The number of patients undergoing surgery for mitral regurgitation has been increasing. While the incidence of rheumatic mitral regurgitation has considerably decreased, ischemic or functional mitral regurgitation is a growing public health problem. This is at least partially because of an increase in life-style related diseases and advances in the management of patients with heart failure. Mitral valve repair is chosen when the valve is suitable for repair and appropriate surgical skill and expertise are available. Transthoracic or transesophageal echocardiography is important for the assessment of reparability by defining cause, mechanism, and location of lesions. Observational evidence suggests that the major surgical determinant of improved long-term outcome is valve repair. Chronic atrial fibrillation and mechanical valve replacement are associated with high risk of embolism and hemorrhagic complications (due to intensive anticoagulation). Increased mortality after replacement emphasizes the importance of early detection and assessment of mitral valve diseases. Experimental studies have shown successful and reliable mitral clip through trans-septal catheterization. A randomised trial comparing percutaneous mitral clip and surgery is in progress in the USA. While there might be important limitations, it is expected to be valuable in patients with impaired cardiac function due to ischemic or functional mitral regurgitation. Valvular function, incidence of leak (paravalvular and transvalvular), grade of regurgitation, and cardiac function are evaluated routinely at postoperative follow-up. The possibility of endocarditis and constrictive pericarditis should be considered. Transthoracic echocardiography is often limited when assessing a prosthetic valve because of the effect of acoustic shadowing. Transesophageal echocardiography provides excellent visualization especially in patients with mechanical valve replacement. The degree of obstruction varies with the type and size of the valve. Indices of echocardiography should be compared to the baseline or previous data.

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Purpose: Ultrasonically activated scalpels are used widely in laparoscope-assisted surgery, but there is concern that they may damage tissue at sites other than the site of the surgical procedure. Cavitation has been cited as a cause of such damage. In this paper, we examined the possibility that the cavitation effect spreads beyond the ultrasonic vibration source. Subjects and methods: We measured the vibration distribution of the blade with a laser Doppler vibrometer, and the sound pressure distribution near the blade with a hydrophone. We also observed the generation of cavitation bubbles underwater using high-speed digital video. Results and Discussion: From the relation between the vibration distribution on the blade and the observed position of bubble generation, it became obvious that cavitation bubbles are mainly generated at the large vibration amplitude region on the blade. We examined the region where cavitation bubbles might be generated from the sound pressure measurement and frequency analysis around the blade in the water. The bubble generation region showed a strong correlation with measurement results of acoustic pressure. It was estimated that bubble generation was localized to the region within several mm from the blade. Conclusion: Cavitation bubbles are generated locally near the blade. It is supposed that the direct effect of cavitation is limited to the vicinity of the blade.

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Timing of regional LV myocardial excitation and contraction could be altered by the location of the RV pacing lead. To our knowledge, late-systolic LV abnormal flow caused by RV pacing has never been reported. We report two cases with late-systolic LV abnormal flow from the mid-LV toward the apex during RV apical pacing. The abnormal flow disappeared with cessation of pacing and reappeared with resumption of pacing. Tissue Doppler imaging (TDI) and strain rate imaging (SRI) revealed that both contraction and relaxation occurred earlier in the apex than those in the basal LV during RV pacing. These findings suggested that the apex started relaxation in late systole while mid-to-basal LV was still contracting, which caused the abnormal pressure gradient leading to the abnormal intra-LV flow towards the apex in late-systole during RV apical pacing.

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A 50-year-old male was admitted to our hospital with symptoms of fever and gradual development of dyspnea. At that time, he was in a state of acute left heart failure, hypoxic, and with bilateral congestion shadow on chest X ray. Respiratory assistance and infusion of diuretics rapidly improved the left heart failure. Transthoracic echocardiography and cardiac catheterization revealed acute severe aortic regurgitation, but transesophageal echocardiography could not identify the cause of the aortic regurgitation, such as infective endocarditis. We figured that this severe aortic regurgitation was a candidate for valve replacement surgery, so a radical operation for aortic regurgitation was undertaken on the 40^th day after the onset of left heart failure in another hospital. During the operation, a localized aortic dissection appeared to be above the left coronary cusp through the right coronary cusp of the aortic valve, so we judged that the cause of aortic regurgitation was this localized aortic dissection. We analyzed the preoperative 3D transesophageal echocardiography findings again, and we verified the presence of a flap lying directly on the right coronary cusp. In addition, we could rebuild the range of localized aortic dissection. Aortic regurgitation due to localized aortic dissection is a relatively rare disorder, and it is often difficult to make a diagnosis of this disorder. We concluded that in cases of acute aortic regurgitation with unidentified cause, suspected on the grounds of the clinical history and transthoracic echocardiography findings, 3D transesophageal echocardiography should be used to make a decision for the purpose of emergency opration.

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Purpose: Although outcomes of surgical treatment for advanced gallbladder carcinoma remain unsatisfactory, radical resection may provide a favorable prognosis for patients with tumors limited to shallow subserosal invasion (<=2 mm: shallow pT2). The aim of this study was to obtain ultrasound images of shallow pT2 gallbladder carcinoma of the papillary invasive type. Subjects and Methods: A retrospective analysis of ultrasound-pathologic correlation was conducted in five patients with shallow pT2 gallbladder carcinoma of the papillary invasive type. Results and Discussion: The outermost hyperechoic layer comprises deep adipose tissue of the subserosa plus serosa. A polypoid gallbladder tumor with a hypoechoic area in its deeper part represents a papillary adenocarcinoma invading the subserosa accompanied by abundant fibrosis and lymphocytic infiltration. All cases in the present study had the deep hypoechoic area. Three of the five cases showed thickening of the outermost hyperechoic layer, and two cases showed no change in the layer. There have been no reports highlighting thickening of the outermost hyperechoic layer. Given the vertical extension of carcinoma invasion, the outermost hyperechoic layer may be pulled up and thickened at first and then thinned later as the deep hypoechoic area enlarges. Conclusion: Ultrasound images of shallow pT2 gallbladder carcinoma of the papillary invasive type show thickening or thinning of the outermost hyperechoic layer. The former demonstrates pulling up the top of the layer at first and then thinning later as carcinoma invasion progresses showing enlargement of the deep hypoechoic area. The latter shows thinning of the layer from beginning to end.

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We report a case of submucous tumor treated using laparoscopic ultrasound. The patient, a 38-year-old female who had undergone hysteroscopic surgery for submucous myomas twice in the past, visited us complaining of hypermenorrhea and dysmenorrhea. Vaginal ultrasound and magnetic resonance imaging (MRI) showed a submucous tumor about 6cm in diameter and an adenomyosis lesion in the uterus. We planned laparoscopic surgery assisted by laparoscopic ultrasound, and carried it out successfully. The laparoscopic ultrasound visualized the adenomyoma and adenomyosis and helped us perform a safe and complete operation.

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