lumic relaxation and deceleration times used adult populations for study. Appleton et al’ obtained normal adult isovolumic relaxation time values for subjects aged < and >40 years, but did not study children. Data from Appleton et al for isovolumic relaxation time (69 f 12 ms) and deceleration time (199 f 32 ms) had higher mean values than those obtained in this study (55 f 10 and 100 f 22 ms, respectively). Myreng and Nitter-Hauge5 found a lesser positive correlation between isovolumic relaxation time and age for adults (r = 0.44). The main limitations of this study are (1) resolution of the time intervals, and (2) limits of variability of the heart rate studies. It is possible that higher correlations could have been found at the extremes of heart rates. Results of this study show that throughout childhood and early adulthood, age is the most important factor
affecting isovolumic relaxation time, whereas body surface area most strongly influences deceleration time.
1. Appleton CP, Hatle LK, Popp RL. Demonstration of restrictive ventricular physiology by Doppler echocardiography. J Am Co11 Cardiol 1988;11:757-768. 2. Appleton CP, Hatle LK, Popp RL. Relation of transmitral flow velocity patterns to left ventricular diastolic function: New insights from a combined hemodynamic and Doppler echocardiographic study. J Am Coil Cardiol 1988;12: 426-440. 3. Gardin JM, Matin K, White D, Henry WL. Effect of aging on peak systolic left ventricular wall stress in normal subjects. Am J Cardiol 1989;63:998-999. 4. Gutgesell HP, Paquet M, Duff OF, McNamara DG. Evaluation of left ventricular size and function by echocardiography. Results in normal children. Circulation 1977;56:457-462. 5. Myreng Y, Nitter-Hauge S. Age-dependency of left ventricular filling dynamics and relaxation as assessed by pulsed Doppler echocardiography. Chin Physiol 1989;9:99-106. 6. Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography. Circulation 1978;58:1072-1083.
Comparison of Transesophageal and Transthoracic Contrast Echocardiography for Detection of a Patent Foramen Ovale Peter Siostrzonek, MD, Massoud Zangeneh, MD, Heinz G&singer, MD, Wilfried Lang, Georn Rosenmayr, Gottfried Heinz, MD, Andreas Stiimpflen, MD, Karl Zeiler, MD, Mar6 Schwarz,-MD, and Herbert MOsslacher, MD resence of a patent foramen ovale may indicate paradoxic embolism in patients with otherwise unexplained embolic disease.1-3 Transthoracic contrast echocardiography has been used as a simple technique for detecting patent foramen ovale.4-6 However, particularly in patients with poor transthoracic image quality, presence of a patent foramen ovale might be missed. Transesophageal contrast echocardiography provides superior visualization of the atria1 septum and therefore is believed to improve diagnostic accuracy. The present study investigates the influence of image quality on the detection of a patent foramen ovale by both transthoracic and transesophageal contrast echocardiography.
P
The study population consisted of 1.50 consecutive patients (88 men, 62 women; mean age 52 f 16 years) who were referred for transesophageal echocardiography to our laboratory. Indications for transesophageal imaging were recent embolic events in 99 patients (66%) native or prosthetic valvular disease in 9 patients (6%) and dilated cardiomyopathy in 24patients (16%). Eighteenpatients (12%) were studied to examine patency of the foramen ovale before neurosurgery of the fossa posterior. From the First Department of Medicine, Division of Cardiology, Department of Neurology, and Department of Neurosurgery, University of Vienna, Austria, Lazarettgasse 14 A-1090 Vienna, Austria. Manuscript received March 15,199l; revised manuscript receivedand accepted June 21,199l.
MD,
Transthoracic and transesophageal echocardiography were performed on the same day with a Vingmed CFM700 system using a 3.5 MHz and 5 MHz transducer for transthoracic and transesophageal study, respectively. After obtaining optimal visualization of the atria1 septum, a bolus of 2 to 5 ml of a hand-agitated 5.5% solution of oxypolygelatine (Gelifundol, Biotest-Pharma) was injected into a large cubital vein over an indwelling 18 gauge cannula. Subsequently, the appearenceof contrast agent in the right atrium was monitored and recorded on videotape. Zn each patient transthoracic and transesophageal contrast studies were performed during normal respiration and during the Valsalva maneuver. Contrast studies were interpreted by 2 experienced observers and judged as positive, negative or undetermined. Studies were judged positive if microbubbles appeared in the left atrium within 3 cardiac cycles of their appearence in the right atrium. In case of a questionable result contrast injections were repeated until consensuswas obtained. Studies were judged undetermined if there was still disagreement between the 2 observers after a maximum of 5 repeated contrast injections or if both examiners believed that the image quality was too poor for proper interpretation. Based on the ability to visualize the atria1 septum during normal respiration and during the Valsalua maneuver quality of the thransthoracic and transeBRIEF REPORTS
1247
and low in 78, 21 and 1% of the patients, respectively. In all but 1 patient (I %), transesophageal image quality was estimated as beingsuperior (79patients, 53%) or at least equal (70 patients, 47%) to that of the transthoracic images. As expected, sensitivity and specificity of transthoracic contrast echocardiography for the detection of a patent foramen ovale was lower in patients with low transthoracic image quality, whereas the number of undetermined studies increased (Table II). However, false-negative studies occurred irrespective of transthoracic image quality. Of note, the rate of falsenegative studies was even highest inpatients with high transthoracic image quality (Table II).
TABLE I Incidence of Positive, Negative and Undetermined Contrast Studies with Transthoracic and Transesophageal Contrast Echocardiography in 150 Patients
+ 0 Undetermined
Transthoracic Contrast Echocardiography
Transesophageal Contrast Echocardiography
Normal Respiration
Valsalva Maneuver
Normal Respiration
Valsalva Maneuver
7 (5%) 125 (83%) 18 (12%)
9 (6%) 119 (79%) 22 (15%)
18 (12%) 132 (88%) 0 (0%)
30 (20%) 120 (80%) 0 (0%)
+ = positive; 0 = negative. TABLE II Sensitivity, Specificity, Positive Predictive Value and Rate of Undetermined Respect to Transthoracic Image Quality Transthoracic image Quality
Sensitivity (%)
High (n = 50) 31 Medium 36 (n = 71) Low (n = 29) 17
and Negative Studies with
Specificity (%I
Positive Predictive Value (%)
Negative Predictive Value (%)
Undetermined Study (%)
92 95
100 100
80 93
9 8
43
100
83
55
sophageal images was arbitrarily classified as high, medium or low. Detection rates of a patent foramen ovale by transthoracic and tramesophageal contrast echocardiography were compared by use of the McNemar test. The rate of undetermined transthoracic and transesophageal studies was compared by chi-square analysis. A p value X0.05 was assumed to be statistically significant. The results of tramsthoracic and transesophageal contrast echocardiography are listed in Table I. The overall detection rate of a patent foramen ovale was sign$cantIy higher with transesophageaI(30 of 150 patients [20%]) than with transthoracic imaging (9 of 150patients [6%]) (p
affecting isovolumic relaxation time, whereas body surface area most strongly influences deceleration time.
1. Appleton CP, Hatle LK, Popp RL. Demonstration of restrictive ventricular physiology by Doppler echocardiography. J Am Co11 Cardiol 1988;11:757-768. 2. Appleton CP, Hatle LK, Popp RL. Relation of transmitral flow velocity patterns to left ventricular diastolic function: New insights from a combined hemodynamic and Doppler echocardiographic study. J Am Coil Cardiol 1988;12: 426-440. 3. Gardin JM, Matin K, White D, Henry WL. Effect of aging on peak systolic left ventricular wall stress in normal subjects. Am J Cardiol 1989;63:998-999. 4. Gutgesell HP, Paquet M, Duff OF, McNamara DG. Evaluation of left ventricular size and function by echocardiography. Results in normal children. Circulation 1977;56:457-462. 5. Myreng Y, Nitter-Hauge S. Age-dependency of left ventricular filling dynamics and relaxation as assessed by pulsed Doppler echocardiography. Chin Physiol 1989;9:99-106. 6. Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography. Circulation 1978;58:1072-1083.
Comparison of Transesophageal and Transthoracic Contrast Echocardiography for Detection of a Patent Foramen Ovale Peter Siostrzonek, MD, Massoud Zangeneh, MD, Heinz G&singer, MD, Wilfried Lang, Georn Rosenmayr, Gottfried Heinz, MD, Andreas Stiimpflen, MD, Karl Zeiler, MD, Mar6 Schwarz,-MD, and Herbert MOsslacher, MD resence of a patent foramen ovale may indicate paradoxic embolism in patients with otherwise unexplained embolic disease.1-3 Transthoracic contrast echocardiography has been used as a simple technique for detecting patent foramen ovale.4-6 However, particularly in patients with poor transthoracic image quality, presence of a patent foramen ovale might be missed. Transesophageal contrast echocardiography provides superior visualization of the atria1 septum and therefore is believed to improve diagnostic accuracy. The present study investigates the influence of image quality on the detection of a patent foramen ovale by both transthoracic and transesophageal contrast echocardiography.
P
The study population consisted of 1.50 consecutive patients (88 men, 62 women; mean age 52 f 16 years) who were referred for transesophageal echocardiography to our laboratory. Indications for transesophageal imaging were recent embolic events in 99 patients (66%) native or prosthetic valvular disease in 9 patients (6%) and dilated cardiomyopathy in 24patients (16%). Eighteenpatients (12%) were studied to examine patency of the foramen ovale before neurosurgery of the fossa posterior. From the First Department of Medicine, Division of Cardiology, Department of Neurology, and Department of Neurosurgery, University of Vienna, Austria, Lazarettgasse 14 A-1090 Vienna, Austria. Manuscript received March 15,199l; revised manuscript receivedand accepted June 21,199l.
MD,
Transthoracic and transesophageal echocardiography were performed on the same day with a Vingmed CFM700 system using a 3.5 MHz and 5 MHz transducer for transthoracic and transesophageal study, respectively. After obtaining optimal visualization of the atria1 septum, a bolus of 2 to 5 ml of a hand-agitated 5.5% solution of oxypolygelatine (Gelifundol, Biotest-Pharma) was injected into a large cubital vein over an indwelling 18 gauge cannula. Subsequently, the appearenceof contrast agent in the right atrium was monitored and recorded on videotape. Zn each patient transthoracic and transesophageal contrast studies were performed during normal respiration and during the Valsalva maneuver. Contrast studies were interpreted by 2 experienced observers and judged as positive, negative or undetermined. Studies were judged positive if microbubbles appeared in the left atrium within 3 cardiac cycles of their appearence in the right atrium. In case of a questionable result contrast injections were repeated until consensuswas obtained. Studies were judged undetermined if there was still disagreement between the 2 observers after a maximum of 5 repeated contrast injections or if both examiners believed that the image quality was too poor for proper interpretation. Based on the ability to visualize the atria1 septum during normal respiration and during the Valsalua maneuver quality of the thransthoracic and transeBRIEF REPORTS
1247
and low in 78, 21 and 1% of the patients, respectively. In all but 1 patient (I %), transesophageal image quality was estimated as beingsuperior (79patients, 53%) or at least equal (70 patients, 47%) to that of the transthoracic images. As expected, sensitivity and specificity of transthoracic contrast echocardiography for the detection of a patent foramen ovale was lower in patients with low transthoracic image quality, whereas the number of undetermined studies increased (Table II). However, false-negative studies occurred irrespective of transthoracic image quality. Of note, the rate of falsenegative studies was even highest inpatients with high transthoracic image quality (Table II).
TABLE I Incidence of Positive, Negative and Undetermined Contrast Studies with Transthoracic and Transesophageal Contrast Echocardiography in 150 Patients
+ 0 Undetermined
Transthoracic Contrast Echocardiography
Transesophageal Contrast Echocardiography
Normal Respiration
Valsalva Maneuver
Normal Respiration
Valsalva Maneuver
7 (5%) 125 (83%) 18 (12%)
9 (6%) 119 (79%) 22 (15%)
18 (12%) 132 (88%) 0 (0%)
30 (20%) 120 (80%) 0 (0%)
+ = positive; 0 = negative. TABLE II Sensitivity, Specificity, Positive Predictive Value and Rate of Undetermined Respect to Transthoracic Image Quality Transthoracic image Quality
Sensitivity (%)
High (n = 50) 31 Medium 36 (n = 71) Low (n = 29) 17
and Negative Studies with
Specificity (%I
Positive Predictive Value (%)
Negative Predictive Value (%)
Undetermined Study (%)
92 95
100 100
80 93
9 8
43
100
83
55
sophageal images was arbitrarily classified as high, medium or low. Detection rates of a patent foramen ovale by transthoracic and tramesophageal contrast echocardiography were compared by use of the McNemar test. The rate of undetermined transthoracic and transesophageal studies was compared by chi-square analysis. A p value X0.05 was assumed to be statistically significant. The results of tramsthoracic and transesophageal contrast echocardiography are listed in Table I. The overall detection rate of a patent foramen ovale was sign$cantIy higher with transesophageaI(30 of 150 patients [20%]) than with transthoracic imaging (9 of 150patients [6%]) (p
