Long-term assessment of right ventricular diastolic filling in patients with pulmonic valve stenosis successfully treated in childhood

Patients with severe pulmonic stenosis (PS) have right ventricular (RV) diastolic filling abnormalities detectable by tricuspid valve pulsed Doppler examination. To determine if these abnormalities persist long term after successful therapy of PS, 19 patients were examined 8 +/- 3 years after PS therapy. At the time of follow-up Doppler examination, the PS gradient was 15 +/- 8 mm Hg. From the tricuspid valve inflow Doppler study, the following measurements were obtained at peak inspiration: peak velocities at rapid filling (peak E) and during atrial contraction (peak A), ratio of peak E to peak A velocities, RV peak filling rate normalized for stroke volume, deceleration time, the fraction of filling in the first 0.33 of diastole as well as under the E and A waves, and the ratio of E to A area. Data from PS follow-up patients were compared with our previously reported data from 12 age-related control subjects and 14 untreated patients with PS. Patients with PS who were followed up had higher peak E velocity (0.75 +/- 0.14 vs 0.59 +/- 0.21 m/s), lower peak A velocity (0.47 +/- 0.09 vs 0.64 +/- 0.28 m/s), higher E/A velocity ratio (1.65 +/- 0.33 vs 1.11 +/- 0.52), higher 0.33 area fraction (0.52 +/- 0.08 vs 0.34 +/- 0.14), lower A area fraction (0.29 +/- 0.06 vs 0.45 +/- 0.21) and higher E/A area ratio (2.48 +/- 0.82 vs 1.73 +/- 1.05) than PS patients without treatment (p < 0.03). All Doppler indexes of the patients with PS who were followed up were the same as those of the control subjects except for the peak E velocity that was slightly higher (0.75 +/- 0.14 vs 0.63 +/- 0.11 m/s), the peak A velocity that was slightly higher (0.47 +/- 0.09 vs 0.38 +/- 0.09 m/s) and the E/A area ratio that was slightly lower (2.48 +/- 0.82 vs 3.50 +/- 1.25) (p < 0.03). Thus, at long-term follow-up, all RV diastolic filling indexes in successfully treated patients with PS improved compared with the untreated patients and approached values found in normal subjects. These data suggest that RV diastolic filling abnormalities in patients with PS are reversible over the long term and are therefore probably related to hypertrophy rather than fibrosis and scarring.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29164/1/0000209.pd

Usefulness of the doppler mean gradient in evaluation of children with aortic valve stenosis and comparison to gradient at catheterization

To assess the usefulness of the Doppler mean gradient as a noninvasive indicator of the need for intervention, 33 children (ages 3 months to 20 years) with valvular aortic stenosis (AS) underwent a 2-dimensional and Doppler echocardiographic examination a median of 1 day before cardiac catheterization. The clinical decision for intervention was based on finding a catheterization peak-to-peak pressure gradient of >75 mm Hg or from 50 to 75 mm Hg in the presence of symptoms or an abnormal exercise treadmill test result. Of the 33 patients, 23 required intervention. The decision for intervention was compared to the Doppler mean gradient, and the Doppler peak and mean gradients were compared to the catheterization peak-to-peak gradient. All 12 patients with a Doppler mean gradient >27 mm Hg had intervention and had a catheterization peak-to-peak gradient of >75 mm Hg. All 3 patients with a Doppler mean gradient From a chi-square table, a Dopppler mean gradient >27 mm Hg predicted the need for intervention with 100% specificity (no false positives) and 52% sensitivity (11 false negatives). if a Doppler mean gradient >24 mm Hg was used to predict intervention, the sensitivity increased to 91% (2 false negatives) but specificity decreased to 70% (3 false positives). To improve the ability to predict the need for intervention in patients with a Doppler mean gradient between 17 and 27 mm Hg, the presence of symptoms or an abnormal exercise treadmill test result was combined with the Doppler mean gradient as criteria for intervention. When the criteria for intervention were a Doppler mean gradient >27 mm Hg or a Doppler mean gradient from 17 to 27 mm Hg in the presence of symptoms or an abnormal exercise test, sensitivity was 96% (1 false negative) and specificity was 80% (2 false positives). Catheterization peak-to-peak gradients correlated well with Doppler mean and peak gradients (r = 0.74 and 0.73, respectively).Thus, the Doppler mean gradient is a useful indicator of the need for intervention in children with AS. A Doppler mean gradient >27 mm Hg indicates the need for intervention with 100% specificity while a Doppler mean gradient < 17 mm Hg predicts mild AS. For patients with Doppler mean gradient between 17 and 27 mm Hg, additional noninvasive data are necessary to determine the need for intervention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27748/1/0000140.pd

Left ventricular ejection fraction measured with Doppler color flow mapping techniques

To determine if left ventricular (LV) ejection fraction (EF) can be accurately measured from the color Doppler examination, 11 patients (aged 0.4 to 22 years) underwent 2-dimensional and color Doppler examinations within 24 hours of cardiac catheterization. With use of a biplane Simpson's rule, LV end-diastolic volume, endsystolic volume and EF were measured from cineangiograms, 2-dimensional echocardiograms and color Doppler examinations. The 2-dimensional echocardiographic and color Doppler measurements were obtained from apical 4-chamber and long-axis views. The color Doppler examinations were performed by placing the color sector over the left ventricle only. The velocity scale was set at the lowest possible Nyquist limit (<0.17 m/s), and the highest possible carrier frequency was used to obtain this limit. With these settings, all flow signals in the LV chamber were aliased so that the entire chamber was filled with mosaic color Doppler signals. Motion of the surrounding LV walls gave rise to nonaliased (pure red-blue) signals. With use of an off-line analysis system equipped with a color frame grabber, the border of the mosaic color flow area was traced to obtain volumes and EF. End-diastolic and endsystolic volumes measured with color Doppler correlated well with those measured from 2-dimensional echocardiography (r = 0.99, standard error of the estimate [SEE] = 11.9 ml; R = 0.99, SEE = 4.4 ml, respectively) and cineangiography (r = 0.92, SEE = 16.8 ml; R = 0.90, SEE = 9.9 ml, respectively). Similarly, EF derived from color Doppler correlated extremely well with that measured from 2-dimensional echocardiography (r = 0.99, SEE = 1.6%) and cineangiography (r = 0.96, SEE = 3.4%). Thus, EF can be accurately measured from the color Doppler examination. With the addition of automatic edge-detecting algorithms, this technique has the potential for providing a quick and automatic on-line calculation of EF.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29166/1/0000211.pd

Echocardiographic detection of pericardiocentesis-induced subepicardial and intramyocardial hematoma

Pericardiocentesis has been widely used to relieve significant pericardial effusion and, in most cases, can be performed safely and without complications. We describe a rare complication of pericardiocentesis not previously reported in a pediatric patient. The crucial role of 2-dimensional echocardiography in the detection of this rare complication is illustrated.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27750/1/0000143.pd

Diastolic function in neonates after the arterial switch operation: effects of positive pressure ventilation and inspiratory time

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41894/1/134-26-7-950_00260950.pd

Doppler evaluation of femoral arteries in children after aortic balloon valvuloplasty or coarctation balloon angioplasty

To assess long-term femoral artery complications after aortic balloon valvuloplasty or coarctation balloon angioplasty, we examined 19 children who were 3 weeks to 21 years old (mean 7.6 years) at the time of catheterization. Two-dimensional and Doppler echocardiographic examinations of the common, superficial, and deep femoral arteries were performed at an average of 2.0 years after balloon dilatation. Pulsatility index (PI) was calculated as the maximum velocity minus the minimum velocity divided by the mean velocity. No patient was suspected clinically of having peripheral arterial disease prior to the echocardiographic examination. Fourteen patients had normal femoral arteries. Of these, 10 had normal two-dimensional and Doppler echocardiographic examinations of both femoral arteries. These patients had triphasic flow patterns (forward in systole, reverse in early diastole, forward in middiastole) and Pls of 3.7–41.6 (mean 9.5). Four of the 14 normal patients had abnormal pulsed Doppler examinations showing continuous forward flow and low Pls (1.7–3.5) reflecting residual coarctation (10–30 mmHg gradients). Five patients had abnormal femoral arteries. Of these, two had no visible obstruction by two-dimensional echocardiography and color-flow imaging but had abnormal pulsed Doppler patterns (continuous forward flow and low Pls of 2.5 and 2.9) only on the side of the balloon catheter insertion. Three of the five abnormal patients had visible obstructions by two-dimensional echocardiography and color-flow imaging and had abnormal pulsed Doppler patterns (continuous forward flow and low Pls from 1.1–3.6). One of these three had bilateral occlusions of the common femoral arteries with multiple collateral vessels; the second had occlusion of the right common femoral artery; and the third had 1–2-cm long severely narrowed segments in both common femoral arteries. All three children were <1 year old at the time of catheterization and had balloon catheter insertions in the affected arteries.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/48099/1/246_2004_Article_BF00794838.pd