtained in the same plane as the maximum regurgitant area was considered. The maximum RJA/LAA was under 20% in 34 of 36 patients with angiographic grade I mitral regurgitation, between 20% and 40% in 17 of 18 patients with grade II mitral regurgitation, and over 40% in 26 of 28 patients with severe mitral regurgitation. Maximum RJA/LAA also correlated with angiographic regurgitant fractions (r = .78) obtained in 21 of 40 patients in normal sinus rhythm and with no evidence of associated aortic regurgitation. Other variables of the regurgitant jet such as maximal linear and transverse dimensions, maximal area, or maximal area expressed as a percentage of the LAA in one or two planes correlated less well with angiography. Color Doppler is a useful noninvasive technique that is not only highly sensitive and specific in the identification of mitral regurgitation but also provides accurate estimation of its severity.

Hypertension complicated by left ventricular hypertrophy is associated with increased morbidity as it leads to left ventricular systolic and diastolic dysfunction. Thus, in the treatment of hypertension, a desirable goal is the regression of left ventricular hypertrophy. Tiapamil, a new calcium antagonist, was evaluated in a 58 week open study to determine its effect on left ventricular mass in relation to its ability to lower blood pressure. Twenty adult patients with mild to moderate hypertension were entered into the study. Blood pressure was significantly reduced from 166 +/- 16/105 +/- 7 mmHg before treatment to 142 +/- 9/88 +/- 4 mmHg after 58 weeks. The posterior and interventricular septal wall thickness and left ventricular systolic dimension did not show any significant change by the end of the trial. On the other hand, left ventricular diastolic dimension, ejection fraction, and left ventricular mass increased significantly (P less than 0.05). Other laboratory parameters were not affected during treatment with the exception of a moderate decrease in the blood glucose. Side effects were mild and self-limiting, and no patients were withdrawn from the study. Although tiapamil appears to be an effective and well-tolerated drug in mild to moderate hypertension, it failed to reduce left ventricular mass.

Wounds of the heart and great vessels caused by needles are not common. Two-dimensional echocardiography (2-D echo) may detect the anatomic location of needles in the heart, as shown by the 2 cases described herein.

A 53 year old man with a history of rheumatic mitral stenosis was admitted to hospital because of recurrent fainting spells. Auscultation showed a variable diastolic rumbling murmur. Simultaneous echo- and phonocardiograms demonstrated a floating left atrial thrombus; when this passed into the left ventricular inflow tract and obstructed the mitral valve orifice the diastolic murmur disappeared.

Pneumopyopericardium is rare. Most cases are associated with trauma, perforation of inflammatory or suppurative foci into the pericardium from neighboring organs, systemic infection or as a complication of recent surgery. 1 Only 10 cases have been reported due to spontaneous gas production from infected fluid within the pericardial sac. 2 The 2-dimensional echocardiographic features of this condition have not been described previously.