In a prospective study, the clinical value of transoesophageal two-dimensional echocardiography (TOE) as compared with transthoracic two-dimensional echocardiography (TTE) was determined in patients with suspected infective endocarditis. Ninety-six patients were studied consecutively with an electronic sector scanner using 2.25 and 3.5 MHz probes for TTE and a 3.5 MHz probe embedded in tip of a flexible 12 mm gastroscope for TOE. Results of surgery and autopsy were available for 20 of the 96 patients with infective endocarditis and echocardiographically demonstrated vegetations and 70 control patients with valvular heart disease without infective endocarditis and no signs of vegetations, who were studied preoperatively with TTE and TOE. For TTE and TOE, the measured sensitivity was 63% and 100%, specificity 98% and 98%, positive predictive accuracy 92% and 95%, and negative predictive accuracy 91% and 100%, respectively. In 39 patients who had positive blood cultures, vegetations were found by TOE in 32 patients (82%), but in only 27 patients (69%) by TTE. Image quality was the main factor contributing to the superiority of TOE over TTE: it was reduced in 11/20 patients (55%) in whom vegetations were not detected by TTE. Another important factor was the size of vegetations. Only 6/24 vegetations (25%) of less than 5 mm but 9/13 vegetations of 6-10 mm, and 14/14 vegetations of greater than 11 mm detected by TOE were also observed with TTE. The clinical importance of detecting vegetations was demonstrated by the rate of embolism. In patients with vegetations embolism was 25% when blood cultures were positive and 21% when they were negative. In patients without echocardiographically detectable vegetations signs of embolism were seen in no patient with positive and 7% of the patients with negative blood cultures. Evidence of vegetations was found on the aortic valve in 14 patients and on the mitral valve in seven patients in whom valvular incompetence was not present, indicating that the valve had not yet been damaged significantly. TOE is superior to TTE in detecting vegetations in suspected infective endocarditis because of better image quality, particularly when vegetations are small. TOE seems to be indicated in patients with suspected endocarditis and reduced image quality or negative TTE results. Early detection of vegetations on valves may help confirm the diagnosis of infective endocarditis at an early stage and hopefully lead to an improved prognosis by reducing delay in instituting appropriate therapy.

Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

Fatigue is a prominent symptom in patients with chronic heart failure, limiting physical activity and impairing quality of life. Although the underlying mechanisms are not clearly identified, alterations associated with peripheral adaptation in heart failure appear to play an important role, including a variably impaired peripheral perfusion during exercise, reduced oxidative capacity of skeletal muscle, impaired muscle strength, and possibly reflex mechanisms associated with alterations in the metabolism of skeletal muscle. Exercise training can, in part, reverse these peripheral alterations, improve exercise capacity, and alleviate fatigue.

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Follow-up of 18 patients with aortic dissection (five with type I, one with type II, 11 with type III dissection according to DeBakey) by transesophageal, two-dimensional and color-coded Doppler echocardiography showed a persistence of the false lumen in five of seven patients (71%) after surgery and in nine of 11 patients (82%) after medical therapy. In two patients treated with surgery, the dissected part of the aorta had been resected, whereas in two patients treated medically, a progressive and complete obliteration of the false lumen was observed. In the false lumen, thrombus formation was absent in four, localized in four, and progressive in six patients. Flow within the false lumen could be registered in 14 patients, and two distinct flow patterns were differentiated (laminar biphasic flow or slowly circulating flow). Persisting intimal tears were visualized by two-dimensional echocardiography in four patients, whereas colorcoded Doppler showed an additional one to three intimal tears in the descending aorta in 10 patients. Flow across these intimal tears was biphasic in 75% of patients; that is, systolic flow was directed from the true to the false lumen with diastolic flow reversal. Unidirectional flow was detected in 25% of the communications, directed in 20%o from the true to the false lumen, serving as an entry only and in one (5%) as reentry only. Additional information concerning complications like extension of the dissection (one of 18 patients), localized dilatation of the aorta (two of 18 patients), mediastinal hematoma (one of 18 patients), or aortic regurgitation (three of 18 patients) were detected by this method. Concerning the morphologic findings and the detection of flow characteristics, the transesophageal approach was superior to conventional echocardiography especially in the descending thoracic aorta. Thus, transesophageal twodimensional and color-coded Doppler echocardiography seems to be an ideal method not only for the easy detection of aortic dissection but also for follow-up. (Circulation 1989;80:24-33 Transesophageal echocardiography overcomes these methodologic limitations and is of great diagnostic value because of high-quality cross-sectional images of the ascending and descending thoracic aorta even in patients in shock or on mechanical ventilation.23-30 Surgery without further diagnostic investigation has been performed successfully in emergency cases.30 In combination with color-coded Doppler flow imaging, which superimposes flow information

Using transesophageal echocardiography, cardiac structures can be imaged with high resolution. The aim of our study was to evaluate whether transesophageal echocardiography is superior in detecting mitral valve prolapse and other cardiac abnormalities compared with transthoracic echocardiography in an age-matched control group and in young patients with cerebral ischemic events (patient group). Forty patients with cerebral ischemic events (mean age 35.2 years) and 29 controls (mean age 30.4 years) were examined using both methods. Transthoracic and transesophageal echocardiography showed a significantly higher incidence of mitral valve prolapse in the patient group compared with the control group (p<0.001). By means of transesophageal echocardiography, it was possible to measure highly significant bulging in both the anterior and the posterior mitral leaflet in the patient group compared with the control group (p<0.001), and the thickness of the mitral leaflets was significantly higher in the patient group. In 9 of 20 (45%) patients with normal transthoracic echocardiograms, transesophageal echocardiography showed pathologic findings. We found transesophageal echocardiography to be a sensitive method for detecting mitral valve prolapse as well as valve changes and other cardiac abnormalities not detectable by conventional echocardiography. Our study underlines the role of mitral valve prolapse in young stroke patients as a relevant risk factor and emphasizes the importance of changed mitral valve morphology. {Stroke 1988;19:345-348)A series of studies has demonstrated an association of mitral valve prolapse (MVP) with cerebral ischemic events in younger patients.1 " 4 In 1980, Barnett and coworkers, by means of M-mode echocardiography, pointed out that the incidence of MVP in stroke patients <45 years of age was significantly higher (40%) than in age-matched controls.5 An increasing number of reports indicate that it is necessary to differentiate between "normal" MVP and a pathologic form with valve thickening and a high degree of myxomatous tissue change. 67 Some clinical retrospective studies address the possibility that the extent of valve involvement may influence the risk of embolic stroke. 8 -9 Transesophageal echocardiography (TEE) is a recently developed imaging technique with a very high degree of reliability and excellent resolution of the cardiac structures, especially the mitral valve.10 Until now, it has not been used for the cardiologic examination of younger patients with cerebral ischemic events.Our investigation examined whether TEE can provide additional diagnostic information in comparison with conventional transthoracic echocardiography ( r i b ) in patients with cerebral ischemic events and in Received March 14, 1987; accepted November 25, 1987. age-matched controls. In addition, we were also interested in analyzing the incidence of MVP by TEE, in quantifying the bulging of the mitral leaflets over the valve plane in normal and changed valves, and in performing measurements related to va...

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Using the transesophageal approach the descending part of the aorta can be imaged by two-dimensional enchocardiography in cross sections comparable to computer tomograms. The value of combined transesophageal and transthoracic echocardiography was evaluated in 53 patients who were studied consecutively from 1983 to 1986 with symptoms of aortic dissection and compared with computed tomography, angiography, surgery and/or autopsy. In all patients the transthoracic aorta could be visualized and the dissection could be classified according to DeBakey: in 9 of 29 patients (34%) type I dissection, in 4 (14%) type II dissection and in 16 (55%) type III dissection was found. Operation was carried out because of acute symptoms in 11 of the 29 patients, and 3 additional patients died before operation. In 24 patients aortic dissection could be ruled out. A sensitivity of 97% for transthoracic and transesophageal echocardiography, of 80% for computed tomography and of 78% for angiography was calculated. The specificity for echocardiography was 100%, for computed tomography 100% and for angiography 95%. The positive predictive accuracy for echocardiography and computed tomography was 100% and 95% for angiography. The negative predictive accuracy for echocardiography was 96%, for computed tomography 77% and for angiography 79%. In no patient was an aortic dissection found by computed tomography or angiography which was not detected by echocardiography. In 1 patient with a large ectasia of the aorta ascendens aortic dissection was overlooked as retrospective analysis demonstrated. Signs of aortic insufficiency and pericardial effusion were detected.(ABSTRACT TRUNCATED AT 250 WORDS)