Our obsession with normal values

Normal values provide the background for interpretation of quantitative imaging data and thus are essential information for daily routine. Nevertheless, the ways how normal values are obtained, presented, and interpreted, often do not receive the attention they deserve. We review the concepts of normalcy, the implications of typical normal ranges including the types of distribution of normal data, the possibilities to index for confounding biological factors like body surface area, and the limitations of the very concept of normal values, demonstrating that there are no easy statistical solutions for difficult clinical problems

Clinical Applications of Contrast Echocardiography

One of the most recent revolutions of echocardiography has been the introduction of intravenous contrast agents for the optimization of echocardiographic imaging. This has proven to be of tremendous value, over and above the parallel improvement of equipment manufactured and new transducers capable of transmitting and receiving ultrasound at different frequencies. There are now clear recommendations by the American Society of Echocardiography jointly with the Europeans that regular use of intravenous contrast agents in echocardiography benefits image interpretation at rest and perhaps even more, during stress [1,2]

Transesophageal Echocardiography

Despite the progress made in the field of ultrasound, the echocardiographic examination is still of a relatively poor quality in a number of patients. This is basically due to obstacles from the thorax and the lung which very often impede the ultrasound beam transmission. Many of these technical limitations can now be overcome with the advent of transesophageal approach. Transesophageal echocardiography (TEE) is particularly useful when the transthoracic study is not diagnostic, when there is clinico-echocardiographic discordance, in patients with suspected endocarditis and valve dysfunction, in patients with prosthetic valves, particularly mitral valve prosthesis, in patients presenting with systemic thromboemboli, in patients with disease of the aorta, in patients with mitral regurgitation needing to define the cause particularly when surgery is contemplated, and during cardiac or non-cardiac surgery. In this brief overview the clinical applications of TEE are discussed

Three-Dimensional Echocardiography

This brief overview relates to the recent introduction of real-time three-dimensional echocardiographic imaging techniques, which has revolutionized echocardiography, as images are obtained in just one beat. A great potential lies ahead as clinical applications are multiple

Response to pulmonary arterial hypertension drug therapies in patients with pulmonary arterial hypertension and cardiovascular risk factors.

The age at diagnosis of pulmonary arterial hypertension (PAH) and the prevalence of cardiovascular (CV) risk factors are increasing. We sought to determine whether the response to drug therapy was influenced by CV risk factors in PAH patients. We studied consecutive incident PAH patients (n = 146) between January 1, 2008, and July 15, 2011. Patients were divided into two groups: the PAH-No CV group included patients with no CV risk factors (obesity, systemic hypertension, type 2 diabetes mellitus, permanent atrial fibrillation, mitral and/or aortic valve disease, and coronary artery disease), and the PAH-CV group included patients with at least one. The response to PAH treatment was analyzed in all the patients who received PAH drug therapy. The PAH-No CV group included 43 patients, and the PAH-CV group included 69 patients. Patients in the PAH-No CV group were younger than those in the PAH-CV group (P < 0.0001). In the PAH-No CV group, 16 patients (37%) improved on treatment and 27 (63%) did not improve, compared with 11 (16%) and 58 (84%) in the PAH-CV group, respectively (P = 0.027 after adjustment for age). There was no difference in survival at 30 months (P = 0.218). In conclusion, in addition to older age, CV risk factors may predict a reduced response to PAH drug therapy in patients with PAH

Obstructive Thrombosis of a Mitral Valve Prosthesis and Live Three-Dimensional Transesophageal Echocardiography

A 67-year-old woman with a bileaflet mitral valve prosthesis since 2007 due to mitral stenosis and chronic atrial fibrillation was admitted because of severe shortness of breath and diarrhea. She had been discharged from the hospital one week earlier on clarithromycin due to lower respiratory tract infection. She gave a history of increasing shortness of breath on exertion ever since, with the recent addition of diarrhea over the last 24 hours. Her past medical history includes previous ischemic stroke in 2004... (excerpt

Severe regurgitation due to perforation of the mitral-aortic intervalvular fibrosa 3 years after aortic valve replacement

We report the case of a 91-year-old man with severe symptomatic mitral regurgitation (MR), referred for assessment of percutaneous edge-to-edge repair 3 years after bioprosthetic aortic valve replacement (AVR). Detailed transthoracic, trans-oesophageal (TEE), and three-dimensional (3D) echocardiography showed a perforation in the subaortic curtain leading to severe regurgitation from the left ventricular outflow tract to the left atrium, which was undiagnosed on previous two-dimensional echocardiography. This regurgitation might be iatrogenic in origin after AVR in the absence of previous known endocarditis. This case highlights the utility and added value of 3D TEE in identifying the mechanism of MR

Post-myocardial infarction left ventricular pseudoaneurysm diagnosed incidentally by echocardiography

A 54-year-old male developed a left ventricular pseudoaneurysm (Ps) along the lateral wall of the left ventricle (LV), which was diagnosed incidentally by two-dimensional transthoracic echocardiography (2DTTE) 6 months after an acute myocardial infarction. Color flow imaging (CFI) showed blood flow from the LV into the aneurysmal cavity and invasive coronary angiography revealed sub-occlusion of the circumflex artery. A complementary study using cardiovascular magnetic resonance (CMR) confirmed a dilated left ventricle with depressed ejection fraction, thin dyskinetic anterolateral and inferolateral walls, a Ps adjacent to the lateral wall of the LV contained by the pericardium and blood passing in and out through a small defect in the LV mid-anterolateral wall. Late gadolinium-enhanced imaging demonstrated transmural myocardial infarction in the lateral wall and delayed enhancement of the pericardium, which formed the walls of the Ps. A conservative approach was adopted in this case, optimizing the patient’s heart failure medications, including cardioselective beta-blocker agents, angiotensin-converting enzyme inhibitors, spironolactone and chronic anticoagulation therapy because of a high risk of ischemic stroke in these patients. At the 13-month follow-up, the patient remained stable with New York Heart Association class II heart failure. In conclusion, 2DTTE and CFI seem to be suitable initial methods for diagnosing Ps of the LV, but CMR is an excellent complementary method for characterizing further this cardiac entity. Furthermore, the long-term outcome of patients with Ps of the LV who are treated medically appears to be relatively benign