bluuebunny/crossref_metadata_2025 huggingface dataset:
DIFFERENT CLINICAL FEATURES OF AORTIC INTRAMURAL HEMATOMA VERSUS DISSECTION INVOLVING THE DESCENDING THORACIC AORTA
Authors: Mariano F. , Pablo O. , Vicente C. , Alberto D. , Daniel B. , Rodolfo. P.
Published: February 2004

Background: Although indicators of surgical and medical treatment have been applied to patients with typical dissection (AD) of the descending thoracic aorta, the natural history of descending aortic intramural hematoma (AIH) is not yet clearly known.

Objective: The goal of this study was to test the hypothesis that the absence of flow communication through the intimal tear in AIH involving the descending aorta has a different clinical course compared with AD.

Methods: We prospectively evaluated clinical and echocardiographic data between AD (76 patients) and AIH (27 patients) of the descending thoracic aorta.

Results: Patients had no differences In age, gender, or clinical presentation. The development of pleural effussion or periaortic hematoma was more frequent in patients with AIH than it was in patients with AD. AIH and AD had same predictors of complications at follow‐up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Although medical treatment was selected in the same proportion between groups, surgical treatment was more frequently selected in AD (39% vs. 22%, p < 0.01). AD patients who received surgical treatment had higher mortality than those with AIH (36% vs. 17%, p < 0.01). There was no difference in mortality between patients who received medical treatment (15% in AD vs 14% in AIH, p = 0.7). In follow‐up imaging studies of 23 patients with AIH,6 patients (25%) showed complete resolution and 6 patients (25%) increased the descending aortic diameter. Typical AD developed in 3 patients (13%). A three‐year survival rate did not show significant difference (82 ± 6% in AIH vs 75 ± 7% in AD, p = 0.37).

Conclusion: AIH of the descending thoracic aorta have relatively frequent complications at follow‐up including dissection and aneurysm formation. Medical treatment with very close imaging follow‐up and timed elective surgery in cases with complications allow better management for patients with AIH of the descending thoracic aorta.
QUANTIFICATION OF REGIONAL MYOCARDIAL FUNCTION: IMPROVED DETECTION OF MYOCARDIAL ISCHEMIA IN DIABETIC PATIENTS DURING DOBUTAMINE DOPPLER MYOCARDIAL IMAGING ECHOCARDIOGRAPHY
Authors: Ilic S. , Ilic M.D. , Petrovic D. , Bosiljka T.V. , Ljubisa. N.
Published: February 2004

The aim of the study was to evaluate the value of pulsed wave Doppler myocardial imaging (PW DMI) in detecting myocardial ischemia (mi) during dobutamine stress echocardiography (DSE) in diabetic patients.

Methods: We studied 40 diabetic patients with known or suspected coronary artery disease. In all patients DSE (from 5 up to 40 mcg/kg/min infused in 3‐minute stages, plus atropine 1 mg if needed) was performed. DSE identified ischemia by the occurrence of wall motion abnormalities (WMA) with stress (positive DSE). Apical views were used to assess myocardial velocities (mv; Acuson‐ Sequoia, PW DMI) on baseline and at peak stres. The left ventricle was divided into 11 segments. The sample volume was placed in each adequately visualized segment and in each segment we measured peak mv of systolic (S), early (E), and late (A) diastolic waves and calculated their ratio (E/A) as an index of regional diastolic function.

Results: Myocardial velocities were measured in 374 (85%) of 440 possible myocardial segments. During DSE in 21 (52.5%) patients WMA were detected in 73 (37%) of 197 adequately visualized segments, while in 19 (47.5%) patients WMA did not appear. Of 21 patients with DSE‐provoked WMA, in 9 (42.9%) patients symptomatic and in 12 (57.1%) patients silent mi appeared. In segments with DSE‐provoked symptomatic and silent WMA the ratio of E/A decreased by 23.7% and 20.1% (p < 0.001 for both) and S decreased by 18.7% (p < 0.005) and 14.4% (p < 0.02) compared to baseline values. Of 301 segments without DSE‐induced WMA in 13 (4.3%) segments (6 in patients with positive and 7 segments in patients with negative DSE) we also found inversion of the E/A ratio (from 1.04 ± 0.08 to 0.94 ± 0.09, p < 0.005). In 288 other segments without WMA ratio E/A and S mv significantly increased (p < 0.001 for both).

Conclusion: Quantification of regional myocardial function during conventional DSE in diabetic patients showed that symptomatic as well as silent mi is associated with significant decrease of E/A ratio and S mv but changes are more pronounced in symptomatic mi. Inverted regional E/A ratio may uncover super‐silent mi, which is not sufficient to provoke WMA.
EFFECTS OF DOBUTAMINE ON TISSUE DOPPLER VELOCITIES IN PATIENTS WITH NORMAL WALL MOTION AT REST
Authors: Pariona M. , Mendoza A. , Rivara. G.
Published: February 2004

Background: Dobutamine stress echocardiography (DSE) is a well‐recognized test to diagnose myocardial ischemia; however, it depends on operator subjective evaluation: it has been reported that pulsed Tissue Doppler (PTD) velocities at the mitral annulus provide information of both left ventricular systolic and diastolic function; we therefore evaluated the effect of dobutamine (DOB) on PTD in search of markers of ischemia.

Methods: We prospectively studied 139 patients with normal wall motion (male: 54%; age: 65 ± 10 years) referred to a dobutamine stress echocardiography (DSE). Measurements were done at the lateral (L) and septal (S) annulus and included early diastolic filling velocity (Em), late diastolic filling velocity (Am), systolic velocity (Sm), and the ratio of early‐to‐late diastolic filling velocities (Em/Am).

Results: One hundred and six (76%) patients had a normal response to DOB and 33 (23%) had an ischemic response. The PTD differences between the patients with either normal or ischemic response,respectively,were: rest L Em 11.6 ± 3.1 vs. 12.± 3.8 (p = 0.1207), peak L Em 14 ± 3.9 vs. 12.7 ± 4 (p < 0.0206); rest S Em 9.6 ± 2.1 vs. 9.1 ± 2.6 (p < 0.4335), peak S Em 12 ± 4.6 vs. 10.7 ± 2.3 (p = 0.0473). Both S and L Sm were significantly different at rest and at peak. A trend to a more negative E/A ratio was found in both groups. PTD velocities (mean ± SD) are shown in table.

 Pulse Tissue Doppler Velocities at Rest and at Peak Stress

Normal
Ischemic
P Value

Rest lateral Em
11.6 ± 3.1
  12 ± 3.8
0.1207

Peak lateral Em
  14 ± 3.9
12.7 ± 4  
0.006 

Rest septal Em
 9.6 ± 2.1
 9.1 ± 2.6
0.4335

Peak septal Em
  12 ± 4.6
10.7 ± 2.3
0.0473

Rest lateral Sm
10.2 ± 2.4
8.73 ± 3.2
0.0139

Peak lateral Sm
21.9 ± 6.1
16.7 ± 5  
0.005 

Rest septal Sm
10.6 ± 2.6
 8.8 ± 4.7
0.0081

Peak septal Sm
21.5 ± 5 
16.7 ± 6.2
0.0183

Conclusion: Pulse tissue Doppler Em could be a useful marker of ischemic response during dobutamine stress echocardiography.
SAFETY OF STRESS ECHOCARDIOGRAPHY. THE RESULTS OF THE INTERNATIONAL STRESS ECHO COMPLICATION REGISTRY
Authors: Lowenstein J. , Varga A. , Rodriguez G.M.A. , Picano. E.
Published: February 2004

Background: The safety of any diagnostic test is a major issue in deciding its practicability and cost‐effectiveness.

Aim: To evaluate the safety of various stress echo modalities in the “real life” an international stress echo complication registry was started.

Methods: Up to January 2001, a simple written questionnaire was distributed to 300 echo laboratories known to perform stress echo. Of these 300, 71 echo laboratories were “responders” and reported on 85,997 examinations.

Results: Exercise was used in 26,295, dobutamine in 35,103, and dipyridamole in 24,599 cases. Life‐threatening events occurred in 86 patients: during exercise in 4 patients (event rate: 1/6,574), during dobutamine infusion (low dose for viability and/or high dose for ischemia) in 63 patients (event rate 1/557), and during dipyridamole stress test in 19 patients (event rate 1/1,294). Of the 86 patients with complications, 5 died during dobutamine stress test (ventricular fibrillation n=2 and cardiac rupture n = 3), and 1 following a dipyridamole test (uncontrollable hypotension).

Conclusion: Stress echocardiography is a safe method in the “real life,” as well, but dreadful complications may occur. Possibly due to preselection criteria, exercise seems safer than pharmacological stress and dipyridamole safer than dobutamine.
OVERWEIGHT IS NOT A LIMITATION FOR CORONARY FLOW MEASUREMENTS BY TRANSTHORACIC DOPPLER ECHOCARDIOGRAPHY
Authors: Lowenstein J. , Quiroz C. , Montaña. O.
Published: February 2004

Background: Coronary flow velocities (CFV) can be measured in the left anterior descending artery (LAD) by transthoracic Doppler echocardiography (TTDE), but many echocardiographers believe that obesity could be a limitation in determining it. The aim of our study was to investigate the feasibility of the measurements of CFV in the distal LAD by TTDE in an unselected population of overweight patients.

Methods: TTDE was performed in 1137 consecutive patients with a 4–7 MHz transducer, color map with a Nyquist scale average of 19.2 cm, without any contrast agent; 160 patients with a weight ≥100 kg, (mean 108.8 ± 9.7 kg, limits 100–150 kg) formed the study group (141 men ; mean age: 57.5 ± 9.8 years, mean body surface area of 2.25 ± 0.13 m2 (limits 1.91–2.64 m2). The baseline systolic velocity (BSV), basal diastolic maximal velocity (BDMV), and basal average diastolic velocity (BDAV) were measured in the distal LAD.

Results: An interpretable Doppler diastolic signal was obtained in 90.6% (145/160) of the determinations in patients ≥ 100 kg, vs. 91.7% (896/ 977) of patients with < 100 kg. (p = NS). The BDAV of the total group was 16.8 ± 5.4 cm/s and in the obese patients was 17.4 ± 4.7 cm/s (p = NS), a BSV was obtained in 82.5% of the total group and 88% in the obese patients (p = NS) The average performing time of all the studies was 1.4 ± 2.0 minute. The population of the 15 obese patients in which it was not feasible to determine Doppler recording of the BDV was significantly older (62.4 ± 7.9 vs 56.9 ± 9.8 years old, p < 0.03). the feasibility in patients ≥ 65 years was 83%, while in patients younger than 65 years it was 93% (p = NS); in patients with a very bad acoustic window there were 26.6% of nonfeasible studies versus 7.6% of patients with good or regular 2D images; gender, height, body surface area, left diastolic ventricular diameter, and mass index did not mark a difference between the feasible and the nonfeasible studies in overweight patients.

Conclusion: In daily practice, assessment of coronary flow velocity by transthoracic Doppler echocardiography of the left anterior descending coronary artery was highly feasible, independent of the body weight; only a very bad acoustic window and an age over 65 years could be considered a slight limitation in overweight patients.
PROGNOSTIC VALUE OF PACEMAKER STRESS ECHOCARDIOGRAPHY
Authors: Kudrle C. , Ferrari G. , Manuale O. , Ludueña C.E. , Figueroa G. , Estepo J. , Caceres M.C. , Gonzalez C. , Humphreys. J.D.
Published: February 2004

Background: Transesophageal atrial pacing echocardiography is an accurate test for detection of coronary artery disease (CAD). In the expanding population of patients with permanent pacemakers, a pacing stress test can be administered noninvasively by external programming of the pacemaker.

Objective: To establish the prognostic value of pacemaker stress echocardiography (PSE) to predict major adverse coronary events (MACE) in patients with suspected or known CAD. [MACE =CAD death, nonfatal myocardial infarction (MI), unstable angina (UA), or need of a myocardial revascularization procedure (MRP)].

Methods: From July 2000 to January 2003, 35 patients with a mean age of 73.9 ± 7 years with known or suspected CAD were consecutively submitted for PSE. Mean follow‐up was 12.8 ± 8 months. 31 patients (88.6%) with permanent implanted pacemakers (23 patients in DDD mode and 7 patients in VVI mode) underwent PSE by external programming and 4 patients (11.4%) had transesophageal atrial pacing performed. A 4‐stage protocol was used (base, 85%, 100% of maximum expected heart rate, and recovery), each lasting 3 minutes. Current medication was not discontinued. Patient features: men 19 (54.3%), hypertension 20 (57.1%), hypercholesterolemia 15 (42.9%), smoking 11 (31,4%), diabetes 10 (26.6%), atrial fibrillation: 5 (14.3%), previous MI 7 (20%), previous CABG 3 (8.6%), previous PCI 3 (8.6%), normal LVEF 27 (77.1%).

Medical treatment: beta‐blockers 14 (40%), Ca‐antagonists 10 (28.6%), nitrates 1 (2.9%), ACE‐I/ARBS 11 (31.4%), aspirin 18 (51.4%), diuretics 5 (14.3%).

Results: Ischemic PSE: 12 p (34,3%); High‐risk 1 patients (2.9%), intermediate‐risk 5 patients (14.3%), low‐risk 6 patients (17.1%). MACE: PCI: 1 patients (2.9%), non fatal MI: 1 patients (2.9%); CAD death and UA: 0 patients (0%). The negative predictive value (PV) of a non‐ischemic PSE was 95% and the positive PV of an ischemic PSE was only 8.3%.

 MACE:
 MACE (+)
 MACE (−)
 PV
Non‐ischemic  PSE(12p)
 1

11
Neg.PV
Ischemic
1
22
Pos.PV

 95%
 PSE(23p)

 8.3%

Conclusion: In this small cohort of patients with suspected or known CAD, a nonischemic PSE has a high negative PV.
DETECTION OF MYOCARDIAL VIABILITY USING DOBUTAMINE STRESS ECHOCARDIOGRAPHY AND MYOCARDIAL CONTRAST AFTER ACUTE MYOCARDIAL INFARCTION
Authors: Sbano J.C. , Tsutsui J.M. , Abreu E. , Nicolau J.C. , Meneghetti J. , Andrade J.L. , Mathias. W.
Published: February 2004

Background: Both low‐dose dobutamine stress echocardiography (LDDE) and myocardial contrast echocardiography (MCE) are capable of identifying myocardial viability by different means. However, it is not well known which of them is more accurate in the setting of AMI.

Objective: We evaluated the diagnostic value of LDDE and MCE using second harmonic with and without intermittent imaging in the detection of myocardial viability after acute myocardial infarction (AMI) treated with successful thrombolysis.

Methods: We studied 50 patients in the first week after AMI, at rest with LDDE, with and without MCE. We evaluated the recovery of left ventricular ejection fraction (LVEF) at rest by two‐dimensional echocardiography as well as by myocardial scintigraphy (Gated Spect), between the fourth and sixth month of follow‐up. According to an absolute 5% increase in LVEF measured by the two Gated Spect studies, pts were divided in group I, with functional recovery (19 patients) and group II, without functional recovery (31 patients). To analyze the contractility and myocardial perfusion, we used a left ventricular wall motion score index and myocardial perfusion score index at rest and during dobutamine. Myocardial viability was defined by LDDE as an improvement segmental wall motion at least one grade in two or more contiguous infarct zones segments at any stage of dobutamine infusion and by MCE as myocardial perfusion grade 1 or 2 at least in one infarct segment, at any stage of the study.

Results: Group 1 had a total of 103 dysfunctioning infarct‐related segments. LDDE revealed the myocardial viability in 61 segments while MCE demonstrated perfusion grade 1 or 2 in 79 of them. In group 2, of 173 dysfunctioning infarct‐related segments, viable myocardium was detected in 23 segments by LDDE and 98 segments by MCE. Only two of 99 segments without viability showed recovery of function at follow‐up. The overall results patient by patient of LDDE in order to predict the LVEF recovery, sensitivity was 95%, specificity 87%, positive predictive value 82%, negative predictive value 96% and diagnostic accuracy 90% (κ= 0.794). When we analyzed the overall results patient by patient of MCE, we demonstrated a sensitivity of 95%, specificity of 52%, positive predictive value of 54%, negative predictive value of 94%, and diagnostic accuracy of 68% (κ= 0.479).

Conclusion: The detection of contractile reserve by the use of LDDE was accurate in predicting LVFR in patients after AMI treated with successful thrombolytic therapy, while MCE demonstrated high negative predictive value.
INCIDENCE OF VERRUCOUS VEGETATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS. THE ASSOCIATION WITH ANTIPHOSPHOLIPID ANTIBODIES
Authors: Moyssakis I. , Pantazopoulos N.J. , Tektonidou M. , Boki K. , Panagiotis M. , Votteas. V.
Published: February 2004

Background: Valvular heart disease is prevalent in systemic lupus erythematosus (SLE) and is a common cause of morbidity and mortality. Valvular thickening and verrucous valvular vegetations (Libman–Sacks) are the most common lesions. The purpose of this prospective study was to analyze the incidence of Libman–Sacks vegetations in patients with SLE.

Methods: Two hundred and seventeen consecutive patients (196 females, 21 males, aged 53 ± 11 years) with SLE were evaluated with M‐mode, 2D, and Doppler echocardiography. Libman–Sacks vegetations were defined as distinct localized masses of varying size and shape on the surface of the valve leaflets and exhibiting no independent motion. In 76 (35%) patients with SLE there were antiphospholipid antibodies (APL) present.

Results: Thirty‐two (14.7%) patients with SLE had Libman–Sacks vegetations and in 21 (65.6%) of them there was a presence of antiphospholipid antibodies. In 22 patients the location of the masses was in the mitral, in 9 in the aortic, and in 1 in the tricuspid valve, whereas in 4 cases in BOTH valves. Valvular regurgitation was the predominant lesion in 18 mitral, 9 aortic, and 1 tricuspid, but only 2 cases had severe mitral regurgitation. Valvular stenosis was detected in 5 cases. Three patients had severe mitral stenosis and one of them died, while in the other two patients mitral stenosis was reversed with treatment of the underlying disease. The remaining two cases had severe aortic stenosis but one of them, also having severe mitral regurgitation, died suddenly.

Conclusion: Our results show that Libman–Sacks vegetations are quite frequent in patients with SLE and are related to the presence of antiphospholipid antibodies. The most common lesion is valvular regurgitation and rarely valvular stenosis.
BILATERAL HOLODIASTOLIC REVERSAL FLOW IN COMMON CAROTID ARTERIES: A SIGN OF SEVERE AORTIC REGURGITATION
Authors: Glenny P. , Altamirano. C.
Published: February 2004

Precedents: Doppler echocardiography is an important tool in the quantification of aortic regurgitation (AR). No single echocardiographic technique is without limitations, and in clinical practice it is reasonable to use a combination of them to estimate the severity of AR.

Objectives: The aim of this study is to determine if the presence of bilateral holodiastolic reversal flow (BHRF) in the common carotid arteries can be used to assess the severity of AR, and if it can be evaluated with the same transducer used to perform the cardiac doppler. Material and method: BHRF and the severity of AR were evaluated prospectively in 77 patients with a cardiac Doppler and a Doppler study of the common carotid flow, both with a 2.5 MHz cardiac transducer. Among the 77 patients, 20 had no AR, in an other 20 it was mild, in 24 it was moderate and 13 had severe AR. The degree of AR was classified using color Doppler mapping of the depth of the regurgitant jet into the left ventricle, the color cross‐sectional area of the regurgitant jet relative to that of the left ventricular outflow tract (less than 25, less than 50, and greater than 50%), the slope of the spectral signal (less than 2, less than 4, and greater than 4 m/s2), and the detection of holodiastolic reversal flow in abdominal aorta. Carotid flow was easily detected in all 77 patients while abdominal aortic flow was not clearly defined in 5 patients (due to obesity and presence of gas). Carotid BHRF was detected in 10 of the 13 patients with severe AR and in none of the 64 patients with no, mild, or moderate AR (sensibility: 77% and specificity: 100%).

Conclusions: The finding of BHRF in the common carotid arteries may be a very helpful sign of severe AR; it can be easily evaluated with the cardiac transducer and it is not time consuming.
CARDIAC FUNCTION BY STRAIN IMAGING: KEY TO THE INCREASED PERFORMANCE CAPACITIES OF ENDURANCE‐TRAINED ATHLETES
Authors: Claessens P. , Claessens C. , Claessens M. , Claessens M. , Claessens. J.
Published: February 2004

Background: To increase the performance capacity of a triathlete (Tri), a variety of adaptations are necessary. The heart is the central and the most important limiting factor. The structural heart adaptations in Tri have important repercussion on cardiac function. The left ventricular diastole shows specific characteristics that determine performance capacity.

Methods: 40 male Tri were compared with 31 active male controls and with 112 patients with ischemic heart disease. All subjects underwent tissue Doppler and strain imaging.

Results: The late diastolic filling period in Tri has specific characteristics. Tissue imaging demonstrated in Tri specific characteristics of both the late passive diastolic filling period and the early active diastolic relaxation period. The significant differences between the three groups concerning the strain values at the basal and the mid septum in the longitudinal axis by aortic valve closure and by mitral valve opening were extremely striking. The values of the end‐diastolic strain by the end of the a‐wave: negative in Tri, near‐zero in normal controls, and marked positive in coronary patients were fascinating (fig. 1).

Conclusions: The marked negative end‐diastolic strain in Tri can be explained by an increased muscular tone after a rapid and almost complete early diastolic filling of the left ventricle. This increased muscular tone is caused by an increase in the sarcomere length and by an increase in the number of actin‐myosin cross‐bridge interactions. These specific systolic and especially supernormal diastolic properties of the left ventricle with an increased diastolic reserve, enhance the aerobic capacities, resulting in an increased performance capacity.
AORTIC VALVE AREA CAN DETERMINE MYOCARDIAL CONTRACTILE DETERIORATION IN SEVERE AORTIC STENOSIS: STUDY WITH TISSUE DOPPLER
Authors: Obregón R. , Garcia E. , Riera J.S. , Cayre. R.
Published: February 2004

Introduction: After‐load increase in aortic stenosis does not alter the left ventricular ejection fraction (LVEF), even in advanced stages of the illness. We analyzed the ventricular long‐axis velocities and amplitude using tissue Doppler (TD) imaging of the mitral annulus, as this perhaps provides a more sensitive index of systolic function than LVEF.

Objectives: (1) To evaluate the left ventricular function in patients with chronically high afterload and (2) determine the effective aortic valve area able to produce changes in left ventricular contractility.

Methods: We studied 111 subjects, mean age 68.7 years (range 29–90 years). Of these, 106 (88%) had a valvular area smaller that 1 cm2, and there were 18 age‐matched normal controls (mean age 63.9 years, range 71–81 years) representing the control group (C). The Doppler sample volume was placed at the lateral and septal margins of the mitral annulus. We measured the peak of the systolic apically directed (S‐wave), early diastolic (E), and late diastolic (A) myocardial velocities, the isovolumetric relaxation time (IVRT), and isovolumetric contraction time (IVCT). Patients were classified in groups representing valvular areas 1.1–1.5 cm2 (Group 1, n = 13), 0.71–1 cm2 (Group 2, n = 42),: and <0.7 cm2 (Group 3, n = 64).

Statistics: Data are expressed as mean (SD). Group data were compared using the unpaired Student's t test or analysis of variance (ANOVA) with Fisher's PLSD test where appropriate. Linear regression analysis was used (stepwise) to compare continuous variables. A probability value of p < 0.05 was considered significant.

Results: The only significant difference observed among groups C and 1 was an increase in the time of ventricular relaxation (103 ± 22 vs.137 ± 35, p < 0.003). Group 2 had a significantly smaller S‐wave than group 1 (5.71 ± 1.15 vs. 6.9 ± 0.91, p < 0.001). Group 3 had significantly smaller A‐wave (6.45 ± 2.5 vs. 8 ± 2.1, p < 0.002), and S‐wave (5.06 ± 1.02 vs. 5.71 ± 1.15, p < 0.005) velocities than group 2, as well as a significant increase in the E/A ratio compared to group 2 (1.00 ± 0.62 vs. 0.74 ± 0.35, p < 0.018). In the regression analysis, we observed a moderate direct relationship between the aortic area and the S‐wave of the TD (r = 0.49, p < 0.0001). LVEF diminished significantly more in group 3 than in group 2 (56 ± 16 vs. 63 ± 15, p < 0.015) but were within normal values.

Conclusions: (1) AS first deteriorates the left ventricular diastolic function, prolonging the IVRT. (2) Left ventricular contraction (S‐wave) deteriorates when the aortic valve area decreases below 1 cm2, and this deterioration has a direct relationship with aortic valve area. LVEF decreases when the valvular area is smaller than 1 cm2, but remains inside what is considered normal values.
COMPLEMENTARY VALUE OF TRANSTHORACIC ECHOCARDIOGRAPHY AND CINEFLUOROSCOPIC EVALUATION OF MECHANICAL HEART PROSTHETIC VALVES
Authors: Cianciulli T.F. , Lax J.A. , Cerruti F.E. , Gigena G.E. , Redruello H.J. , Orsi M.A. , Gagliardi J.A. , Dorelle A.N. , Riccitelli M.A. , Prezioso. H.A.
Published: February 2004

Many different mechanical heart valve prostheses (MVP) are used but in most of the cases transthoracic echocardiography (TTE) cannot recognize the type and the information obtained from the patients about the implanted prostheses is incomplete or lacking.

Objective: (1) To compare TTE transprosthetic gradients with cinefluoroscopic (F) prosthetic disc opening angles, and (2) To determine F utility in MVP dysfunction diagnosis.

Methods: 100 MVP implanted in 84 patients (47 men and 37 female; mean age 59 ± 17 y/o, 63 in sinus rhythm) were prospectively evaluated with F; 68 had aortic and 32 mitral.

Results: TTE was not useful in identifing the type of prosthesis, but F was successful in all cases. F could not obtain the “in profile projection” (with the radiographic beam parallel to both the valve ring plane and the tilting axis of leaflets) in 15% aortic and 30% mitral valve prostheses. F identified Tri‐Technologies and HP‐Biplus prostheses, but no functional data were obtained due to disc radiopacity absence. In aortic valve prostheses, the opening angle was 53 ± 17°, the maximal and mean pressure gradients were 27 ± 14 mmHg, and the correlation gradient‐opening angles was r =−0.73 (95% CI, −0.85 to −0.53) p < 0.0001. In mitral valve prostheses the opening angle was 56 ± 24°, the effective orifice area was 1.43 ± 0.52 cm2 and the correlations effective orifice area‐opening angles was: r =−0.74 (95% CI 0.21 to 0.93) p < 0.001).

Conclusions: (1) Fluoroscopy is a low‐cost, quick, and simple noninvasive procedure that permits distinguishing between normal and dysfunctioning MVP. (2) With adequate orientation of the X‐ray film, fluorosocpy measured the complete opening of the prosthetic valve, indicating free motion of the tilting disc and allowed distinguishing between normal and dysfunctioning MVP. (3) When TTE detected high gradients with fluoroscopic normal motion of the disc, prosthetic–patient mismatch is diagnosed. (4) Fluorosocpy is superior to TTE for identifing the motion of the disc; nonetheless, both techniques should be considered complementary and not exclusive.
ECHOCARDIOGRAPHIC QUANTIFICATION OF RIGHT VENTRICULAR FUNCTION IN THE LATE FOLLOW‐UP OF SENNING PROCEDURE
Authors: Morhy S. , Soares A. , Ribeiro Z. , Wilberg T. , Bustamante L. , Parga J. , Atik E. , Lopes A. , Mathias, Jr. W. , Andrade. J.
Published: February 2004

Background: Deteriorating ventricular function is a major concern after Senning operation. Echocardiographic assessment of right ventricular (RV) function is limited because of the complex geometry of this ventricle. A myocardial performance index (MPI) that is a Doppler‐derived nongeometric measurement has been reported in adults and children. Because this index is independent of geometry it may be particularly useful in the evaluation of the RV function. The aims of this study were: (1)‐ to prospectively determine normal values for RVMPI in patients in the late follow‐up of Senning procedure; (2)‐ to correlate the ejection fraction (EF) and dP/dt measured by echocardiography (ECHO) with the EF measured by magnetic resonance imaging (MRI).

Methods: From August 1999 to March 2003, 44 patients submitted to Senning procedure were prospectively studied by echo and MRI. Mean age was 16.7 years (12–26 years). Mean postoperative period was 15.3 years (10–23.5 years). Forty‐one patients were in NYHA Class I, and 3. The RVMPI was calculated using PW Doppler from tricuspid inflow and aortic outflow, the EF by the modified Simpson's rule, and the dP/dt by CW Doppler tricuspid regurgitation signal. All patients underwent MRI and Echo within one month. The Echo results were compared to RV EF calculated by MRI.

Results: RVMPI ranged from 0.16 to 1.42 (mean = 0.50). The EF calculated by echo ranged from 6% to 63% (mean = 39%). Th dP/dt was calculated in 29 raging from 457 to 3213 mmHg/s (mean = 1398 mmHg/s). By MRI the EF ranged from 16% to 85% (mean = 60%). A cut‐off value of 0.47 for the RVMPI was determined (ROC curve), with a sensitivity of 75% and a specificity of 62.5%. There was no correlation between the EF and dP/dt calculated by ECHO and the EF calculated by MRI (R2= 0.29 and 0.04 respectively). The NYHA functional classes of the patients did not correlate with RVMPI or MRI values (Kappa).

Conclusion: (1)‐Patients with normal RV function had RVMPI values <0.47, and this index could be useful in the evaluation of Senning procedure; (2)‐ no correlation between the EF and dP/dt calculated by ECHO and the EF calculated by MRI was found.
EVALUATION OF PULMONARY FLOW BY DOPPLER ECHOCARDIOGRAPHY AND SCINTIGRAPHY AFTER PERCUTANEOUS CLOSURE OF PATENT DUCTUS ARTERIOSUS
Authors: Soares A. , Andrade J. , Morhy S. , Soares, Jr. J. , Kajita L. , Mathias, Jr. W. , Lopes A. , Aiello. V.
Published: February 2004

Background: Most patients who submitted to percutaneous closure of a patent ductus arteriosus (PCPDA), show some degree of protrusion of the occlusive device into the left pulmonary artery (LPA). The purpose of this study is to assess the prevalence of coil protrusion, and whether it causes significant obstruction.

Methods: A study group (SG) of 70 patients was submitted to PCPDA with Gianturco coils (mean age: 8.6 years). Doppler Echocardiographic studies were performed, with a mean time follow‐up of 55 months. Coil and LPA were assessed by suprasternal, short‐axis, and high left parasternal views. LPA diameter was indexed to body surface area. A Doppler Index was calculated by the differences of the velocities from each pulmonary artery in relation to the pulmonary trunk, expressed in percentage (VD index). Pulmonary scintigraphy was performed using intravenous injection of 99 Tcm labeled macroaggregated albumin to evaluate lung perfusion. The diameters and disturbances in flow velocities by Doppler echocardiography of the pulmonary arteries were compared with lung perfusion by pulmonary scintigraphy. The same measurements were performed in a control group (CG) of 22 patients (normal or with minimal heart defects). VD Index values of the SG were compared with pulmonary scintigraphy values of the CG to establish normal and abnormal values. Mean time interval between the two studies was 81 days.

Results: In 66 patients (95%), the coil protruded into the LPA. Mean LPA diameter was 13mm (SG and CG). Mean VD Index was 22% in the SG and 1.7% in the CG. A cut‐off value of 50% for the VD Index was determined (ROC curve), with 100% sensibility and 98% of specificity. In 8 patients (11%) the VD Index was > 50%, with abnormal left pulmonary perfusion (LPP) in 7 patients. A significant correlation between the VD Index and LPP was demonstrated (R2= 65.19). To estimate the LPP by Doppler a regression equation was obtained: LPP = 47.8 − 0.09 × VD Index. The LPA diameter was compared between patients with VD Index > 50%, < 50%, and CG, with no statistically significant difference (p = 0.6).

Conclusion: Protrusion of the coil to LPA was frequently found. LPA diameters did not correlate with flow disturbances and reduced LPP. Patients showing blood flow acceleration >50% at the left pulmonary artery by Doppler have significantly lower values of lung perfusion.
DIAGNOSIS AND FOLLOW‐UP OF FETAL CARDIAC TUMORS
Authors: Marantz P. , Guerchicoff M. , Villa A. , Gutierrez A. , Elias D. , Fustiñana C. , Otaño. L.
Published: February 2004

Background: Cardiac tumors in childhood are rare, although they would probably appear with greater frequency in fetal life upon closer examination during obstetric ultrasound studies. Prevalence is approximately 0.13%, as reported by fetal echocardiographic studies. We sought to determine the prevalence and natural history of cardiac tumors in patients referred to our laboratory for fetal echocardiography (FE).

Methods: Between May 1998 and May 2003, five fetuses with cardiac tumors have been sent to FE out of 8,589 obstetric echographic studies. Gestational age varied from 20 to 34 weeks and maternal age from 19 to 38 years.

Results: Prevalence of fetal cardiac tumors was 5 out of 8,589 fetuses: 0.05% in the general population, and 5 of 66: 7.5% of congenital heart disease. Two patients presented with multiple rhabdomyomas in the left venticle (LV), interventricular septum (IVS), and left ventricular outlet; they also had tuberous sclerosis (TS) with intracerebral tumors detected by magnetic resonance imaging (MRI) and cardiac tumors regressed during the first year of life and were asymptomatic. Another fetus with a single tumor with a rhabdomyoma echocardiographic appearance with attachment at the IVS and with a 50‐mmHg LV outlet gradient did well in postpartum, and at 5 months of life the mass became smaller and the gradient decreased to 35 mmHg. One patient with a large LV mass, which in the echo appeared as fibroma, required early surgery at 10 days; the tumor was almost completely resected, and 4 years later the small residual mass has not grown. Histopathological exams revealed cardiac fibrosarcoma. The last fetus, with a single intraseptal tumor, which also appeared as a large fibroma in the echo and that had increased in size after birth, died at 7 months with low cardiac output. MRI did not identify brain tumors. Autopsy was not authorized by the parents. All the prenatal diagnoses were confirmed after birth.

Conclusions: (1) Prevalence of fetal cardiac tumors in our hospital was 0.05% and represented 7.5% of congenital heart disease in a 5‐year period; (2) the majority were rhabdomyomas with spontaneous regression after birth; (3) multiple rhabdomyomas were associated with TS; (4) no deaths occurred during fetal life in this series, one died at 7 months due to progresive invasion of the LV cavity and another patient required surgery to relieve the obstruction; (5) fetal echocardiography permits an accurate diagnosis, which allows for pregnancy follow‐up and parental counselling.
IS IT POSSIBLE TO PREDICT THE SEVERITY OF AORTIC REGURGITATION IN A POST‐VALVULOPLASTY PROCEDURE THROUGH KNOWLEDGE OF AORTIC ANATOMY BY ECHO?
Authors: De Dios Ana Maria S. , Flores E. , Fischman E. , Zarlenga B. , Granja M. , Trentacoste L. , Orence V. , Barboza J. , Kreutzer. E.
Published: February 2004

Objectives: To determinate if it is possible to predict the severity of aortic regurgitation before balloon aortic valvuloplasty through knowledge of aortic anatomy by echo.

Background: Twenty patients with severe aortic stenosis were evaluated by echocardiography (echo), before and after the balloon aortic valvuloplasty (BAV) procedure. Two clearly distinct types of bicuspid aorta were found: with vertical and horizontal closing. Those with the vertical closing had a significantly greater severity of aortic regurgitation than those with horizontal closings.

Methodology: Before and after the BAV procedure there were recordings in 20 patients with severe aortic stenosis. At the time of the valvuloplasty procedure (BAV), the patients ranged in age from 3 days to 19 years (mean 3.3 years ± 5). Transthoracic parasternal long‐ and short‐axis views at the level of the aortic valve were used to determine cusp fusion site, and aortic regurgitation was graded using pulsed or colored Doppler or both. Criteria of regurgitation were: light (detectable jet adjacent to the valve or narrow jet of low amplitude detected near the aortic valve), moderate (easily detected, moderate amplitude jet associated with left ventricular dilatation), and severe (wide and easily detected high amplitude jet with marked left ventricular enlargement). We found two clearly distinct types of bicuspid aorta: those that had fusion of the right and noncoronary cusp (showed vertical closings in previous echo), and those with fusion of left and right coronary cusps (showed horizontal closings).

Statistical Analysis: Statistical significance p < 0.05.

Results: Of twenty patients with severe aortic stenosis, with an average age of 4.5 ± 5 (range: 3–19 years) at the time of BAV was effective in 18, with a mean gradient of 87 ± 12 pre‐BAV / 30 ± 11 post‐BAV. Of the 20 patients with aortic BAV, 15 had horizontal closings in the previous echo, and 5 had vertical closings. Of the 15 with horizontal closings, 14 had light regurgitation. Only one patient had early moderate regurgitation and two more had moderate regurgitation later on, at 4.5 and 16 years. No patient, except the patient with early moderate regurgitation, had severe regurgitation; only in one patient BAV was not effective. While there were 5 patients with vertical closing, 4 with effective BAV had early moderate‐to‐severe regurgitation in immediate post‐procedure, 1/5 was no effective.

Conclusion: A light post‐procedure insufficiency may be expected in a bicuspid aorta with horizontal closing post aortic valvuloplasty (14/15). We also expected an efficient procedure in the reduction of the aortic stenosis (14/15). A significative aortic regurgitation may be expected in a bicuspid aorta with vertical closing post BAV (4/4).
FOLLOW‐UP IN CLOSING OF ATRIAL SEPTAL DEFECT BY CATHETERISM WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) GUIDANCE
Authors: De Dios Ana Maria S. , Granja M. , Damsky Barbosa J. , Trentacoste L. , Zarlenga B. , Kreutzer E. , Ackerman J. , Fischman E. , Flores E. , Orence. V.
Published: February 2004

Background: Follow‐up in closing atrial septal defects (ASD) by transcatheter device, with TEE guidance.

Methodology: In 137 patients with ASD ostium secundum (os) the mean (X) age of the patients was 8.78 years (range from 2 to 50 years). 120 patients with isolated defects, 12 with other small ASDs, 2 with fenestrated ASDs (fASD),1 patients had patent ductus arteriosus, 2 had ventricular Septal Defects (VSD). Following a routine hemodynamic evaluation in the catheter laboratory a TEE was conducted to measure in millimeters the location and size of the defect, as well as the distance from the defect to the upper pulmonary vein (upv), the tricuspid (TV) and mitral (MV) valves, and the superior (SVC) and inferior (IVC) cava veins. The residual shunt as well as complications were evaluated.

Statistical Analysis: Statistical significance p < 0.05.

Results: The ASD measured by TEE in short axis: X: 14.4 ± 4.53 mm (range: 7.4 ± 32), in 4‐chamber view: X: 14.77 ± 5 mm (range: 6.5–33), in sagittal, at level of cava veins: X: 17.49 ± 10,29 mm (range: 6.5–38); balloon sizing: 18.3 ± 5.39 mm (range: 10–38); mean size of the device: 18.11 ± 5.57 mm (range 10–38). The distance from the upper edge to the upper pulmonary vein (upv): X: 9.11 ± 2.44 mm (range: 5.3–15); to tricuspid valve (T.V): X: 13.35 ± 3.17 mm (range: 6.5–19), mitral valve (M.V): X: 11.26 ± 2.36 (range: 7–14.4), left superior vena cava (SVC): X: 11.21 ± 2.83 mm (range: 6.2–16.9) and inferior vena cava (IVC): X: 10.21 ± 3.12 mm (range: 7–17.7). The Qp/Qs: 1.97 ± 0.45 (range: 1.25–3.5), pressure in RA: 5.79 ± 3 mmhg (range: 2–12), in LA: 7.42 ± 3.19 mmhg (range: 2–12); in RV: 33.82 ± 6.73 mmhg (24–50) and in pulmonary artery: 29.5 ± 5.92 mmhg (range 20–60), the wedge pressure X: 13.76 ± 3.92 mmhg (range: 9–25). The closure was effective in 137 of 134 cases (97.8 %); there were three embolizations: two defects with size in upper limit, and 1 accidental. These three were operated and the device was recovered, 1 died at 48 hours post‐surgery. Residual shunts were found in 16 patients: 12 trivial, 4 light. Four remained permeable to another small ASD (3mm); 1patient had progressive mitral regurgitation and required mitral replacement. Ten patients had arrhythmia (2 with complete branch block, 2 with second degree block, 3 with supraventricular arrythmia, and 1 with sinusal tachycardia).

Conclusion: Closure with the Amplatzer device was an effective procedure in 97.8% of the cases (137/134). During the procedure dangerous complications could take place (3 embolizations). The arrhythmias were not frequently in later evolution (10/137). Mortality was 0.72%. We still require further experience to be able to determine which procedure is best in each case.
ABSENCE OF CORRELATION BETWEEN QRS DURATION AND ECHOGRAPHIC PARAMETERS OF VENTRICULAR DESYNCHRONIZATION. CAN WE STILL TRUST THE ELECTROCARDIOGRAPHIC CRITERIA?
Authors: Cozma D. , Kalifa J. , Pescariu S. , Lighezan D. , Ionac A. , Deharo J.C. , Djiane P. , Dragulescu. S.I.
Published: February 2004

Background: Identification of the responder candidates for multisite pacing is still difficult and severe heart failure, dilated left ventricle with reduced ejection fraction, prolonged QRS with left bundle branch block (LBBB) are still considered the principal indicators of ventricular desynchronization. The aim of the study was to assess if echographic ventricular desynchronization parameters measured in patients with dilated cardiomyopathy and severe heart failure are correlated with the duration of the QRS on surface electrocardiogram.

Methods: This study included 51 patients aged 58.8 ± 7.4 years with idiopathic DCM. The following parameters were measured: QRS duration; effective contraction time (ECT) measured as the interval between QRS onset and closure of aortic valve, interventricular delay (IVD) measured as the time between onset of aortic and pulmonary flow, left ventricular mechanical delay (LVD) as the time from maximal interventricular septum contraction and posterior wall contraction, posterior (P), lateral (L), and posterolateral (PL) wall delays, as the time from QRS onset to maximal wall contraction. Regional post‐systolic contraction was defined in a given wall as the difference (contraction delay − ECT)> 50 ms.

Results: 29 patients presented complete LBBB, 22 patients had QRS duration < 120 ms. 39 patients had a post‐systolic contraction of the PL wall (32 patients of the L wall and 26 patients of the P wall). 16 patients with QRS duration <120 had a post‐systolic contraction of the PL wall (as for the LBBB the rest of 39 patients). In 40 patients the sequence of regional ventricular contraction was: P‐L‐PL wall (16 patients with QRS < 120). LVD was > 100 ms in 36 patients (26 patients with LBBB and 10 with QRS < 120). 27 patients with LBBB and 6 with QRS < 120 ms presented IVD > 30 ms. There was no correlation between the QRS duration and the parameters listed above.

Conclusions: In a population of patients with severe heart failure and dilated cardiomyopathy there is no correlation between the duration of the QRS and echocardiographic parameters of ventricular desynchronization. These results show that mechanical ventricular desynchronization can be observed in patients with a QRS duration < 120 ms. Further studies are needed to evaluate if this population could beneficiate of multisite pacing therapy.
REDUCED SYSTOLIC PERFOMANCE BY TISSUE DOPPLER IN PATIENTS WITH PRESERVED AND ABNORMAL EJECTION FRACTION: NEW INSIGHTS IN CHRONIC HEART FAILURE
Authors: Garcia E. H. , Perna E. , Eduardo F. , Ricardo O. , Stella M. , Jorge P. , Marcelo A. , Ariel P. , Eduardo T. , Leonardo. R.
Published: February 2004

Background: Tissue Doppler imaging (TDI) is a new tool in the evaluation of the systolic and diastolic function. We sought to compare TDI findings in patients with chronic heart failure (CHF) due to systolic and diastolic dysfunction as well as to assess its usefulness for diagnosing diastolic CHF.

Methods and Results: One hundred and ten outpatients with CHF and 68 controls were prospectively included. Ejection fraction (EF) was obtained by two‐dimensional echocardiography and systolic and diastolic wall motion velocities were recorded for basal septum. Patients without CHF were classified as Group A (controls); those with CHF were classified according to EF in Group B1: > 45% and B2: £ 45%. In groups A, B1, and B2 the mean peak S was 7.74; 5.45 and 4.89 cm/sec (p < 0.001); the mean peak E was 8.56; 5.72, and 6.1 cm/sec (p < 0.001); and the mean A peak was 10.2; 7.3 and 5.3 cm/sec (p < 0.001). Control and CHF groups were different in all terms except E/A ratio (p = 0.001), the E peak and IVRT among groups with CHF were comparable (p = ns). The most useful parameters for identifying diastolic CHF were IVRT and S peak, with area under ROC curves of 0.93 and 0.89. The cut‐off of 115 msec for IVRT and 5.8 cm/sec for S peak showed a sensitivity of 94% and 97%, with a specificity of 82% and 73%, respectively.

 Parameter
Group A  (n = 68)
Group B1  (n = 37)
Group B2  (n = 73)
 p value

EF (%)
66.1 ± 7.9
  57 ± 7.8
28.8 ± 9.7
0.001

E peak
8.56 ± 2.4
5.72 ± 2.2
 6.1 ± 1.9
0.001

A peak
10.2 ± 1.9
 7.3 ± 2.9
 5.3 ± 2.8
0.001

S peak
7.74 ± 1.4
5.45 ± 1.6
4.89 ± 1.2
0.001

E/A ratio
0.87 ± 0.3
0.96 ± 0.6
 1.7 ± 1.5
0.001

IVTR
 98 ± 26
166 ± 38
153 ± 42
0.001

IVTC
 67 ± 18
110 ± 34
132 ± 47
0.001

Conclusion: TDI velocities were reduced in CHF compared with normal subjects, there were not differences among CHF with preserved or reduced EF in E peak and IVRT. In addition, the systolic velocity as well as IVRT were useful to diagnose CHF with preserved EF. These findings suggest that impairment of left ventricular systolic function is present even in those with diastolic heart failure, and that abnormalities may have an important role to identify that condition.
REGIONAL PULSED DOPPLERMYOCARDIAL MAPPING DURING EXERCISE ECHOCARDIOGRAPHY
Authors: Trivi M. , Kuschnir P. , Gimenez De Paz E. , Marcolongo G. , Lombardero M. , Lardani. H.
Published: February 2004

Background: Exercise effects on regional myocardial velocities have not been well described.

Objectives: To evaluate regional systolic and diastolic velocities by pulsed Doppler myocardial mapping during exercise echocardiogram in patients without apparent cardiac disease and to explore feasibility of regional tissue Doppler during exercise.

Methods: 49 consecutive patients (61 ± 10 years) without cardiovascular history who underwent 3 stages of supine bicycle exercise echocardiography were prospectively selected, if they showed normal wall motion at rest, during, and post‐submaximal exercise. Were excluded patients with a bad acoustic window and significant valvular or myocardial diseases. Maximal spectral Doppler velocities during systole and early diastole (within 3 minutes) were recorded at each stage in the basal third of the inferior, lateral and anterior walls and in the middle septum from the apical 2 and 4 chambers views.

Results: All patient performed regional tissue Doppler during exercise. See table. D: diastolic, S: systolic, Exer: exercise Incr: increase% from rest ″p < 0.05 compared with other segments; *p < 0.001 compared with rest.

cm/sec
Drest
Dexer
Incr%
Dpost
Incr%
Srest
Sexer
Incr%
Spost

Septal
 8.38
11.09
32
10.44
24
6.34
8.27
30
 8.61

Lateral
10.97
14.51
32
13.41
22
7.82
10.05 
28
10.36

Inferior
10.64
13.78
29
13.30
25
7.71
10.20 
32
10.30

Anterior
 9.79
10.04
43
12.88
32
6.92
9.70
40
10.59

Average
 9.94
 12.35*
34
 12.50*
26
7.19
 9.55*
32
  9.95*

Conclusion: Exercise increases diastolic and systolic myocardial Doppler velocities around 30% in all segments in patients without apparent cardiac disease. Post exercise there are no different to peak exercise velocities. Middle septal velocity is lower than the other basal segments. Regional tissue Doppler may be performed during exercise echocardiogram.