11/1571. Transesophageal echocardiography with a single-plane probe. Long-axis views of the heart from the apical (transgastric) approach. The literature suggests that during transesophageal echocardiography (TEE), a short-axis view can be obtained in the gastric position using a single-plane probe. Recently, we have found that a long-axis apical display of the heart can be achieved by placing the tip of the probe in the fundus of the stomach. In a 3-month period, we attempted to obtain this view in 54 consecutive patients. Twelve of the patients had TEE done under general anesthesia, while the other 42 patients had the procedure performed under sedation with midazolam at hospital bedside or as an outpatient. The long-axis transgastric view was obtained in 51 of the 54 patients (94%). The image quality was graded subjectively as good in 39 (72%) and fair in the other 12 patients (22%). This view helped to establish the diagnosis in eight patients (15%) and to increase the level of confidence about the accuracy of the diagnosis in 23 (43%) other patients. Four patients' findings are described. We conclude that the new long-axis transgastric view is easy to obtain, does not add much time to the usual TEE study, does not add to the low complication rate of TEE, and may help to interrogate the distal structures of the heart. ( info) |
| echocardiography has brought about a new modality of surgical decision making in open heart surgery. Especially in urgent and emergency surgery, echocardiography can provide decisive insight into the underlying pathophysiological processes, improved monitoring of cardiac function, as well as immediate quality control after the procedure. The importance of intraoperative echocardiography for the cardiac surgeon is illustrated in a number of selected case reports. ( info) |
13/1571. T wave lability: a clue for separating the good from the bad, when ugly. Non-specific T wave abnormalities have challenged both the clinician and the insurance medical director for decades. Distinction between pathologic and physiologic T wave changes often requires costly and time-consuming diagnostic studies. The literature is reviewed on the subject of T wave manipulation by the oral administration of both potassium and glucose, introducing the concept of T wave lability. Based on this concept, a simple technique is suggested which, in many cases, can safely, expeditiously and inexpensively distinguish between organic and functional T wave changes. When employed in the investigation of asymptomatic insurance applicants with unexplained T wave abnormalities but no known cardiovascular or renal disease, this technique appears to be sufficiently reliable to classify the risk posed by non-specific T wave changes without resorting to a sophisticated, lengthy and costly cardiovascular investigation. ( info) |
14/1571. Chordal rupture: a common complication of myxomatous degeneration of the mitral valve. In two patients with a clinical picture of acute mitral insufficiency, the presence of chordal rupture secondary to myxomatous degeneration of the mitral valve was disclosed during surgery. There was no evidence of previous rheumatic valvulitis, subacute bacterial endocarditis or other etiologies. It appears from the literature and from the cases described that ruptured chorda tendinea is a not uncommon complication of myxomatous transformation of the mitral valve. While this fact has been mentioned in anatomophological reports, clinicians are less aware of the association. In the absence of supportive evidence for a rheumatic or arteriosclerotic etiology, a clinical picture of acute mitral insufficiency should suggest ruptured chorda tendinea secondary to myxomatous degeneration of the mitral apparatus. This is particularly true in older patients, especially among those followed for a midsystolic click-late systolic murmur or an apical pansystolic murmur of pure mitral regurgitation. ( info) |
| Three allied conditions are described in this paper: (i) haemopericardium with cardiac rupture (5 cases); (ii) haemopericardium without rupture (2 cases); (iii) pseudoaneurysm (1 case). In the first 2 of these, the significant features were clinical deterioration with shock 3 or more days after infarction, recurrent cardiac pain, cardiac tamponade, and immediate or later ineffectiveness of counterpulsation. An additional feature in the second group was the development of haemopericardium after heparin therapy. In the third group, infarction followed by left ventricular failure and progressive cardiac enlargement was the significant feature. An apical systolic murmur was not present, as a false sac had not been formed. Ante-mortem diagnosis depends upon an appreciation of these features. Without it successful surgery is impossible. There were 4 survivors in this group of 8 patients. ( info) |
16/1571. phrenic nerve injury following cardiac surgery: a review. phrenic nerve injury following cardiac surgery is variable in its incidence depending on the diligence with which it is sought. Definitive studies have shown this complication to be related to cold-induced injury during myocardial protection strategies and possibly to mechanical injury during internal mammary artery harvesting. The consequences are also variable and depend to a large extent on the underlying condition of the patient, particularly with regard to pulmonary function. The response of the patient may range from an asymptomatic radiographic abnormality to severe pulmonary dysfunction requiring prolonged mechanical ventilation and other associated morbidities and even mortality. Two cases are presented to demonstrate the variability in clinical responses to diaphragmatic dysfunction secondary to phrenic nerve injury from cardiac surgery. In addition, treatment strategies are reviewed including early tracheostomy and diaphragmatic plication, which appear to be the most effective options for patients who are compromised by phrenic injuries. ( info) |
17/1571. The liver in hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease). The livers of four patients with hereditary hemorrhagic telangiectasia--including the original case of Osler--were examined at autopsy. Characteristic random focal fibrovascular lesions were found in all. The importance of recognizing the apparently common and seemingly benign hepatic involvement in this disease is emphasized in view of its possible confusion with more serious types of liver disease that may complicate the condition. ( info) |
18/1571. Young-Simpson syndrome: further delineation of a distinct syndrome with congenital hypothyroidism, congenital heart defects, facial dysmorphism, and mental retardation. Young-Simpson syndrome is a rare congenital disorder, characterized by congenital hypothyroidism, congenital heart defects, facial dysmorphism, cryptorchidism in males, hypotonia, mental retardation, and postnatal growth retardation. We describe the cases of a 5-year-old boy and a 7-year-old girl with a similar constellation of symptoms and compared them with previously reported patients. ( info) |
19/1571. Septal cystic mass in the right atrium: echocardiographic evaluation. Right atrial masses rarely are seen in children and are usually benign. Clinical manifestations mainly depend on the location of the mass and whether it alters blood flow. This report describes the clinical course, echocardiographic findings, pathology, and serial follow-up of an unusual cystic mass with a mixture of tissue common to the atrioventricular septum located in the posteroinferior right atrium. ( info) |
20/1571. Adrenal neuroblastoma in an adult with tumor thrombus in the inferior vena cava. We describe the appearance of an adrenal neuroblastoma associated with tumor thrombus occurring in an adult patient. The tumor measured 14 x 12 x 12 cm, showed heterogeneous signal intensity on both T1-weighted and T2-weighted images, and displayed peripheral nodular enhancement on early post-gadolinium images. Tumor thrombus was identified within the inferior vena cava, which extended into the right atrium. ( info) |