Background and Objective: The purpose of this study was to survey carotid ultrasonography practices at major institutions performing carotid ultrasonography, and to develop a procedure manual. Subjects and methods: A questionnaire survey of 61 institutions was conducted in May 2010, and basic parameters and procedures for carotid ultrasonography screening were formulated from the results. Results and Discussion: The results of the questionnaire indicated that the most emphasized parameter was max IMT. Parameters such as blood flow velocity and plaque properties, while considered essential, were not judged to be well reproduced. Based on these findings, a screening procedure divided into three stages was developed: A) essential parameters (CCA, bifurcation, ICA max IMT, CCA blood flow velocity, VA blood flow velocity, VA diameter); B) secondary essential parameters (CCA mean IMT, ED ratio of CCA, ICA blood flow velocity); and C) additional parameters (CCA diameter, ICA diameter, ECA blood flow velocity, right SCA IMT). Conclusion: With reference to this study and guidelines, examination procedures relevant to actual clinical practices were developed.

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Congenital quadricuspid aortic valve (QAV) is a very rare valvular malformation. We report four cases of congenital QAV with moderate to severe aortic regurgitation. All cases were accidentally diagnosed by echocardiography, and none of the patients complained of any symptoms related to valvular dysfunction. Three of the four cases had QAV with an accessory cusp smaller than the other three cusps, and the four cusps were the same size in one case. There are some morphologic classifications of QAV, but the prognostic differences in the morphology of QAV have not been clarified. However, careful echocardiographic observation of QAV is important, because it has been reported that the surgical management of QAV is affected by the position of the accessory cusp.

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A man in his 50s was admitted to our hospital for acute visual disturbance, headache, and vomiting while driving his car. Brain computed tomography imaging revealed multiple cerebral embolisms. Transthoracic and transesophageal echocardiography on admission showed an abnormal mass echo (18 mm in length) attached at the atrial side of the anterior mitral leaflet. The other characteristics of the mitral valve did not show valvular destruction findings, prolapse, or significant regurgitation. There were no inflammatory laboratory findings and blood culture was negative. During anti-coagulation therapy, however, the abnormal mass echo diminished on follow-up echocardiography, which indicated that the mass echo was nonbacterial thrombotic endocarditis (NBTE). Further examination performed to determine the underlying cause of NBTE showed no malignancy, autoimmune disease, or abnormal coagulation status. We herein report a rare case of NBTE without apparent clinical underlying disease, and discuss the usefulness of echocardiography in the diagnosis of this disease.

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This case is a 70-year-old woman. Two years ago, she underwent surgery for a primary ovarian tumor, which was diagnosed as an ovarian carcinoid tumor based on the pathological findings. Asymptomatic severe tricuspid regurgitation was observed at that time. No medication was prescribed. One month prior to admission, she started to take diuretics for leg edema, and she was admitted to our hospital because of anasarca. Echocardiogram on admission demonstrated severely thickened and shortened tricuspid and pulmonary valves with severe regurgitation. The mobility was restricted. The right atrium and the right ventricle were dilated. She underwent tricuspid valve replacement on the 30th hospital day because of intractable heart failure. After the surgery, the symptoms and activity level improved to the level of using a wheelchair. However, she passed away because of septic shock on the 39th hospital day. Autopsy showed highly thickened, shortened and hardened tricuspid valve leaves and subvalvular tissue. Mobility of the leaflets was highly reduced. The pulmonary valve had similar findings. Pathological examination revealed deposition of myofibroblasts, smooth muscle cells, and mucus substrate in leaflets of both valves, and this denaturalization was diagnosed as carcinoid heart disease. We have experienced an unfortunate case that progressed rapidly after the obvious symptoms appeared. Primary tricuspid regurgitation is irreversible, and it might deteriorate rapidly. We need to pay attention to any signs of the symptoms, and we need to consider surgery at an appropriate time.

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An 84-year-old woman was diagnosed with atrial septal defect (ASD) accompanied by multiple holes in 2007. In March 2015, she was admitted with congestive heart failure due to ASD. Surgical closure was recommended because her pulmonary to systemic flow ratio was 1.8, but she declined due to her advanced age. In August 2015, she developed acute inferior myocardial infarction, and coronary angiography showed an occluded proximal right coronary artery. Direct percutaneous coronary angioplasty was successfully performed. After the operation, her condition was stable, but she suddenly fell into refractory hypoxemia on the day after admission. Transthoracic echocardiogram showed acute right-to-left shunting through ASD. Although surgical closure was again recommended, her family asked for conservative medical treatment, not surgical treatment. She ultimately died in spite of medical treatment. Some case reports documented that right ventricular infarctions were complicated by refractory hypoxemia with right-to-left shunting through patent foramen ovale (PFO) or ASD. In the present case, various causes for the right-to-left shunting were considered, e.g., a shift in inferior vena cava flow associated with a stretched atrial septum or a shift in tricuspid regurgitation flow associated with a pacemaker lead. We report this case with a review of some of the literature on right-to-left shunting through PFO or ASD in inferior myocardial infraction.

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Breast cancers with intraductal components are usually evaluated by contrast-enhanced MRI, but contrast agents for MRI are contraindicated for persons with asthma and severe renal dysfunction. Sonazoid^®, an ultrasound contrast agent, has few side effects, and it can be used in patients with asthma and severe renal dysfunction. We report two cases of breast cancer in which contrast-enhanced ultrasonography (CEUS) was useful in diagnosing intraductal spread. These patients were unable to undergo contrast-enhanced CT/MRI due to asthma and severe renal dysfunction, but they could receive CEUS with no side effects. Case 1 was a 73-year-old woman. On mammography (MG), the tumor and segmental pleomorphic calcifications contiguous to the tumor were recognized, suggesting the presence of intraductal components. However, only the tumor could be detected on B-mode ultrasound. Case 2 was a 67-year-old woman. Segmental pleomorphic calcifications around the tumor were detected on MG, and low echoic regions leading to the tumor were recognized on B-mode ultrasound, indicating the presence of intraductal components. In both cases, CEUS showed streamed zonal enhancement leading to the tumor. On TIC, the intraductal components showed curves equal with their tumors. Based on the results of CEUS, breast-conserving surgery was selected in case 1 and breast removal was selected in case 2. Pathologically, the zonal enhancement regions leading to the tumor reflected intraductal components. CEUS could contribute to surgical planning.

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Thoracic outlet syndrome (TOS) is a complex of signs and symptoms caused by compression of the vital neurovascular structures at the thoracic outlet region. TOS is classified into three distinct subtypes based on the involved structure: neurogenic, arterial, and venous. Vascular TOS (arterial and venous) is a rare disease that accounts for only 5% of all TOS cases. Ultrasound examination can be performed very easily and quickly, and it can also be done during the hyperabduction maneuver. We report two cases where an ultrasound examination was useful in detecting these rare diseases. Case 1: A 59-year-old female who presented with pallor of the left upper limb on hyperabduction was diagnosed with arterial TOS after early detection by ultrasound examination. Case 2: A 31-year-old male who presented with progressive swelling of the right upper limb due to subclavian vein thrombosis successfully treated with anticoagulant therapy was diagnosed with venous TOS.

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