Publications

Because of the better resolution of higher frequency transducers and the proximity of the coronary arteries to the esophageal window, TEE is emerging as a valuable method for evaluation of coronary artery disease. TEE allows imaging of the proximal coronary arteries, measurement of coronary flow reserve, identification of coronary artery anomalies, and observation of wall motion during transesophageal atrial pacing. The application of TEE in evaluation of coronary artery disease will continue to grow as technology improves.

The superior imaging capabilities of TEE have rapidly thrust this technique into the mainstream of noninvasive cardiology. However, the semi-invasive nature of this procedure requires specialized training on the part of the echocardiographer and adaptations of the traditional echocardiographic laboratory. These requirements will become even more evident as this technique is employed increasingly for interventional studies such as transesophageal atrial pacing and pharmacologic stress. TEE has proved efficacious and safe, even in critically ill patients, and its applications continue to expand. Following an article on anatomy, encompassing single and biplane orientation, the remainder of this monograph addresses the established as well as the emerging applications of TEE.

Many echocardiographic signs of severe MR are clearly demonstrated, particularly when both TEE and TTE are used. When these signs are assiduously sought, the recognition of severe MR should pose little problem. Part of the confusion concerning MR and the grading of its severity comes from the fact that the hemodynamic consequences of a given degree of MR vary widely from one individual to another. A regurgitant volume of 50 mL might prove incapacitating to one patient while seeming inconsequential in a second patient. A regurgitant fraction of 50% is poorly tolerated in some patients and asymptomatic in others. Similarly, a regurgitant orifice 0.5 cm2 has unpredictable consequences to the organism, and, in fact, this orifice may vary considerably in size depending on hemodynamic conditions. Thus, a universal definition of the severity of MR is lacking, and there is no agreement on the units with which to quantitate it. The net effect of this confusion is not an inability to recognize severe MR but frustration in differentiating moderate MR from severe MR. We believe that precise quantitation of MR will occur when comprehensive pharmacologic interventions with either TEE or surface echocardiographic monitoring are performed to define the severity of MR by its range of responses to these agents. We have had some success with Doppler measurement of the response of pulmonary artery pressure to dynamic exercise. Patients with normal pulmonary artery pressure at rest tend to show exaggerated rises in pulmonary pressure when MR is clinically important and has resulted in left ventricular dysfunction. Anticipated progress notwithstanding, competently performed TEE is the method of choice for recognizing severe MR.

Transesophageal echocardiography is ideally suited for imaging during CPR because high-quality images can be obtained immediately and continuously without interruption of cardiac compression and ventilation. Use of TEE during CPR is increasing to help monitor resuscitative efforts, for diagnosis, to assist in understanding the physiology of blood flow, and for evaluation of new methods of CPR.

BACKGROUND

There are two competing theories of the mechanism of blood flow during cardiopulmonary resuscitation. The "cardiac pump" theory postulates that blood flows because the heart is squeezed between the sternum and the spine. The "thoracic pump" theory postulates that blood flows from the thorax because intrathoracic pressure exceeds extrathoracic vascular pressure and that flow is restricted to the venous-to-arterial direction because of venous valves that prevent retrograde flow at the thoracic inlet. To determine which mechanism is operative during actual cardiopulmonary resuscitation, 20 patients were imaged with transesophageal echocardiography during resuscitation.

METHODS AND RESULTS

Transesophageal two-dimensional and pulse Doppler echocardiography was begun within 7 minutes of initiation of cardiopulmonary resuscitation. In the 18 patients who could be analyzed, the mitral valve opened during the release phase (diastole) and closed during the compression phase (systole) of cardiopulmonary resuscitation. Mitral velocity-time integral measured 8 +/- 3 cm during diastole. There was compression of right and left ventricular cavities with significant reduction in measured left ventricular volume during cardiopulmonary resuscitation. In five patients, mitral regurgitation was present.

CONCLUSIONS

Transesophageal echocardiography performed during actual cardiopulmonary resuscitation showing mitral valve opening during cardiac release, reduction of ventricular cavity size with compression, and atrioventricular regurgitation support the cardiac pump theory of cardiopulmonary resuscitation. This study demonstrates the feasibility and usefulness of transesophageal echocardiography during cardiopulmonary resuscitation.

Although pulmonary hypertension is a well-described manifestation of systemic lupus erythematosus, there are few data regarding the pulmonary artery pressure response to exercise. We hypothesized that exercise capacity was reduced and that the pulmonary artery pressure response to exercise was abnormal in patients with systemic lupus erythematosus. To test these hypotheses, we performed Doppler exercise echocardiography in 18 patients with lupus and 10 normal control subjects. Exercise duration was significantly reduced in the patients with lupus (8.1 vs 14.4 minutes for control subjects, p < or = 0.001). Pulmonary artery pressure was significantly higher in the patients with lupus at rest and during the first two stages of exercise (p < 0.05). Cardiac indexes at rest were similar in the two groups, suggesting that increased pulmonary vascular resistance was the mechanism for the higher pulmonary pressure we observed. We conclude that abnormal exercise hemodynamics may contribute to reduced exercise capacity in patients with lupus.

The cytokine interleukin 1 alpha (IL-1 alpha) is a critical mediator of the immune and inflammatory responses. A unique determinant of its activity as compared with IL-1 beta may be its association with the plasma membrane. While the biologic activity of "membrane IL-1" has been extensively reported, the mechanism of membrane binding remains unclear. We report that the N terminus of the 31-kDa IL-1 alpha precursor is myristoylated on specific internal lysine residues. Immunoprecipitation of [3H]myristic acid-radiolabeled human monocyte lysates with IgG antibodies to the 31-kDa IL-1 alpha precursor recovered a protein with the physicochemical properties of the IL-1 alpha N-terminal propiece (16 kDa, pI 4.45). Glycyl N-myristoylation of this protein is precluded by the absence of a glycine residue at position 2, suggesting that the propiece is myristoylated on epsilon-amino groups of lysine. To determine which lysine(s) are acylated, a series of synthetic peptides containing all lysines found in the IL-1 alpha N-terminal propiece were used in an in vitro myristoylation assay containing peptide, myristoyl-CoA, and monocyte lysate as enzyme source. Analysis of the reaction products by reverse-phase HPLC and gas-phase sequencing demonstrated the specific myristoylation of Lys-82 and Lys-83, yielding predominantly monoacylated product. A conserved sequence in the IL-1 beta propiece was myristoylated with at least 8-fold less efficiency. Acylation of the IL-1 alpha precursor by a previously unrecognized lysyl epsilon-amino N-myristoyl-transferase activity may facilitate its specific membrane targeting.