Echocardiographic diagnosis of mitral regurgitation due to ruptured chordae tendineae

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal

The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed “moderate” MR.

Spontaneous chordae tendineae rupture during peripartum

Acute cardiopulmonary distress in pregnancy always carries exceptionally arduous challenge for physicians. Here we report a patient who sustained spontaneous chordae tendineae rupture complicated with severe mitral regurgitation and acute pulmonary edema during peripartum period. Probable causes of chordae tendineae rupture include mitral valve prolapse, infectious endocarditis, congenital heart disease, rheumatic heart disease, ischemic heart disease, connective tissue diseases, previous mitral valve surgery or pregnancy itself. The pathophysiology of spontaneous chordae tendineae rupture due to pregnancy remains unclear. However, certain physiological stress, including hormone changes related matrix remodeling, increased cardiac output during pregnancy or labor pain may precipitate to this condition. Literature reviews from previously reported cases showed that those who were diagnosed chordae tendineae rupture at very preterm period all had preterm delivery.

Morphologic characterization and quantitative assessment of mitral regurgitation with ruptured chordae tendineae by transesophageal echocardiography

To compare the accuracy of transesophageal echocardiography (TEE) with that of transthoracic echocardiography (TTE) in the detection of morphologic characteristics and in the quantitative assessment of the severity of mitral regurgitation with ruptured chordae tendineae, 40 patients with ruptured chordae tendineae (group 1) and 20 patients with moderate or severe mitral regurgitation due to other causes (group 2) were studied. All echocardiograms were recorded before cardiac surgery. Cardiac catheterization was performed in 55 patients (92%). TEE showed greater sensitivity and negative predictive value than TTE (100 vs 65%, and 100 vs 56%, respectively; p < 0.005) in the diagnosis of ruptured chordae tendineae. Visualization of the ruptured chordae (termed snake-tongue sign) was highly sensitive and specific (93 and 95%, respectively) for establishing the diagnosis of ruptured chordae tendineae. The severity of mitral regurgitation in group 1 patients evaluated by TTE color flow mapping was underestimated by 2 grades in 1 patient and by 1 grade in 6 patients, and overestimated by 1 grade in 1 patient, compared with left ventriculography. In contrast, by TEE color flow mapping it was underestimated by 1 grade in 1 and overestimated by 1 grade in 1 patient. TEE color flow mapping showed better correlation with angiography than did TTE color flow mapping (r = 0.82 vs r = 0.49).

The flail mitral valve: echocardiographic findings by precordial and transesophageal imaging and Doppler color flow mapping

To determine the echocardiographic and Doppler characteristics of mitral regurgitation associated with a flail mitral valve, precordial and transesophageal echocardiography with pulsed wave and Doppler color flow mapping was performed in 17 patients with a flail mitral valve leaflet due to ruptured chordae tendineae (Group I) and 22 patients with moderate or severe mitral regurgitation due to other causes (Group II). Echocardiograms were performed before or during cardiac surgery; cardiac catheterization was also performed in 28 patients (72%). Mitral valve disease was confirmed at cardiac surgery in all patients. By echocardiography, the presence of a flail mitral valve leaflet was defined by the presence of abnormal mitral leaflet coaptation or ruptured chordae. Using these criteria, transesophageal imaging showed a trend toward greater sensitivity and specificity than precordial imaging in the diagnosis of flail mitral valve leaflet. By Doppler color flow mapping, a flail mitral valve leaflet was also characterized by an eccentric, peripheral, circular mitral regurgitant jet that closely adhered to the walls of the left atrium. The direction of flow of the eccentric jet in the left atrium distinguished a flail anterior from a flail posterior leaflet. By transesophageal echocardiography with Doppler color flow mapping, the ratio of mitral regurgitant jet arc length to radius of curvature was significantly higher in Group I than Group II patients (5.0 +/- 2.3 versus 0.7 +/- 0.6, p less than 0.001); all of the Group I patients and none of the Group II patients had a ratio greater than 2.5.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct visualization of ruptured chordae tendineae by transesophageal two-dimensional echocardiography

To determine the value of transesophageal echocardiography in the detection of ruptured chordae tendineae, 28 patients who had surgical therapy for pure mitral regurgitation were evaluated prospectively by conventional transthoracic and transesophageal two-dimensional echocardiography. Seventeen patients (Group I) had ruptured chordae tendineae and 11 (Group II) had intact chordae tendineae. Transthoracic echocardiography detected ruptured chordae tendineae in 6 patients from Group I (sensitivity 35%) and flail leaflets in 11 patients from Group I (sensitivity 65%). Transesophageal echocardiography disclosed ruptured chordae tendineae in all 17 Group I patients (sensitivity 100%); the sensitivity was significantly higher than that of transthoracic echocardiography. No abnormal chordal echoes were visualized in any patient from Group II by either transthoracic or transesophageal echocardiography (specificity 100%). Transesophageal echocardiography is a highly sensitive method for detecting ruptured chordae tendineae and is superior to transthoracic echocardiography in establishing its diagnosis.

Reliability of M-mode, two-dimensional and Doppler echocardiography in diagnosing a flail mitral valve leaflet

The purpose of this study was to evaluate the M-mode, two-dimensional, and Doppler echocardiographic signs for a flail mitral valve leaflet. This was a retrospective evaluation of 54 patients who had (1) significant mitral regurgitation, (2) a technically adequate echocardiographic study, and (3) description of valve anatomy done at surgery or necropsy. The following M-mode signs were examined for their ability to detect a flail valve: (1) systolic flutter of the mitral valve closure line, sensitivity 29%, specificity 76%; (2) abnormal diastolic posterior leaflet motion, sensitivity 73%, specificity 71%; (3) abnormal diastolic anterior leaflet motion, sensitivity 67%, specificity 86%; (4) systolic atrial echoes, sensitivity 28%, specificity 68%; (5) multiple independent systolic closure lines, sensitivity 71%, specificity 52%. The two-dimensional echocardiographic signs evaluated were (1) diastolic inversion of the anterior leaflet toward the left atrium, sensitivity 29%, specificity 96%; (2) diastolic inversion of the posterior leaflet toward the left atrium, sensitivity 54%, specificity 93%, (3) systolic inversion of the anterior leaflet into the left atrium, sensitivity 57%, specificity 93%; (4) systolic inversion of the posterior leaflet into the left atrium, sensitivity 79%, specificity 86%; (5) systolic whipping of the mitral leaflets, sensitivity 73%, specificity 74%; (6) presence of floating apical chordae, sensitivity 30%, specificity 91%. Doppler echocardiographic signs evaluated were (1) presence of left atrial systolic antegrade flow, sensitivity 30%, specificity 91%; (2) vertical striations superimposed on the typical regurgitant flow pattern, sensitivity 75%, specificity 69%. When all the two-dimensional signs except systolic whipping and the M-mode signs for abnormal diastolic leaflet motion were combined, the sensitivity for detecting a flail mitral valve was maximized at 97%, but specificity was reduced to 64%. In conclusion, two-dimensional echocardiographic signs are more sensitive and specific than either M-mode or Doppler signs for detecting a flail mitral valve. The various M-mode, two-dimensional, and Doppler echocardiographic signs, however, are complementary to each other, and sensitivity is maximized when they are combined.

Echocardiography in mitral valve disease: a review

Echocardiographic evaluation of the mitral valve has attracted much attention and generated much discussion since its beginnings, some thirty years ago. Echocardiography affords the physician a detailed assessment of mitral valve integrity unequalled by any other non-invasive test. Aside from the normal appearance of the valve, a variety of pathological conditions have been studied in detail; mitral stenosis was the first and over the years the state-of-the-art has evolved from simply looking at the EF slope as an indicator of severity to the accurate quantification utilizing planimetry and 'pressure half-time.' Mitral regurgitation, although not as well quantified as mitral stenosis, can be detected and its etiology usually determined. Mitral valve prolapse may easily be overdiagnosed by echocardiography, however together with auscultation, ultrasound remains the best way to evaluate this common condition. Echocardiography is also invaluable in the evaluation of endocarditis and prosthetic mitral valves.

Flail mitral valve syndrome: comparison with chronic mitral regurgitation of other etiologies

Thirty-nine patients with symptomatic severe mitral regurgitation (MR) were studied by cardiac catheterization and two-dimensional echocardiography (2DE) prior to mitral valve replacement. A flail mitral valve was found at surgery in 23 patients (group 1); 16 patients had intact chordae tendineae (chronic MR, group 2). No difference was found between groups 1 and 2 with regard to hemodynamic findings. Left atrial volumes in end systole (LAESV) and end diastole (LAEDV) were determined by 2DE from apical four- and two-chamber views with the use of a biplane area-length method and a light pen system. The LAESV and LAEDV measured 116 +/- 66 ml and 56 +/- 48 ml, respectively, in group 1, as compared with 185 +/- 101 ml and 105 +/- 62 ml in group 2 (p less than 0.025). Ten patients from group 1 with LAESV less than or equal to 100 ml (group 1A) were compared to the remaining 13 patients with LAESV greater than 100 ml (group 1B). Patients in group 1A had significantly smaller left ventricular volume and higher mean pulmonary wedge pressure, pulmonary artery, and left ventricular end-diastolic pressure compared to patients in groups 1B and 2 (p less than 0.05). Thus, a subset group of patients with flail mitral leaflets and smaller LAESV has hemodynamic features of acute MR, whereas the remainder with larger LAESV are indistinguishable from patients with chronic MR.

The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome

Echocardiographic studies were performed on 134 consecutive patients with idiopathic mitral valve prolapse syndrome. Fifteen patients (11.2%) were noted to have ruptured chordae tendineae on M-mode examination and in 12 of them the diagnosis was confirmed by bidimensional studies. Only four patients were referred for surgery as a result of severe mitral regurgitation. At operation one patient was found to have rupture of the anterior mitral chorda and the other three had posterior mitral chordal rupture. Eleven patients with chordal rupture had either mild symptoms or were completely asymptomatic. It is concluded that chordal rupture in patients with the mitral valve prolapse syndrome does not always result in severe hemodynamic deterioration and may go undetected unless a high index of suspicion is maintained. Serial echocardiographic studies may reveal the natural history of this condition in asymptomatic patients.

Infective endocarditis--a 25 year overview of diagnosis and therapy

Diagnosis and management of infective endocarditis have significantly changed in the past 25 years. Improved bacteriologic techniques have allowed detection of cases of infective endocarditis caused by unusual organisms. Bactericidal therapy has become available for patients with gram-negative endocarditis and antimicrobial therapy has improved. Echocardiography has become an important diagnostic and management aid, and cardiac valve replacement has dramatically improved the outlook for many patients.

The correlates of an abnormal first heart sound in mitral-valve-prolapse syndromes

In 52 patients with mitral-valve prolapse we studied the intensity of the first heart sound (S1) in relation to the timing of the prolapse and to the presence of leaflet tip coaptation. Sixteen normal subjects served as controls. With two-dimensional echocardiography, three distinct groups were identified. Sixteen patients had early systolic mitral prolapse coincident with initial mitral-leaflet coaptation at the S wave on electrocardiography. Twenty-one had middle to late systolic mitral prolapse. Fifteen had flail mitral leaflet without normal leaflet coaptation at the free margins. The intensity of S1 was expressed as the ratio of the S1 amplitude to that of the aortic component of the second heart sound. This ratio was greater in the patients with early prolapse (6.2 +/- 3.1, mean +/- S.D.) than in the controls (1.4 +/- 0.7) (P less than 0.01). The ratio was reduced in patients with flail valves (0.3 +/- 0.5) (P less than 0.01) and did not differ between patients with middle to late prolapse (1.3 +/- 0.6) and controls. We conclude that the amplitude of S1 may provide a clue to the type and timing of mitral-valve prolapse.

The demonstration of vegetations by echocardiography in bacterial endocarditis. An indication for early surgical intervention

The visualization of vegetations by M-mode echocardiography in patients with infective endocarditis has been suggested to imply a poor prognosis regarding the development of major systemic emboli, congestive heart failure and the need for early surgical intervention. The question of using the finding of vegetations by echocardiography as an indication for surgery is controversial. To answer this question, 30 patients with the clinical diagnosis of endocarditis were studied by echocardiography. In 17 of the 30 (57 per cent) vegetations were present (aortic eight, mitral four, both mitral and aortic five), whereas in 13 (43 per cent) no vegetations were visualized. Infecting organisms were similar in each group; Streptococcus viridans being the most common. The patients with echocardiographically demonstrable vegetations had a higher incidence of congestive heart failure compared to the patients without (14 of 17 versus six of 13, p less than 0.05), major emboli (eight of 17 versus two of 13, p = NS) and need for valve surgery (17 of 17 versus two of 13, p less than 0.001). Mortality was not significantly different in the two groups (six of 17 versus three of 13, p = NS). Urgent or emergency surgery was required in 16 of 17 patients with vegetations. Thus, the demonstration of vegetations by echocardiography identified a subset of patients with more severe disease in whom early operative intervention was required.

Statistical comparison of M mode and two dimensional echocardiographic diagnosis of flail mitral leaflets

Forty-five patients who had surgical therapy for pure mitral insufficiency were evaluated prospectively with both M mode and two dimensional echocardiography; 26 patients (Group I) had a flail mitral valve leaflet, and 19 patients (Group II) had intact chordae tendineae. The M mode echocardiographic criteria of a flail valve (systolic left atrial echoes, systolic mitral valve flutter, diastolic mitral flutter and chaotic paradoxic diastolic posterior leaflet motion) were compared statistically with the two dimensional echocardiographic criterion (loss of systolic leaflet coaptation). The presence of one M mode echocardiographic finding had a sensitivity of 60 percent, a specificity of 53 percent, a predictive accuracy of 63 percent and a predictive value of 50 percent. The sensitivity (96 percent), specificity (84 percent), predictive accuracy (89 percent) and predictive value (94 percent) of the two dimensional echocardiogram were statistically superior to those of the M mode study (p less than 0.05 or better for each criterion). Thus, two dimensional echocardiography is distinctly superior to M mode echocardiography in the diagnosis of flail mitral valve leaflets.

Acquired cyanotic heart disease secondary to traumatic tricuspid regurgitation. Case report with a review of the literature

A case of traumatic tricuspid insufficiency leading to right atrial enlargement and to a patent foramen ovale with right to left shunting is presented. Six similar cases previously reported are reviewed. The time course of clinical deterioration was related to the type of tricuspid valve damage incurred. Papillary muscle rupture led to surgery within a year, whereas less severe chordal damage allowed a more benign course that lasted from 10 to 25 years from the time of injury to the time of surgery. Surgical repair of the incompetent tricuspid valve and closure of the atrial septal defect led to significant improvement. The diagnostic usefulness of radionuclide imaging and echocardiography is demonstrated in this case. A mechanism of right to left interatrial shunting in the presence of normal pulmonary arterial pressures is proposed; this invokes phasic increases in right atrial pressure from tricuspid insufficiency and streaming of blood from the inferior vena cava into the left atrium across a patent foramen ovale in a manner that resembles conditions in the fetal circulation.

M mode and cross-sectional echocardiographic features of flail posterior mitral leaflets

Seventeen patients with accepted M mode echocardiographic criteria for flail mitral leaflet were studied. M mode echocardiograms revealed characteristic disordered mitral valve motion: (1) 16 (94 percent) had chaotic diastolic mitral motion; (2) 14 (82 percent) had systolic mitral flutter; (3) 14 (82 percent) had systolic left atrial echoes; and (4) 12 (71 percent) had systolic mitral valve prolapse. In 8 patients (47 percent) all four findings were present, with three findings present in 16 (35 percent) and two findings present in 13 (18 percent); none had fewer than two findings. Cross-sectional echocardiographic studies in 10 patients revealed a systolic whipping motion of the posterior mitral leaflet into the left atrium in all, abnormal systolic mitral coaptation in all and an abnormal mass of systolic left atrial echoes in 4. None of the first three M mode criteria were observed in 230 patients with uncomplicated "mid systolic click-late systolic murmur" syndrome; cross-sectional echocardiography in 30 of 230 patients revealed normal systolic mitral coaptation and no systolic whipping of the tip of the posterior mitral leaflet into the left atrium.

Abnormal mitral valve motion associated with ventricular septal defect following acute myocardial infarction

It is often difficult to make the clinical distinction between acute mitral regurgitation caused by papillary muscle dysfunction or rupture and ventricular septal defect complicating an acute myocardial infarction. A case of a patient with rapidly progressive congestive heart failure and a loud murmur is presented. Echocardiography strongly suggested the presence of a flail posterior mitral leaflet. However, the patient was subsequently found to have rupture of the interventricular septum. This diagnosis was made with bedside right heart catheterization and was later confirmed by left ventriculography and direct inspection at the time of surgery. The mitral valve apparatus was completely normal. Thus this case demonstrates the apparent lack of specificity of the accepted echocardiographic criteria for flail mitral leaflet and acutely ruptured interventricular septum, and the potential necessity of cardiac catheterization to distinguish between these entities.

Incidence of ruptured chordae tendineae in the mitral valvular prolapse syndrome: an echocardiographic study

Echocardiographic studies were performed in 190 consecutive patients with mitral valvular prolapse. All patients had either midsystolic posterior motion of the mitral valve or holosystolic hammock-like movement of the valve in systole. Thirteen patients (7 percent) were noted to have ruptured chordae tendineae. In four patients, a combination of abnormalities was observed. Five patients had clinical and bacteriologic evidence of infective endocarditis, two of whom had severe intractable pulmonary edema consequent to acute mitral regurgitation which required mitral valvular replacement. At surgery, one of these patients had ruptured chordae tendineae to both leaflets, and the other had chordal rupture of the posterior leaflet. The other patients probably had spontaneous rupture of the chordae tendineae. A spectrum of clinical findings was noted. Six patients had marked mitral regurgitation, while two had isolated systolic clicks. Thus, chordal rupture does not always result in severe hemodynamic deterioration. Serial echocardiographic studies will be of value in studying the natural history and progression of disease in patients with chordal rupture.

The role of cross-sectional echocardiography in the diagnosis of flail mitral leaflet

Cross-sectional echocardiography was performed on two patients with mitral regurgitation in whom M-mode echocardiographic findings were not specific for the etiology of mitral regurgitation. In one patient, flail motion of the free edge of the anterior mitral leaflet into the left atrium was demonstrated only by cross-sectional echocardiograms. In the second patient, the flail posterior mitral leaflet was suggested to be a result of bacterial endocarditis. Cross-sectional echocardiograms clearly identified a flail motion of a mass of vegetation attached to the posterior mitral leaflet. Thus, cross-sectional echocardiography can provide critical information in recognizing patients with a flail mitral leaflet.

Bilateral atrial myxomas. Echocardiographic considerations

In this report we describe a patient with bilateral atrial myxomas, which were diagnosed preoperatively by echocardiography and angiography, and successfully removed. The excised tumor mass consisted of mobile right and left atrial myxomas connected by a common stalk which passed through the atrial septum, collectively resembling the shape of a dumbbell. Preoperative echocardiographic and angiographic observations were instrumental in planning the surgical approach, and correlated well with intraoperative findings and with the anatomic configuration of the intact pathologic specimen. Diagnostic aspects of echocardiography are emphasized as they relate to both isolated and bilaterally-occurring atrial myxomas.

Echocardiographic features of an aneurysm of the left sinus of Valsalva

The echocardiographic features of an aneurysm of the left sinus of Valsalva are described and correlated with angiographic findings. The echocardiogram showed the presence of a thin line of echoes occurring proximal to the anterior leaflet of the mitral valve and moving in and out of apposition with the posterior aortic wall. During systole, this line of echoes moved away from the aorta into the left atrium, and during diastole, the line moved into the aorta. Recognition of these features provides a potential noninvasive way to diagnose aneurysms of the left sinus of Valsalva prior to rupture.

Pitfalls and limitations of M-mode echocardiography

Newer diagnostic applications as well as the ability of obtaining physiologic information has resulted in a greater interest in echocardiography. As with any new technique, certain classical criteria have not been found to be as specific and diagnostic as was originally believed. This review has focused on the more important clinical applications in echocardiography. We have not attampted to discuss every single clinical entity. A critical evaluation as to the sensitivity and specificity of echocardiography in each clinical application is necessary. A thorough knowledge of the basic principles of ultrasound, a familiarity with recording devices, and a realization of the pitfalls and limitations of the technique in each cardiac disorder is essential. Hazards of echocardiographic interpretation may actually hamper its development as a diagnostic tool. Before embarking on complex and sophisticated two-dimensional echocardiography, problems with regard to technique and interpretation of M-mode echocardiography must be overcome.

Echocardiographic observations in opiate addicts with active infective endocarditis. Frequency of involvement of the various values and comparison of echocardiographic features of right- and left-sided cardiac valve endocarditis

Echocardiographic observations are described in 25 opiate addicts with active infective endocarditis involving apparently previously normal valves. Infective endocarditis was isolated to the tricuspid valve in 11 patients, involved both right- (tricuspid valve) and left-sided valves in 7 and was isolated to the left-sided valves in 7 (mitral valve in 6). Twenty patients (80%) had tricuspid valve regurgitation, 12 had mitral regurgitation, 3 had aortic regurgitation and none had pulmonary valve regurgitation. Considering the 75 cardiac valves (excluding the pulmonary) in the 25 patients, echocardiographic abnormalities consistent with active infective endocarditis were detected in 26 (74%) of the 35 clinically incompetent valves but in none of the 40 competent valves. Comparison of the 20 incompetent tricuspid valves with the 12 incompetent mitral valves indicated that (1) the echocardiogram was less sensitive in detecting tricuspid valve lesions, (2) rupture of tricuspid valve chordae tendineae was absent or not detectable, and (3) tricuspid valve vegetations tended to be larger.

Echocardiography in valvular vegetations

Echocardiography represents the only noninvasive technic available for detecting vegetations. In fact, the technic is more sensitive in indentifying these lesions than even angiography. The invasive examination is only capable of detecting very large valvular vegetations. Although echocardiography frequently discloses no abnormalities in patients with clinically suspected or proved bacterial endocarditis, the presence of vegetations can be very helpful in the management of these patients. In addition to identifying vegetations echocardiography can be of great assistance in demonstrating disruption of the affected valve and in identifying that valve which might require surgical replacement.

Clinical significance of the V wave in the main pulmonary artery

Among 68 patients with mitral insufficiency who had right and left cardiac catheterization and left ventriculography, 6 had retrograde transmission of the left atrial V wave into the main pulmonary artery. All of these patients had mitral insufficiency of acute onset. The remaining 62 patients had chronic mitral insufficiency that was considered severe in 17. Pulmonary vascular resistance was lower in the group with acute insufficiency (mean 139 dynes sec cm-5) than in the group with chronic severe insufficiency (mean 631 dynes cm-5) (P less than 0.005). Nondistensibility of the left atrium and low pulmonary vascular resistance were the two factors favoring retrograde transmission of V waves. Because both factors are present in acute mitral regurgitation, this finding is helpful in differentiating patients with acute mitral insufficiency.

Systolic mitral flutter, an echocardiographic clue to the diagnosis of ruptured chordae tendineae

A new finding of fine systolic fluttering of the mitral leaflet is described in two patients with ruptured chordae tendinease and severe mitral regurgitation. The flutter is caused by the action of high-velocity blood flow upon the leaflet margin that has lost its support. The jet stream of blood evokes a high-frequency vibratory motion of the tensed leaflet as opposed to the previously described, lower frequency, less specific, diastolic flutter. This finding was not seen in the echocardiograms of 75 patients with other forms of mitral regurgitation. Systolic flutter appears to be specific for ruptured chordae tendineae.

Echocardiography in bacterial endocarditis

We examined 129 standard M-mode echocardiograms obtained in 65 patients (16 to 73 years old) with bacterial endocarditis. Twenty of the 22 patients with vegetations recognizable by echocargiography died, or underwent cardiac operation (mean interval from admission 22 days, and range two to 120 days). Vegetations were seen on the echocardiograms in 22 (aortic 10, mitral nine and tricuspid three, with anatomic confirmation in 19). Of patients without vegetations on echocardiography none underwent emergency operation or died as a result of cardiac disease (mean follow-up period of 14 months, range of two to 38 months). Other echocardiographic findings in those with vegetations included early mitral-valve closure (six), "flail" aortic leaflet (three), and "flail" mitral leaflet (three). Echocardiography can provide a rapid, reliable noninvasive diagnosis of bacterial vegetations in certain patients with bacterial endocarditis and may identify patients with more severe disease who may require operative intervention.

Echocardiography in the differential diagnosis of the large heart

Echocardiography is an extremely useful noninvasive technic in the differential diagnosis of a large heart. It may show whether a large heart is due to left ventricular hypertrophy or dilatation, or if it is due to a pericardial effusion. The hypertrophied heart may be further characterized by determining whether it is symmetrical, as caused by aortic stenosis or hypertension, or whether it is assymmetrical, which is characteristic of hypertrophic cardiomyopathy. Similarly, dilatation of the heart may be due to volume overload of the left ventricle secondary to valvular insufficiency, congestive cardiomyopathy or ischemic heart disease; these can be distinguished by echocardiography. As certain types of mitral insufficiency are associated with specific valvular dysfunction, the possible etiology of the mitral insufficiency and therefore of the volume overload of the left ventricle may be determined using echocardiography. Finally, mediastinal tumors may simulate a large heart, and demonstration of normal cardiac dimensions and wall motion can exclude a cardiac etiology for the "large heart."

Echocardiography in Marfan's syndrome

Echocardiographic examinations were performed in 26 patients with clinical evidence of Marfan's syndrome. Twelve patients were demonstrated to have isolated dysfunction of the mitral valvular apparatus of varying severity. Four patients demonstrated involvement of the aortic root as well as mitral valvular abnormalities, and six patients had problems involving the aortic root only. Four patients had no demonstrable cardiac abnormalities. Therapeutic decisions which could previously have been made with confidence only on the basis of cardiac catheterization with angiocardiographic studies were made by ultrasonic evaluation.

Applications of diagnostic ultrasound and radionuclides to cardiovascular diagnosis. Part I. Acquired cardiovascular disease in the adult

Noninvasive methods have become an important part of the diagnostic process for evaluation of cardiovascular anatomy and function in adults and in the young. Because there is a multiplicity of noninvasive methods presently available, in some cases with overlapping capabilities, there has been some confusion as to which constitutes the method of choice in a given clinical circumstance. The reviews that follow outline some of the practical strengths and limitations of two methods (echocardiography and radionuclide cardiography), hopefully thereby providing some rationale for choosing the more appropriate technique in the approach to specific clinical problems. We have found that the information available from radionuclide and from ultrasound studies frequently is complementary and that the most optimal diagnostic results often are obtained when they are combined. Since advances in technique and improvements in instrumentation are occurring continually in both of these areas, we have tried to provide only an overview. Further investigations and clinical experience will help to define the specificity, sensitivity, and capabilities of these methods in terms of present and future applications.

Measurement of diastolic closure rate of normal mitral valve

Published values for the diastolic closure rate of the normalmitral vary and reflect diffference in methods of recording and measurement. From strip chart records it was concluded that the form of the recorded mitral diastolic closure slope can vary, that reproducible measurements of the closure rate can be made from echograms in which diastolic closure approximates closely to a monophasic form, that the amplitude of these echograms is maximal, and that their closure movements remain essentially monophasic at chart speeds up to 100 mm/s. Measuring only complexes with essentially monophasic closure movements, the within and between-subjected variation of the normal mitral diastolic closure rate was investigated. The ranges obtained from multiple measurements in a single subject and from a group of 45 normal subjects were comparable but the distribution of the results differed. It was concluded that there was a real between-subject variation in the normal mitral diastolic closure rate and that the diastolic closure rate in a single subject should be determined by measurement of a series of complexes. The accuracy of measurement of the diastolic closure rate of the normal mitral valve has been improved by using strip chart records and by measuring only echograms in which diastolic closure approximates closely to a monophasic form.

Echocardiography in valvular heart disease

Echocardiography is a useful new technique that allows for the diagnosis and assessment of the severity of various forms of valvular heart disease. It is a safe and noninvasive procedure that can readily be used on the critically ill as well as the ambulatory patient. Since the examination can be easily repeated, echocardiography can be used to study a patient over an extended period of time to follow the severity of the disease. With proper care and experience in the performance and interpretation, the cardiologist can derive much useful information to aid in the initial evaluation and long-term follow-up of patients with various forms of valvular disease. With improvements in instrumentation and the use of newer techniques, the usefulness of ultrasound will be further enhanced.