Post-infarct ventriculoseptal rupture is a lethal and thankfully uncommon complication of an acute myocardial infarction. It accounts for 1-2% of post-infarct patients at autopsy. Most patients who suffer a septal rupture die within a week, with 90% mortality at 12 months. Following VSD formation, both ventricles suffer acute volume overload. This occurring in an ischemic or post-infarct compromised heart leads to a rapid deterioration in cardiac output and therefore tissue perfusion. Death eventually ensues through multi-organ failure.
Ventriculoseptal rupture usually occurs 3-8 days following an otherwise stable, myocardial infarct that involves the septum. Following rupture there is a sudden onset of a harsh, systolic murmur (50% of cases) and congestive cardiac failure and shock. Note that acute papillary muscle rupture and resultant acute severe mitral regurgitation is a differential diagnosis that may be difficult to distinguish clinically. Echocardiography is one of the best investigations to identify the cause of the acute cardiac deterioration. Here is a video from a recent case in a deep transgastric view with colour flow doppler. For our readers' review we also have an additional video loop and two digital images (Img #1; Img #2) from the same case.
But how are these patients best managed? What are the cardiovascular goals that can be achieved medically to stabilise the patient in the acute setting? See more for answers.

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A reader has found us by searching MSN for "differentiating cardiac masses from thrombus in echo".

Here is a system that I tend to utilize when I try to distinguish between intracardiac masses and blood clots.

1. Location
Most intracardiac tumors are myxomas, located in atria. Myxomas typically have well-defined stalks, with an attachment to the interatrial septum. Thrombi usually align themselves along the myocardial wall or a vessel, and, of course, don't have a stalk attachment.

2. Intrinsic structure and borders
Myxomas and other cancers are usually visualized on the echo as masses with distinct smooth borders. The internal structure of most intracardiac masses is uniform in composition, hence the uniform visualization on the echo. The structure of the clot is almost never homogeneous (some old clots might even contain calcium phosphate deposits as a result of dystrophic mineralization). In addition, clots have irregular borders.

Further ideas from our readers?

New study, published in today's Journal of the American Medical Association, shows that coronary graft patency is equal for the off-pump coronary artery bypass (OPCAB) surgeries as compared to the traditional CABGs. Enrolling a total of 200 patients, and following up 197 patients at 30 days and 185 at 1 year, the following results have been obtained:

Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P = .19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P = .27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was $2272 (95% CI, $755-$3732) less for OPCAB (P = .002) and $1955 (95% CI, -$766 to $4727) less at 1 year (P = .08).

Today's study directly contradicts the previous research that has shown decreased patency of coronary grafts for OPCAB patients. There is a theoretical concern that OPCAB patients might be hypercoagulable, predisposed to thromboembolic events (pdf).

There is a growing controversy among doctors, scientists and ethicists about the use of prenatal ultrasound to produce "early" portraits of the baby. With the help of a newly emerging 3D and 4D ultrasound technologies, pictures of the child in utero has never been easier to produce and quality of pictures has never been better.

Company Baby Insight describes its mission:

"Seeing your baby for the first time will touch your heart. Baby Insight records 3D and 4D ultrasounds in many formats to forever capture the magic of first seeing your baby."

Others are not that happy:

Dr. Marsden Wagner, a perinatal epidemiologist and former director of Maternal and Child Health at the World Health Organization, notes that there have been no long-term studies of children exposed to ultrasound. He says several small studies indicate a possible link between ultrasound exposure and neurological problems.

FDA has also expressed concerns on several fronts:

- Technicians performing the exams may not have the proper credentials to perform the scan.

- Appropriate and necessary guidelines are not being followed in terms of the length of time a woman is being scanned.

- The level of ultrasound energy a pregnant woman is exposed to is not properly regulated.

"We don't know all the effects and it's not clear that this is a good idea," said Dr. David Feigal, a spokesman for the FDA.

In addition, these new high quality scans are more powerful and can last longer time, especially in the hands of technicians that are not properly trained or licensed.
Operating ultrasound without the prescription or medical indication is clearly against the law. "The FDA shut down several ultrasound studios about 10 years ago. Due to the resurgence of the business, Deputy Director Dr. Kimber C. Richter said the agency is now considering regulatory action, which typically can mean warning letters, injunctions, fines or seizures," reports USA Today. Some have also raised concerns regarding the lack of proper counseling mechanisms, in case an unexpected congenital problem is discovered during the scan.

The history repeats itself. Whenever new technology is developed or the old technology is applied in a novel way, ethical questions inevitably arise. Stay tuned...

Technology is continuing to move forward. A quick bedside diagnosis can now be performed using the Titan ultrasound system from SonoSite.

Some features of the Titan, as listed on the manufacturer's website:

- Full diagnostic capability. High quality imaging; color power Doppler (CPD); pulsed wave (PW) Doppler; Tissue Harmonic Imaging (THI); M-mode; SiteLink DICOM; on-board DICOM .

- Versatility of two systems in one. The TITAN system can be used in its Mobile Docking System (MDS) or as a mobile point-of-care solution using the mini-Dock.

- Rugged design. Durability that meets the demands of mobile applications including potential droppage and substantial wear and tear.

- Flexibility. Upgrade path for new capabilities, including Triple Transducer Connect (TTC) that allows for rapid application changes.

- Reliable, fast technology. State-of-the-art ASIC based system cold boots in seconds and offers highly consistent performance.

- Convenient industry standard flashcard storage. High capacity for on-board information storage.

Combine this with a 21.3-centimeter LCD screen, 3.5 kilograms of weight, 2 to 3 hours on a single battery run and 12 seconds "boot time", and you have a very powerful echo system. Also check out their clinical images page. Price tag? Just $40,000. Delivery date? June 2004.

UPDATE: We have received the following message from SonoSite. It is in response to our inquiry regarding cardiac calculation capabilities of the new system.

"Currently we do not have a Cardiac calculations package on the TITAN ultrasound system. However, we will be releasing a new version of the TITAN with a Cardiac Package in June of this year. The Cardiac Package will be similar to that of our currently released 180PLUS or SonoHeart ELITE. It is a fairly comprehensive cardiac package with 2D, M-mode, and Doppler results saved to a report format."

Ann Ann Lambert RDMS, RDCS

Clinical Product Manager

www.sonosite.com

Aortic dissection can be a life threatening condition. Blood, under arterial pressure, enters the aortic wall through a defect in the intimal layer, forcing apart two layers of the vessel wall (usually the media and adventitia) thus creating a false passage for blood flow. Blood then dissects apart the wall of the vessel, establishing a blind pouch. Blood from the blind pouch can also penetrate back through the intima and into the true lumen or, more commonly, it can rupture through the adventitia causing the internal haemorrhage and patient's death. Clinical diagnosis of aortic dissection can be very difficult and is commonly missed. TEE, along with MRI, is the best investigation to make the diagnosis. Identifying the true lumen from the false lumen can be a difficult task. Video clip of color flow Doppler interrogation from a recent case shows a typical appearance of aortic dissection.

Usually the true lumen:
- is smaller
- expands with systole
- has a greater colour doppler signature
- does not contain spontaneous echo contrast (smoke)
- does not contain thrombus
- the dissection flap curves towards the true lumen as it joins the aortic wall.

Often, an entry and/or exit site can be identified, as in this example.
Are there any other TEE identifying features of the true lumen used by others?

An excellent review article by Joanna Chikwe, Axel Walther and John Pepper from London titled "The Surgical Management of Mitral Valve Disease", that has originally been published in the British Journal of Cardiology [Br J Cardiol 11(1):42-48, 2004], is now available online at Medscape.

Of interest to echocardiographers, there is an enclosed diagram illustrating the Carpentier classification, a method that classifies mitral regurgitation into three pathoanatomic types based on leaflet and chordal motion:

Type I - normal leaflet, normal chordal motion
Type II - leaflet prolapse, excessive chordal motion
Type III - restricted leaflet or restricted chordal motion

At the present time, the Carpentier category is the best way to determine surgical options available to repair the diseased mitral valve. It is an excellent article and I recommend reading the whole thing.

"This is the first time a whole food, not its isolated components, has shown this beneficial effect on vascular health," said Emilio Ros, at the Hospital Clinic of Barcelona, lead author of a new study. And what food is that? Walnuts, of course! Walnuts are known to be packed with alpha-linolenic acid (ALA), a plant-derived omega-3 fatty acid, that might provide antiatherosclerotic protection.

The study's findings are published in the March 23rd edition of Circulation. Medscape has a nice summary of the study (link requires free registration with Medscape):

- Subjects were 21 nonsmoking men and women with moderate hypercholesterolemia not receiving anticholesterolemic medication.

- Inclusion criteria were age 25 to 75 years (after menopause for women), serum LDL cholesterol level of 3.36 mmol/L or higher, triglyceride level of 2.82 mmol/L or less, absence of chronic illness or secondary hypercholesterolemia, and no known nut allergy.

- All subjects completed a 4-week Mediterranean-type, cholesterol-lowering diet prior to entry. Then 12 subjects were randomized to receive 4 weeks of an isoenergetic diet enriched with walnuts and switched to a control, Mediterranean-style diet for another 4 weeks. 9 subjects were randomized to the same two diets in reverse order.

- Self-report of dietary intake was used to estimate dietary content. Serum gamma-tocopherol levels during the walnut diet confirmed compliance with walnut consumption.

- Primary outcome was vasomotor function, as seen with postprandial brachial artery ultrasound, which measured EDV. Secondary outcomes were total cholesterol and LDL cholesterol levels.

- The study was powered at 90% to detect a difference of 2% in EDV between the 2 diet interventions, at an α of 0.05. Data were collected at baseline, before, and after each 4-week dietary intervention. Blood tests consisted of cholesterol, LDL, VLDL, HDL, triglycerides, Apo A1 and B and lipoproteins, folic acid, and homocysteine and C-reactive proteins. EDV measurements at the brachial artery were made 3 times per subject, by blinded radiologists (interobserver reliability = 0.74), before and after each 4-week intervention.

- In the walnut diet, subjects were provided with 40 to 65 g (8 to 13 raw, shelled) walnuts daily according to total energy intake requirements. Walnuts were consumed as snacks or with meals and contributed 18% of total energy. They replaced 32% of the energy obtained from MUFA (as olive oil) in the control diet.

- The composition of walnuts per 100 g was 14 g protein (18% arginine), 14 g carbohydrate, and 69 g fat (10% saturated, 17% MUFA, 60% polyunsaturated fatty acids, and 13% ALA). There was 1.8 mg alpha-tocopherol and 155 mg gamma-tocopherol per 100 g walnuts.

- The daily dose per subject was 3.7 to 6.0 g of ALA and 90 to 135 mg of gamma-tocopherol. Walnuts increased L-arginine by 0.9 to 1.4 g per day.

- 8 men and 12 women completed the study, and 18 subjects had available EDV readings. Mean age was 55 years. At baseline, mean weight was 70 kg (body mass index was not reported for subjects), mean total cholesterol was 6.8 mmol/L, LDL cholesterol was 4.7 mmol/L, and total cholesterol:HDL ratio was 4.5. Mean baseline blood pressure was normal (systolic, 127-131 mmHg; diastolic, 75-80 mm Hg).

- Body weight and blood pressure were stable throughout the study.

- The prestudy 4-week Mediterranean diet reduced total cholesterol by 3.4% +/- 7.2% (P = .031).

- Compared with the control Mediterranean diet, the walnut diet produced a relative increase of 64% improvement in EDV (from 3.6% +/- 3.3% to 5.9% +/- 3.3%; P = .043). EDV improved more than 2% in 9 subjects on the walnut diet.

- For the walnut diet, there was a significant reduction in total cholesterol (-4.4% +/- 7.4%; P < .05) and LDL cholesterol (-6.4% +/- 10%; P < .05) compared with the control Mediterranean diet. This was not affected by sex or baseline values. HDL cholesterol was unaffected by the walnut diet.

- Cholesterol reductions for patients on the walnut diet were inversely related to self-reported dietary ALA intakes.

In related developments, Food and Drug Administration has approved the "qualified" health claim for walnuts. The new label to be attached to packages of walnuts will read: "Supportive but not conclusive research shows that eating 1.5 oz. of walnuts per day, as part of a low saturated fat and low cholesterol diet, and not resulting in increased caloric intake, may reduce the risk of coronary heart disease." Walnut is the first food to get such a health claim.

TEG (Thromboelastogram)

•R time to initial fibrin formation. Dep on factors, inhibitors (nl 6-12min)
•k is time from R to 20mm amp, and dep on platelet-fibrin interactions (nl 3-5min)
•alpha angle (29-43 degrees) is slope from R to k; dep on rate of clot formation
•MA (48-60mm) reflects plt function and clot strength, reflects plt/fibrinogen interaction (G = clot strength in dynes/cm5)
•lysis times LY30 and LY60 provide info about fibrinolysis.
•celite activates clotting
•reopro allows the MA to more specifically reflect fibrinogen activity
•heparinase allows TEG during anticoag w/heparin and detection of residual heparinization

For explanation, please go here.

Rx of angina
nitrates-
•decrease O2 demand by decreasing preload (> afterload) & wall tension
•increase O2 supply by dilating cor art and incr subendocardial flow.
Ca channel blockers-
•decrease O2 demand by decreasing afterload. Verap & dilt also decr HR.
•increase O2 supply by cor vasodil.
Beta-blockers-
•decrease O2 demand by decreasing HR, contractility, and afterload

For explanation, please go here.

Mitral Repairs
Carpentier classification of MR based on leaflet mobility
•type 1: normal (annular dilation, leaflet perforation)
•type 2: excessive (chordal or PM elongation or rupture) prolapse
•type 3: restricted leaflet motion (comm fusion, leaflet thickening, chordal fusion or thickening)
3a valvular/subvalv thickening
3b PM displacement
simple repairs
commisurotomy +/- balloon (not if calc), quad resect, alfieri, annuloplast

Complex repairs:
chordal transp, shortening,fenest, resect; artif chordae; leaflet repair; sliding tech; calc annulus.

For explanation, please go here.