The acute aortic syndromes carry significant morbidity and mortality, especially when detected late. Symptoms may mimic myocardial ischemia, and physical findings may be absent or, if present, can be suggestive of a diverse range of other conditions. Maintaining a high clinical index of suspicion is crucial in establishing the diagnosis. All patients with suspected aortic disease and evidence of acute ischemia on electrocardiogram should undergo diagnostic imaging studies before thrombolytics are administered. The demonstration of an intimal flap separating 2 lumina is the basis for diagnosis. Tear detection and localization are very important because any therapeutic intervention aims to occlude the entry tear. The goals of medical therapy are to reduce the force of left ventricular contractions, decrease the steepness of the rise of the aortic pulse wave, and reduce the systemic arterial pressure to as low a level as possible without compromising perfusion of vital organs. Surgical therapy still remains the gold standard of care for type A aortic dissection, whereas in type B dissection, percutaneous aortic stenting and fenestration techniques have been developed and are sometimes used in conjunction with medical therapy in certain situations.

OBJECTIVE The study was undertaken to assess the correlation between the presence and degree of aortic atheroma with degree of Left ventricular (LV) mass index and subsequent clinical outcomes. MATERIAL AND METHOD The authors studied the clinical profiles of 87 patients with aortic atherosclerosis and controls, who had undergone TEE between 1995 and 2000. RESULTS Mean LV mass index was 116 gram/m2 in atherosclerosis group compared to 81 gram/m2 in the control group (p < 0.009). In the atherosclerotic group, there was a close correlation between LV mass index score and severity of the plaque in the aortic arch and descending aorta (p < 0.001, 0.001). The presence of large ulcerated plaque had a significant correlation with stroke (p < 0.002). CONCLUSION 1) LV mass index correlates with the severity of aortic atheroma. 2) Smoking, elevated mean arterial blood pressure and a high LV mass index score are significantly correlated with large ulcerated plaque and stroke. 3) These findings may in part explain the higher cardiovascular risk in patients with increased left ventricular mass.

Tunneled dialysis catheter–associated right atrial thrombus (RAT) is a rarely reported complication. We reviewed hospital records of 10 patients from a teaching hospital dialysis unit, in whom RAT was diagnosed by trans‐esophageal echocardiography (TEE). Patients were treated with chronic anticoagulation (heparin followed by warfarin) and followed over time. The group included 7 women; 6 patients were African American, 3 were Caucasian, and 1 was Hispanic. The average age was 52.1 ± 15.3 years. The most common presenting symptom was poor catheter flow on hemodialysis followed by fever and chills. On average, the patients had had 3.4 ± 2.7 catheter insertions before diagnosis of RAT, and the tunneled dialysis catheter (TC) had been in place for a mean of 91 ± 89.4 days when the thrombi were diagnosed. Trans‐thoracic echocardiography (2‐D echo) was done in 4 patients, but it identified RAT in only 1 patient. The catheter tip was at the junction of the superior vena cava and right atrium (SVC/RA) in most patients.Thrombolysis (unsuccessful) was attempted with urokinase in 3 patients, complicated in 2 patients by hemorrhage. After anticoagulation, 90% of the RAT resolved on repeated TEE. One patient had persistent RAT for 23 weeks and underwent surgical thrombolysis, but died postoperatively.We conclude that RAT is a frequently missed complication of a TC. Positioning the tip of the TC at the SVC/RA junction may not prevent RAT. Trans‐esophageal echocardiography is a more sensitive diagnostic tool than 2‐D echo and should be obtained early. Most patients can be successfully treated with anticoagulation alone. Thrombolytic therapy and surgical thrombolysis have high morbidity and mortality.

EchocardiographyVolume 17, Issue 6 p. 577-578 Complete Rupture of the Papillary Muscle Pairoj Rerkpattanapipat M.D., Pairoj Rerkpattanapipat M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorEnakshi Bajpai M.D., Enakshi Bajpai M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorRajiv Maraj M.D., Rajiv Maraj M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorJohn Pym M.D., John Pym M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorLarry E. Jacobs M.D., Larry E. Jacobs M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorMorris N. Kotler M.D., Morris N. Kotler M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this author Pairoj Rerkpattanapipat M.D., Pairoj Rerkpattanapipat M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorEnakshi Bajpai M.D., Enakshi Bajpai M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorRajiv Maraj M.D., Rajiv Maraj M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorJohn Pym M.D., John Pym M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorLarry E. Jacobs M.D., Larry E. Jacobs M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this authorMorris N. Kotler M.D., Morris N. Kotler M.D. Division of Cardiology and Division of Cardiothoracic Surgery, Albert Einstein Medical Center, Philadelphia, PennsylvaniaSearch for more papers by this author First published: 28 July 2003 https://doi.org/10.1046/j.1540-8175.2000.00577.xCitations: 1 Address for correspondence and reprints: Morris N. Kotler, M.D., Albert Einstein Medical Center, 363 Klein Profes-sional Building, 5401 Old York Road, Philadelphia, PA 19141. Fax: 215-456-6189. Supported in part by The Women's League for Medical Research, Albert Einstein Medical Center, Philadelphia, Pennsylvania. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume17, Issue6August 2000Pages 577-578 RelatedInformation

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.

Mycotic aneurysms of the aorta are prone to rupture. Thus rapid and accurate diagnosis is essential so that surgical repair can be undertaken. We report a case of mycotic aortic aneurysm caused by mitral valve endocarditis. The aneurysm situated at the junction of the thoracoabdominal aorta was readily detected by transesophageal echocardiography. Computed tomography and aortography were complementary to transesophageal echocardiography in establishing the diagnosis. The patient underwent successful repair and acute inflammation of the aneurysm was present at histologic examination.

We present an unusual case of biopsy-proven myocardial sarcoidosis in which the transthoracic and transesophageal echocardiographic findings suggested metastatic tumor involvement of the myocardium and pericardium. The pathologic, clinical, and echocardiographic features of cardiac sarcoidosis are reviewed, with emphasis on the role of echocardiography.

The accurate assessment of the distal extent of vena caval invasion of renal cell carcinoma into the hepatic veins, inferior vena cava, and right atrium is critical before surgical resection. We present two cases of renal carcinoma with vena caval extension in which preoperative transesophageal echocardiography accurately assessed tumor extent and guided surgical therapy. The role of transesophageal echocardiography in comparison to other diagnostic modalities is discussed.

Elderly patients undergoing conventional exercise stress testing (CST) rely predominantly on an increased preload (Starling mechanism) to augment cardiac output (CO). In contrast, younger patients rely predominantly on an increased heart rate (HR) and decreased systemic vascular resistance (SVR) to augment CO. To determine normal physiologic hemodynamic responses to incremental dobutamine Infusion in young (&lt;65 yo) as compared to elderly (≥65 yo) patients, we analyzed the results of 50 consecutive patients with normal regional wall motion and normal ejection fraction at rest. All patients underwent 2-D echocardiography and continuous wave Doppler evaluation of the left ventricular outflow tract (LVOT) during each stage of the dobutamine infusion protocol. No patients developed regional wall motion abnormalities during dobutamine infusion. HR, velocity time integral (VTI) across the lVOT and end diastolic dimensions (EDD) were recorded. Stroke volume (SV=VTI × cross sectional area of LVOTL, CO (HR × SV) and SVR (80 × mean arterial pressure ÷ CO) were calculated. The mean % change from baseline of HR, Sv. EDD, SVR and CO are shown:

Paravalvular regurgitation (PVR) is an uncommon complication of mitral valve replacement (MVR). Although severe PVR is almost always repaired immediately when recognized during surgery, there are little data available on the management of patients with mild and moderate PVR. This study includes eight patients with mild (n = 6) and moderate (n = 2) PVR identified by transesophageal echocardiography at the time of MVR who were treated conservatively. Clinical and echocardiographic follow-up was obtained at a mean of 16.3 months. Two of six patients with mild PVR at the time of MVR and two of two patients with moderate PVR at the time of MVR deteriorated clinically and echocardiographically over time. We suggest that moderate PVR should be corrected at the time of valve-replacement surgery, if this can be performed without high operative risk. Mild PVR should probably also be repaired, if this can be performed at low risk, because some will progress. Patients left with mild PVR after surgery, or patients in whom PVR is recognized only after surgery, should be followed up carefully with serial clinical and echocardiographic examinations.

The precise diagnosis of the presence of significant left main coronary artery disease has profound prognostic and therapeutic implications. Coronary cineangiography has shown to be imprecise and inaccurate to determine the percent stenosis of the left main coronary artery. We report a case with significant left main coronary artery disease in whom coronary cineangiography was in discordance with the clinical data and intravascular ultrasonography. Based on the intravascular ultrasound findings, the patient underwent coronary artery bypass graft surgery. Therefore, the intravascular ultrasonography may be the procedure of choice for assessing indeterminant left main coronary artery lesions by coronary angiography.intravascular ultrasound, left main coronary artery, coronary cineangiography

Atrial fibrillation is the most common cardiac arrhythmia in the elderly. It is associated with significant morbidity and mortality due to hemodynamic and cardioembolic complications. The incidence of stroke in elderly patients is 5 times higher than in patients in sinus rhythm. Atrial fibrillation should be actively treated in the elderly. Treatment should be directed toward the correction of reversible factors, control of ventricular response rate, restoration and maintenance of sinus rhythm, and prevention of cardioembolic events. Treatment of atrial fibrillation in the elderly should be individualized with careful regard for risk-benefit ratio.

Atrial fibrillation is the most common cardiac arrhythmia in the elderly. It is associated with significant morbidity and mortality due to hemodynamic and cardioembolic complications. The incidence of stroke in elderly patients is 5 times higher than in patients in sinus rhythm. Atrial fibrillation should be actively treated in the elderly. Treatment should be directed toward the correction of reversible factors, control of ventricular response rate, restoration and maintenance of sinus rhythm, and prevention of cardioembolic events. Treatment of atrial fibrillation in the elderly should be individualized with careful regard for risk-benefit ratio.