Abstract: OBJECTIVE: Beta-blockers are often cautiously prescribed to older heart failure diabetics because of the paucity of published data and their perceived unfavourable effects on glucose metabolism, in spite of the evidence of their effectiveness and safety in middle-aged diabetic patients. The aim of this study was to compare the safety, tolerability and efficacy of long-term administration of carvedilol in a group of elderly patients with chronic heart failure, with and without concomitant diabetes. METHODS: Two hundred and fifty-two patients aged > or =70 years with heart failure and left ventricular ejection fraction < or =40% were followed in specialised heart failure clinics. Diabetes was present in 29.7%. Carvedilol was associated with conventional optimised treatment in 64% of diabetics and 65% of non-diabetics (P = NS). RESULTS: At baseline, diabetics presented with a longer duration of symptoms, higher Charlson comorbidity index, more frequent renal dysfunction and smaller left ventricular volumes than non-diabetics. New York Heart Association functional class and ejection fraction were similar in the two groups. At 1-year follow-up, tolerability (93.7 vs. 92.2%) and mean daily dose (24 +/- 17 vs. 23 +/- 14 mg/day) of carvedilol were similar in diabetics and non-diabetics. No worsening of fasting glucose, glycosylated haemoglobin and creatinine levels as well as the incidence of deaths and hospitalisations was observed in diabetics treated with carvedilol. Similar improvements in New York Heart Association class and mitral regurgitation severity were observed in diabetic and non-diabetic patients taking carvedilol. Ejection fraction showed a significant improvement, more pronounced in non-diabetics than in diabetics (+10 vs. +7 points; improvement of at least 10 points: 15 vs. 36%, P = 0.03). CONCLUSIONS: Similarly to younger ones, also in older patients, diabetes does not negatively influence the safety, tolerability and efficacy of carvedilol. However, diabetes remains a strong prognostic factor limiting the reversibility of left ventricular systolic dysfunction and the effect of treatment on subsequent outcome.
Abstract: In a 60-year-old woman with episodic exertional faintness, a large left ventricular (LV) myxoma attached by a pedicle to the apical interventricular septum and prolapsing through the LV outflow tract and the aortic valve causing a severe obstruction was found by echocardiography. Early surgical excision was successfully performed using the transaortic approach.
Abstract: BACKGROUND: Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up. METHODS AND RESULTS: Twenty patients selected for the study (12 men and 8 women, mean age 60 +/- 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 +/- 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed. CONCLUSION: Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.
Abstract: OBJECTIVE: Elderly heart failure patients are at high risk of events. Available studies and systematic reviews suggest that elderly patients benefit from disease management programmes (DMPs). However, important questions remain open, including the optimal follow-up intensity and duration and whether such interventions are cost-effective during long-term follow-up and in different healthcare systems. The aim of this study was to determine the long-term efficacy of a hybrid DMP in consecutive older outpatients. METHODS: Intervention consisted in combined hospital-based (cardiologists and nurse-coordinators from two heart failure clinics) and home-based (patient's general practitioner visits) care. The components of the DMP were the following: discharge planning, education, therapy optimisation, improved communication, early attention to signs and symptoms. Intensive follow-up was based on scheduled hospital visits (starting within 14 days of discharge), nurse's phone call and home general practitioner visits. RESULTS: A group of 173 patients aged > or =70 years (mean age 77 +/- 6 years, 48% women) was randomly assigned to DMP (n = 86) or usual care (n = 87). At 2-year follow-up, a 36% reduction in all-cause death and heart failure hospital admissions was observed in DMP vs. usual care. All-cause and heart failure admissions as well as the length of hospital stay were also reduced. DMP patients reported, compared to baseline, significant improvements in functional status, quality of life and beta-blocker prescription rate. The intervention was cost-effective with a mean saving of euro 982.04 per patient enrolled. CONCLUSIONS: A hybrid DMP for elderly heart failure patients improves outcomes and is cost-effective over a long-term follow-up.
Abstract: OBJECTIVE: To compare the efficacy and safety of transoesophageal (TOC) vs. transthoracic (TTC) electrical cardioversion, both with biphasic shocks, for sinus rhythm (SR) restoration in patients with persistent atrial fibrillation (AF). METHODS: We randomised 210 patients (151 male, 59 female, mean age 66 +/- 9 years) with persistent AF into two groups: group 1 (n = 104) undergoing TOC with a step-up protocol of 30, 50, 70 and 100 J, and group 2 (n = 106) undergoing TTC with a step-up protocol of 70, 100, 120 and 150 J. RESULTS: The two groups were homogeneous as for clinical and instrumental characteristics, except for left ventricular ejection fraction (50.5 +/- 10% in group 1 vs. 53 +/- 8% in group 2, P < 0.05) and thoracic impedance (63 +/- 8 Omega in group 1 vs. 66 +/- 6 Omega in group 2, P < 0.005). SR was restored in 98 (94%) group 1 patients vs. 99 (93%) group 2 patients (P = NS). First shock was effective in 48 (46%) group 1 patients vs. 54 (51%) group 2 patients (P = NS). Mean delivered energy was 50.4 +/- 23.6 and 95.1 +/- 29.6 J; mean effective energy was 47.3 +/- 20.7 and 91.2 +/- 26.6 J in group 1 and group 2, respectively. Cross-over to the highest energy level was never effective. TOC tolerability was optimal (mean discomfort score 1.2 on a 1-4 grading scale). Markers of myocardial necrosis did not increase and no procedure-related complications occurred. On logistic regression analysis, the most predictive variables of unsuccessful cardioversion were AF duration (P = 0.0001) and low left atrial appendage emptying velocity (P = 0.02). CONCLUSIONS: Both TOC and TTC with biphasic shocks are effective and safe for SR restoration in patients with persistent AF; however, the considerably lower levels of delivered and effective energies for SR restoration allow TOC to be performed during mild sedation with optimal tolerability, thus avoiding general anaesthesia.
Abstract: BACKGROUND: The prosthesis used for aortic valve replacement in patients with small aortic root can be too small in relation to body size, thus showing high transvalvular gradients at rest and/or under stress conditions. This study was carried out to evaluate rest and Dobutamine stress echocardiography (DSE) hemodynamic response of 17-mm St. Jude Medical Regent (SJMR-17 mm) in relatively aged patients at mean 24 months follow-up. METHODS AND RESULTS: The study population consisted of 19 patients (2 men, 17 women, mean age 69.2 +/- 7.3 years). All patients underwent rest Doppler echocardiography before and after surgery and basal and DSE at follow up (infused at rate of 5 microg/Kg/min and increased by 5 microg/Kg/min at 5 min intervals up to 40 microg/Kg/min). The following parameters were evaluated at rest and/or under DSE: heart rate (HR), ejection fraction (EF), cardiac output (CO), peak and mean velocity and pressure gradients (MxV, MnV, MxPG, MnPG), effective orifice area (EOA), indexed EOA (EOAi), left ventricular mass (LVM), indexed LVM (LVMi), Velocity Time Integral at left ventricular outflow tract (VTI LVOT) and transvalvular (Aortic VTI), Doppler velocity index (DVI). At rest MxPG and MnPG were 29.2 +/- 7.1 and 16.6 +/- 5.8 mmHg, respectively; EOA and EOAi resulted 1.14 +/- 0.3 cm2 and 0.76 +/- 0.2 cm2/m2; DVI was normal (0.50 +/- 0.1). At follow-up LVM and LVMi decreased significantly from pre-operative value of 258 +/- 43 g and 157.4 +/- 27.7 g/m2 to 191 +/- 23.8 g and 114.5 +/- 10.6 g/m2, respectively. DSE increased significantly HR, CO, EF, MxGP (up to 83.4 +/- 2 1.9 mmHg), MnPG (up to 43.2 +/- 12.7 mmHg). EOA, EOAi, DVI increased insignificantly (from baseline up to 1.2 +/- 0.4 cm2, 0.75 +/- 0.3 cm2/m2 and 0.48 +/- 0.1 respectively). Two patients developed significant intraventricular gradients. CONCLUSION: These data show that SJMR 17-mm prostheses can be safely implanted in aortic position in relatively aged patients, offering a satisfactory hemodynamic performance at rest and under DSE, with full utilization of its available orifice, suggesting that a possible mild prosthesis-patient mismatch is not an issue of clinical relevance when this small prosthesis is used. Rest and Dobutamine stress echocardiography is a useful and effective means for evaluating prosthesis hemodynamics and for monitoring the expected LVH regression.
Abstract: OBJECTIVE: The aim of the present study was to define a method to pre-determine the correct size of neo-sinuses of Valsalva in the reimplantation type of valve-sparing aortic operation. METHODS: The objective was achieved in three steps: (1) evaluation in the healthy population, of the normal size of sinuses of Valsalva expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area; (2) elaboration of a normogram by which, given a known annular diameter, it is possible to select the appropriate graft size to obtain a normal beyond leaflets area; (3) validation of the normogram by comparing, in a population of 20 patients undergoing a valve-sparing procedure, the predicted and observed beyond leaflets area. RESULTS: The following values for beyond leaflets area were observed: mean normal 320.6+/-120.6mm(2), mean predicted 355+/-63.2mm(2), mean observed 364.7+/-72.8mm(2).No significant differences were obtained for predicted versus observed values. Regression analysis showed a linear distribution with an r value of 0.95. CONCLUSIONS: We proposed a simplified approach for sizing of the neo-aortic root in the reimplantation type of valve-sparing aortic operation focussed on the size of sinuses of Valsalva. Our normogram showed to be reliable in anticipating beyond leaflets area. It can be helpful in avoiding the selection of an undersized or excessively oversized graft.
Abstract: PURPOSE: To detect coronary artery stenoses, we compare breath-hold magnetic resonance coronary angiography (MRCA) to conventional coronary angiography (CA). MATERIALS AND METHODS: Sixty-five patients with suspected coronary artery disease underwent MRCA and CA within one week. MRCA examination was performed by using the two-dimensional (2D) breath-hold technique with a fast spoil gradient-echo sequence/spiral. Each imaging sequence was obtained within one breath-hold in expiration (14 seconds of apnoea). The assessment of coronary artery stenoses on magnetic resonance (MR) angiograms was independently performed by two blinded readers and compared to conventional CA images. RESULTS: Three hundred and ninety segments were evaluated by the two imaging techniques. MRCA correctly detected 76 of 88 (86%) stenoses, and recognized 242 of 302 (80%) not affected segments. The Pearson correlation coefficient between MRCA and CA in assessing coronary narrowings was very high: r = 0.85. Despite this the mean difference was 4.5 with a standard error of estimate of 0.21, indicating that MRCA slightly overestimates the degree of stenoses. CONCLUSIONS: Our study showed that 2D breath-hold MRCA is an accurate technique in displaying and quantifying the most significant stenoses in the proximal and middle segments of the coronary arteries.
Abstract: AIMS: The aim of the present study was to assess the relative prognostic value of clinical variables, the exercise electrocardiography test and the pharmacological stress echocardiography test either with dipyridamole or dobutamine early after a first uncomplicated acute myocardial infarction in a large, multicentre, prospective study. METHODS AND RESULTS: Seven hundred and fifty-nine in-hospital patients (age=56+/-10 years) with a recent and first clinical uncomplicated myocardial infarction, with baseline echocardiographic findings of satisfactory quality, an interpretable ECG and able to exercise underwent a resting 2D echocardiogram, a pharmacological stress test with either dipyridamole or dobutamine and an exercise electrocardiography test at a mean of 10 days from the infarction; they were followed-up for a median of 10 months. During the follow-up, there were 13 deaths, 23 non-fatal myocardial infarctions and 59 re-hospitalizations for unstable angina. When all spontaneous events were considered, with multivariate analysis, the difference between the wall motion score index at rest and peak stress (delta wall motion score index), and exercise duration were independent predictors of future spontaneous events (relative risk 7.2; 95% CI=2.73-19.1; P=0.000; relative risk 1.1, 95% CI=1.02-1.18; P=0.008, respectively). Kaplan-Meier survival estimates showed a better outcome for those patients with a negative pharmacological stress echocardiography test compared to patients with low dose positivity (94.7 vs 74.8%, P=0.000). CONCLUSION: Stress echocardiography tests provide stronger information than historical and exercise electrocardiography test variables. Pharmacological echocardiography as well as the exercise ECG is able to predict all spontaneously occurring events when the presence as well as the timing, severity, and extension of stress-induced wall motion abnormalities are considered.
Abstract: BACKGROUND: Late cardiac events after non-cardiac major vascular surgery are an important cause of morbidity and mortality. The aim of the present study was to assess the value of a preoperative dipyridamole echocardiography test (up to 0.84 mg/kg over 10 min) in predicting late cardiac events in survivors of major non-cardiac vascular surgery. DESIGN: Large-scale, multicenter, prospective, observational study design. METHODS: Two hundred and seventy-six patients (mean age 66 +/- 9 years) were studied prior to vascular surgery by dipyridamole stress echocardiography in four different centres. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. All underwent dipyridamole stress echocardiography according to standard high-dose protocol. RESULTS: No major complications occurred during dipyridamole stress echocardiography. Sixty-three patients (23%) had a positive test. Patients were followed up for a median of 20 months. Cardiac events occurred in 43 patients (16%): five deaths, 18 myocardial infarctions and 20 cases of unstable angina. The difference between wall-motion score index (WMSI) at rest and peak stress (delta WMSI), using multivariate analysis, was an independent predictor of late cardiac death. CONCLUSION: Dipyridamole stress echocardiography performed before major vascular surgery identifies patients at high risk for late cardiac events. Stress echocardiographic parameters outperformed clinical variables in the long-term risk stratification in this set of patients.
Abstract: BACKGROUND: In the present study, the safety and diagnostic accuracy of a modified protocol with accelerated high-dose dipyridamole-atropine stress echocardiography, utilized in an attempt to significantly shorten the test imaging time with respect to the standard protocol, were evaluated. METHODS: Three hundred and thirty-seven patients (231 men, 106 women, mean age 63 +/- 9 years) with known or suspected coronary artery disease underwent 404 tests. The ECG and blood pressure were continuously monitored during constant infusion of 0.21 mg/kg/min of dipyridamole over 4 min; atropine (0.50 mg at 5 and 6 min) was given in order to reach > or = 85% of the age-predicated heart rate. The wall motion score index and the 16-segment model were used to evaluate contractility. Eighty-nine patients underwent selective coronary angiography. Coronary artery stenosis was considered significant if the vessel diameter was < 50% of the normal value. RESULTS: Eight-eight out of 404 tests were positive: 72 for echocardiographic criteria, 11 for ECG criteria, 2 for clinical symptoms, and 3 for combined criteria. Three hundred and sixteen tests were negative. In 303 tests atropine was administered and 380 tests were performed in pharmacological wash-out. The maximal heart rate was 105.8 +/- 9 b/min and the maximal blood pressure was 128 +/- 19/78 +/- 9 mmHg. No major side effects nor life-threatening complications were observed. In 24 tests (5.9%) only minor side effects occurred and in no case did these effects cause premature suspension of the test. The sensitivity, specificity and diagnostic accuracy of angiographically assessed coronary artery disease were 56, 86 and 73% respectively. CONCLUSIONS: Accelerated high-dose dipyridamole echocardiography is practical, feasible and safe and allows for a significant reduction in the imaging time, with an increased cost-effectiveness and tolerance of the patients. In our experience the diagnostic accuracy of this new protocol was quite good and similar to that of the standard test.
Abstract: BACKGROUND: While syncope is generally considered a frequent finding in clinical practice, no clear epidemiological evidence is available about the relevance of such an event in the general population of Italy. METHODS: The OESIL Study was designed and undertaken in 15 hospitals of the Italian region of Latium in order to assess the percentage of emergency-room visits and admissions due to syncope, as well as to analyze the in-hospital diagnostic work-up performed for this condition. RESULTS: During a two-month observation period, 781 (372 males and 409 females, mean age 55.2 (22.8 years) consecutive patients came to the emergency rooms of the 15 hospitals included in the investigation due to a syncope spell (0.9% of emergency room visits); 450/781 patients (57.6%) were subsequently hospitalized (1.3% of all admissions): 48.0% of the admissions were admitted to a general medical ward, 29.3% to an observation ward, 13.3% to a cardiology section, 1.6% to a neurology section and 7.8% to other clinical sections (neurosurgery, general surgery). The mean duration of in-hospital stay was 6.9 (5.8 days; range 1-40 days). During the hospitalization period, 93.1% of patients underwent an ECG, 51.0% an EEG, 44.3% a CT scan of the central nervous system, 40.2% an echocardiogram and 19.5% a tilt-test. The syncope spell was considered to have a cardiovascular origin in 33.8% of the cases and a non-cardiovascular in 11.6% of the cases, while the origin was unknown in 54.4% of the cases. CONCLUSIONS: Collected data support the idea that syncope represents a frequent event in the general population and is responsible for a significant percentage of emergency-room visits and hospital admissions. However, the performance of conventional diagnostic work-ups is far from being satisfactory.
Abstract: BACKGROUND: Patients undergoing major vascular surgery are at a relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for perioperative risk stratification. The aim of the current study was to evaluate the value of dipyridamole echocardiography test (up to 0.84 mg/kg over 10 minutes) in predicting cardiac events in a large-scale, multicenter, prospective, observational study design. METHODS AND RESULTS: Five hundred nine patients (mean age 66+/-10 years) were studied before vascular surgery by dipyridamole stress echocardiography in 11 different centers. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. No major complications occurred during dipyridamole stress echocardiography. Technically adequate images were obtained in all patients; however, in 4 patients only the low dipyridamole dose (0.56 mg/kg over 4 minutes) was given for limiting side effects. Eighty-eight (17.3%) had a positive test. Perioperative events occurred in 31 (6.1%) patients: 6 deaths, 11 myocardial infarctions, and 14 episodes of unstable angina. Sensitivity and specificity of dipyridamole stress echocardiography for predicting spontaneous cardiac events were 81% and 87%, respectively, with a positive predictive value of 28% and negative predictive value of 99%. By multivariate analysis, the difference between wall motion score index at rest and peak stress (Deltawall motion score index), test positivity, and ST-segment depression during dipyridamole infusion were independent predictors of any perioperative cardiac event. CONCLUSIONS: Dipyridamole stress echocardiography is safe and well tolerated in patients undergoing major vascular surgery and provides an effective preoperative screening test for the risk stratification of these patients, mainly because of the extremely high negative predictive value, which is a potent predictor of complication-free procedure.
Abstract: OBJECTIVES: The study compared the prognostic value of dipyridamole and dobutamine stress echocardiography in patients with known or suspected coronary artery disease. BACKGROUND: Extensive information is available on the relative diagnostic accuracy of the two tests assessed in a head-to-head fashion, whereas comparative data on their prognostic yield are largely preliminary to date. METHODS: Dipyridamole (up to 0.84 mg/kg over 10 min) atropine (up to 1 mg over 4 min) (DIP) and dobutamine (up to 40 microg/kg/min)-atropine (1 mg over 4 min) (DOB) stress tests were performed in 460 patients with known or suspected coronary artery disease. Patients were followed up for 38+/-21 months. RESULTS: The DIP was negative in 253 and positive in 207 patients. The DOB was negative in 242 and positive in 218 patients. During the follow-up, there were 80 cardiac events. For all cardiac events, the negative and positive predictive value were 83% and 17% for DOB, 84% and 19% for DIP, respectively (p = NS). Considering only cardiac death, by univariate analysis Wall-Motion Score Index (WMSI) at DIP peak dose (chi-square 13.80, p<0.0002) was the strongest predictor, followed by WMSI DOB (chi2 = 8.02, p<0.004) and WMSI at rest (chi2 = 6.85, p<0.008). By stepwise analysis, WMSI at DIP peak dose was the most important predictor (RR [relative risk] 7.4, p<0.0001). CONCLUSIONS: In patients at low-to-moderate risk of cardiac events, pharmacological stress echocardiography with either dobutamine or dipyridamole allows effective and grossly comparable, risk stratification on the basis of the presence, severity and extension of the induced ischemia.
Abstract: BACKGROUND: Residual viable myocardium identified by dobutamine stress after myocardial infarction may act as an unstable substrate for further events such as subsequent angina and reinfarction. However, in patients with severe global left ventricular dysfunction, viability might be protective rather than detrimental. The aim of this study was to assess the impact on survival of echocardiographically detected viability in medically treated patients with global left ventricular dysfunction evaluated after acute uncomplicated myocardial infarction. METHODS AND RESULTS: The data bank of the large-scale, prospective, multicenter, observational Echo Dobutamine International Cooperative (EDIC) study was interrogated to select 314 medically treated patients (271 men; age, 58+/-9 years) who underwent low-dose (</=10 microg x kg-1 x min-1) dobutamine for the detection of myocardial viability and high-dose dobutamine for the detection of myocardial ischemia (</=40 microg x kg-1 x min-1 with atropine </=1 mg) performed 12+/-6 days after an acute uncomplicated myocardial infarction and showing a moderate to severe resting left ventricular dysfunction (wall motion score index [WMSI] >1.6). Patients were followed up for 9+/-7 months. Low-dose dobutamine stress echocardiography identified myocardial viability in 130 patients (52%). Dobutamine-atropine stress echocardiography was positive for ischemia in 148 patients (47%) and negative in 166 patients (53%). During the follow-up, there were 12 cardiac deaths (3.8% of the total population). With the use of Cox proportional hazards model, delta low-dose WMSI (the variation between rest WMSI and low-dose WMSI) was shown to exert a protective effect by reducing cardiac death by 0.8 for each decrease in WMSI at low-dose dobutamine (coefficient, -0.2; hazard ratio, 0.8; P<0.03); WMSI at peak stress was the best predictor of cardiac death in this set of patients (hazard ratio, 14.9; P<0.0018). CONCLUSIONS: In medically treated patients with severe global left ventricular dysfunction early after acute uncomplicated myocardial infarction, the presence of myocardial viability identified as inotropic reserve after low-dose dobutamine is associated with a higher probability of survival. The higher the number of segments showing improvement of function, the better the impact is of myocardial viability on survival. The presence of inducible ischemia in this set of patients is the best predictor of cardiac death.
Abstract: The case of a 16-year-old patient with L. tredecimguttatus poisoning complicated by myocardial damage is reported. Symptoms (typical chest pain), electrocardiographic (ST-T changes in precordial leads) and echocardiographic (akinesia of interventricular septum with depressed left ventricular function) features and laboratory findings (increased myocardial enzymes) are described.
Abstract: In October 1996 a 67-year-old man underwent transthoracic and transesophageal echocardiography (TEE) because of dyspnea on exertion and was found to have 2 left atrial cardiac masses. The 2 masses were surgically removed from the atrium and showed histopathologic and ultrastructural features of a leiomyosarcoma. Seven months later a double recurrence of left atrial masses was found with TEE; the patient refused surgery and decided instead to receive chemotherapy. In May 1998 he was in stable condition (New York Heart Association class III), but a further growth of the 2 left atrial masses was observed at TEE. We describe the echocardiographic features of the 2 cardiac masses and the clinical and prognostic implications.
Abstract: PURPOSE: To evaluate efficacy and indications of therapy for ventricular arrhythmias in patients with chronic congestive heart failure. DESIGN: A review of most significant and recent clinical trials was performed. RESULTS: In patients with severe left ventricular dysfunction, the desirable actions of antiarrhythmic drugs are attenuated and their negative inotropic and proarrhythmic actions are enhanced. Treatment should be limited to patients with malignant ventricular arrhythmias, or to patients considered at high risk. When indicated, amiodarone is usually well tolerated and safe. The prevention of sudden death in patients with heart failure should be based on optimized therapy of pump failure, reducing left ventricle work load and modulating neurohormonal systems with ACE-inhibitors and betablockers drugs. Further, an important role is held by anti-ischemic therapy, revascularization procedures, anticoagulant therapy and prevention of electrolytes unbalances. Patients with sustained of high risk arrhythmias, resuscitated from a cardiac arrest, should be considered for transvenous Implantable Cardioverter Defibrillator (ICD) implant. CONCLUSIONS: Ventricular arrhythmias are common in heart failure patients, represent an important cause of sudden death and the choice of treatment is difficult because of the complexity of underlying mechanisms, frequency of adverse reactions and the severity of left ventricular dysfunction.
Abstract: The influence of the calcium antagonist gallopamil on the contractility of asynergic viable myocardium after acute myocardial infarction treated with thrombolysis was investigated by two-dimensional echocardiography. Sixteen patients with > or = 1 viable segment(s), identified during the low-dose phase (up to 10 micrograms/kg/min) of a dobutamine echocardiographic test (up to 40 micrograms/kg/min) performed 4-5 days after a first acute myocardial infarction, were given a gallopamil intravenous bolus (50 micrograms/kg) 12-24 hours later. Two-dimensional echocardiography was done before and 15 minutes after the bolus. A score index of 1 (normokinesis) to 4 (dyskinesis) and a 16-segment model were used. A segment was considered viable when a resting asynergy (score > or = 2) improvement of > or = 1 grade was seen during low-dose dobutamine. Follow-up echocardiograms were done 3-5 months later. A total of 30 viable segments were found; of these, 10 showed sustained improvement in contractility (group A) during high-dose dobutamine, while 20 exhibited a biphasic response returning to their basal contractile state (group B). After the gallopamil bolus, 9 of 10 group A segments improved their contractility, in comparison with 0 of 20 group B segments (P < .001). Infarct-related vessel significant (> or = 75%) coronary stenosis was present in the tributary vessel of 0 of 10 group A and of 20 of 20 group B segments (P < .001). At follow-up, 9 of 10 group A segments showed a spontaneous contractile improvement; of the 20 group B segments, 8 of 10 that underwent revascularization (7 angioplasty, 3 bypass graft) showed contractile improvement, in comparison with 0 of 10 segments not revascularized (P = .001). We conclude that gallopamil may reverse the contractile dysfunction of postischemic stunned myocardium in patients with acute myocardial infarction, whereas no effects are apparent on ischemic/hibernating myocardium.
Abstract: OBJECTIVES: The aim of this multicenter, multinational, prospective, observational study was to assess the relative value of myocardial viability and induced ischemia early after uncomplicated myocardial infarction. BACKGROUND: Dobutamine-atropine stress echocardiography allows evaluation of rest function (at baseline), myocardial viability (at low dose) and residual ischemia (peak dose, up to 40 micrograms with atropine up to 1 mg) in one test. METHODS: Dobutamine-atropine stress echocardiography was performed 12 +/- 5 days (mean +/- SD) after a first uncomplicated acute myocardial infarction in 778 patients (677 men; mean age 58 +/- 10 years) with technically satisfactory rest echocardiographic study results. Patients were followed-up for 9 +/- 7 months. RESULTS: Dobutamine-atropine stress echocardiographic findings were positive for myocardial ischemia in 436 of patients (56%) and negative in 342 (44%). During follow-up, there were 14 cardiac-related deaths (1.8% of the total cohort), 24 (2.9%) nonfatal myocardial infarctions and 63 (8%) hospital readmissions for unstable angina. One hundred seventy-four patients (22%) underwent coronary revascularization (bypass surgery or coronary angioplasty). Spontaneous events occurred in 61 of 436 patients with positive and 40 of 342 patients with negative findings on dobutamine-atropine stress echocardiography (14% vs. 12%, p = 0.3). When only spontaneously occurring events were considered, the most important predictor was myocardial viability (chi-square 9.7). Using the Cox proportional hazards model, only the presence of myocardial viability (hazard ratio [HR] 2.0, p < 0.002) and age (HR 1.03, p < 0.001) were predictive of spontaneously occurring events. When only hard cardiac events were considered, age was the strongest predictor (chi-square 3.6, p = 0.056), followed by wall motion score index (WMSI) at peak dose (chi-square 3.3, p = 0.06) and remote ischemia (chi-square 2.25, p = 0.1). When cardiac death was considered, WMSI at peak dose was the best predictor (HR 9.2, p < 0.0001). CONCLUSIONS: During dobutamine stress, echocardiographic recognition of myocardial viability is more prognostically important than echocardiographic recognition of myocardial ischemia for predicting unstable angina, whereas WMSI at peak stress was the best predictor of cardiac-related death. Different events can be recognized with different efficiency by various stress echocardiographic variables.
Abstract: BACKGROUND: Rational prognostic algorithm should be developed considering the logical progression of the information as it becomes available to the physician, with clinical data first, ECG data second and stress imaging data last. The aim of the present study was to assess in a clinically realistic fashion the relative prognostic value of exercise electrocardiography test (EET) and dipyridamole-echocardiography test (DET) early after first acute uncomplicated myocardial infarction. METHODS AND RESULTS: Five hundred and forty-seven in-hospital patients (age = 56 +/- 9 years) with recent clinically uncomplicated first myocardial infarction, baseline echocardiographic findings of satisfactory quality, interpretable ECG and capability to exercise underwent a resting 2D echocardiogram, a DET and an EET at a mean of 10 days from the infarction and were followed up for 16.2 +/- 11 months. During the follow-up, there were 17 cardiac deaths, 19 non-fatal myocardial infarctions and 49 unstable angina. When cardiac death was considered as the only significant event, with multivariate analysis, peak dipyridamole Wall Motion Score Index was the only significant predictor (chi 2 = 5.66; p = 0.013; relative risk estimate = 4.7; confidence intervals = 1.35-16.08). In presence of a negative exercise electrocardiography test for both chest pain and electrocardiographic criteria, the death rate was 2%. CONCLUSION: DET provides stronger information in comparison with historical and EET variables. However, a negative maximal EET is sufficient to identify a very low risk subset in whom additional testing may not be warranted.
Abstract: The influence of the beta-blocker metoprolol on the capacity either of low-dose dobutamine echocardiography or the recently introduced enoximone echocardiography to detect viable dysfunctioning myocardium after myocardial infarction was investigated. Initial clinical experience would suggest that the phosphodiesterase III inhibitor enoximona could be an alternative pharmacological stimulation, inducing an increase in contractility in the presence or absence of beta-receptor stimulation. Ten patients with a baseline low-dose dobutamine-echocardiographic test (up to 10 micrograms/kg/min) positive for myocardial viability in > or = 1 segment(s), performed 4-5 days after a first acute myocardial infarction treated with rtPA, were randomized after the administration of intravenous metoprolol (15 mg in three 5-mg boluses) either to dobutamine (up to 15 micrograms/kg/min) or to an enoximone intravenous bolus (1 mg/kg over 5 min) under echocardiographic monitoring, in a crossover sequence, with a 24-h interval. The infarct related artery was patent (TIMI grade 2 o 3) in all the patients. Follow-up echocardiograms were performed 5-7 weeks later. Resting asynergy was found in 40 segments; of these, 17 were viable. All the viable segments remained unresponsive during the post-metoprolol dobutamine infusion, while improved their contractility during enoximone echocardiography. Two patients suffering from early post-infarction angina underwent coronary angioplasty successfully. Eight out of ten patients (2 revascularized and 6 not) showed contractile recovery in a total of 14 segments at the follow-up echocardiogram. Sensitivity, specificity and overall accuracy in predicting reversible dysfunction after acute myocardial infarction for enoximone echocardiography were 93, 85, and 88%, respectively. Our results support the value of enoximone echocardiography in the identification of myocardial viability after myocardial infarction, in patients treated with beta-blockers, which interfere heavily with the results of dobutamine echocardiography.
Abstract: Resting and stress echocardiography is a 'one-stop shop', which enables a wide range of information to be collected on resting function, myocardial viability, and induced ischaemia, all of which are useful for prognostic stratification. Large scale, multicentre, prospectively collected data show the prognostic failure of resting function and inducible ischaemia, both independently and combined, which are especially effective in predicting cardiac death. The GISSI data show that the increment of risk as a result of reduction in ventricular function has a hyperbolic trend, with a relatively moderate increase in mortality for ejection fraction values between 50 and 30%, but with marked increases below 30%. The EPIC data show that the 1-year risk of cardiac death is as low as 2% in patients with negative dipyridamole stress echocardiography: it doubles if the test is positive at a high dose, and is almost four times higher if it is positive at a low dose. In the field of prognostic stratification, in the absence of carefully controlled studies, the choice between coronary angiography as the only essential study, or use of a non-invasive test to discriminate access to catheterization currently reflect alternate philosophical approaches rather than scientifically based decisions. In the invasive approach, stress echocardiography offers relief from the vicious circle of chest pain-coronary angiography revascularization. In the non-invasive and physiological approach, stress echo is capable of offering, in one sitting, an insight into the main determinants of survival: function, viability, and ischaemia.
Abstract: The aim of this study was to compare dipyridamole and dobutamine stress echocardiography, performed early in patients with acute myocardial infarction (AMI) to evaluate residual ischemia, viability, and prognosis. Fifty patients (mean age 55 +/- 9 years, 47 men, 3 women) with AMI, all treated with thrombolytic therapy, underwent standard dipyridamole and dobutamine tests, within the fifth day of the event. Wall motion score index and the 16 segments model were used to evaluate contractility. Forty-seven patients underwent coronary angiography within the tenth day of the event. The mean follow-up was 24 +/- 12 months. No side effects occurred during both tests. Both dipyridamole and dobutamine tests were positive for ischemia, in 32 and 33 of 47 patients, respectively (sensitivity 73% and 75%; specificity 67% and 67%); these tests induced an improvement of contractility in 23 and 38 of 139 abnormal segments at baseline, respectively (sensitivity 52% and 86%; specificity 100% and 100%). Cardiac events occurred in 26 of 50 patients, 22 with a positive dipyridamole test and 21 with positive dobutamine test. Thus, both tests were feasible, safe, and useful to evaluate residual ischemia, viability, and prognosis. No significant differences were found in sensitivity and specificity between tests.
Abstract: OBJECTIVES. This study sought to compare, head to head, the two most popular pharmacologic stress echocardiographic tests--dipyridamole and dobutamine--with state of the art protocols in a large multicenter prospective study. BACKGROUND. In the continuing quest for ideal diagnostic accuracy, pharmacologic stress echocardiography has quickly moved over the years from low to high dose regimens and is currently performed with atropine coadministration. METHODS. Dobutamine (up to 40 microgram/kg body weight per min) plus atropine (up to 1 mg over 4 h) and dipyridamole (up to 0.84 mg/kg per min over 10 h) plus atropine (up to 1 mg over 4 h) stress echocardiography was performed on different days, in random order and within 1 week in 360 patients with chest pain syndrome. Thirteen different echocardiographic laboratories, all fulfilling quality control criteria for stress echocardiographic reading, contributed to the study. RESULTS. No major complications occurred during either test. The test was interrupted before achievement of predetermined end points for limiting side effects in 37 dobutamine-atropine and 7 dipyridamole-atropine stress echocardiographic studies (feasibility 90% vs. 98%, p < 0.01). Diagnostic accuracy was assessed in a subset of 110 patients with no obvious rest dyssynergy (akinesia or dyskinesia) who underwent coronary angiography independently of test results and within 1 week of testing. Significant coronary artery disease (> or = 50% diameter reduction in at least one major coronary vessel by quantitative coronary angiography) was found in 92 patients. Sensitivity for detection of coronary artery disease was 84% (77 of 92) for dobutamine-atropine and 82% (75 of 92) for dipyridamole-atropine stress echocardiography (p = NS), with a specificity of 89% (16 of 18) for dobutamine-atropine and 94% (17 of 18) for dipyridamole-atropine stress echocardiography (p = NS). A significant correlation was present between peak wall motion score index during dipyridamole-atropine and dobutamine-atropine stress echocardiography (r = 0.83, p < 0.0001). CONCLUSIONS. Dobutamine-atropine and dipyridamole-atropine stress echocardiography are safe and feasible, although submaximal studies are more frequent with dobutamine. The two stresses have comparable accuracy in the detection of angiographically assessed coronary artery disease, although dobutamine is marginally more sensitive and dipyridamole marginally more specific. Stratification of the ischemic response in the space domain is also comparable with the two stresses.
Abstract: OBJECTIVES. This study sought to assess the value of dipyridamole echocardiography in predicting reinfarction in patients evaluated early after uncomplicated acute myocardial infarction. BACKGROUND. The identification of future nonfatal reinfarction seems an elusive target for physiologic testing. However, a large sample population is needed to detect minor differences in phenomena with a low event rate. METHODS. We assessed the value of dipyridamole echocardiography in predicting reinfarction in 1,080 patients (mean [+/- SD] age 56 +/- 9 years; 926 men, 154 women) evaluated early (10 +/- 5 days) after uncomplicated acute myocardial infarction and followed up for 14 +/- 10 months. RESULTS. Submaximal studies due to limiting side effects occurred in 14 patients (1.3%); these test results were included in the analysis. Results of dipyridamole echocardiography were positive in 475 patients (44%). During follow-up, there were 50 reinfarctions: 45 nonfatal, 5 fatal (followed by cardiac death < or = 4 days after reinfarction). Reinfarction (either nonfatal or fatal) occurred in 30 patients with positive and 20 with negative results (6.3% vs. 3.3%, p < 0.01). Nonfatal reinfarction occurred in 25 patients with positive and 20 with negative results (5% vs. 3.3%, p < 0.05). Reinfarction was fatal in 5 of 30 patients with positive and in none of 20 with negative results (16.6% vs. 0%, p = 0.07). The relative risk of reinfarction was 1.9. CONCLUSIONS. Dipyridamole echocardiographic positivity identifies patients evaluated early after uncomplicated acute myocardial infarction at higher risk of reinfarction, especially fatal reinfarction.
Abstract: The significance of anterior ST segment depression in inferior acute myocardial infarction (AMI) remains controversial. The aim of this study was to relate precordial ST segment depression to the topography of residual myocardial ischaemia, with myocardial mapping of the asynergic area and coronary anatomy. Twenty-five patients with first inferior AMI (15 patients with anterior ST segment depression: group A and 10 patients without anterior ST segment shift: group B), all underwent: (1) electrocardiographic evaluation on admission to the Coronary Care Unit and at 24 h intervals thereafter; (2) 2D-echocardiographic study within 3 h of CCU admission; (3) dipyridamole echocardiographic test (DET) (doses of dipyridamole up to 0.84 mg.kg-1 i.v. over 10 min) 4 days after AMI; (4) coronary arteriography within 14 days from AMI. To assess regional left ventricular wall motion, a 16 segment model was used and a wall motion score index (WMSI) was derived. The results of DET were correlated to the anatomy of the infarct-related vessel. Compared to group B, group A patients showed a significantly greater maximal ST segment elevation in inferior limb leads (lead III: 3.9 +/- 1.9 mm vs 2.2 +/- 1.1 mm, P < 0.05; aVF: 3.5 +/- 1.3 mm vs 1.7 +/- 0.8 mm, P < 0.001). Group A patients showed greater WMSI (1.35 +/- 0.22 vs 1.17 +/- 0.12, P < 0.05), with more frequent postero-lateral wall involvement (72% vs 20%, P < 0.05). No patient of either group showed asynergy of the anterior, anterolateral or anteroseptal segments. No differences in the distribution of coronary artery disease were observed.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: OBJECTIVES. This study was conducted to assess the feasibility, safety and prognostic value of dipyridamole echocardiography in elderly patients recovering from an uncomplicated acute myocardial infarction in a subset analysis performed on the patients entered in the subproject "residual ischemia" of the Echo Persantine Italian Cooperative Study (EPIC). BACKGROUND. Coronary heart disease accounts for two thirds of all deaths in the age group > 65 years, and > 50% of all patients admitted to the hospital with acute myocardial infarction are > 65 years old. The prognostic value of dipyridamole-induced left ventricular dysfunction was clearly established in patients evaluated early after acute infarction. METHODS. In a subgroup analysis of the Echo Persantine Italian Cooperative Study (EPIC), we assessed the value of dipyridamole echocardiography in predicting cardiac events in 190 elderly (> or = 65 years) patients (age 68.4 +/- 3.3 years, range 65 to 78; 147 men and 43 women) evaluated early (mean 10 days) after uncomplicated acute myocardial infarction and followed up for 14 +/- 9.8 months. RESULTS. There was no major side effect during dipyridamole echocardiography. A positive test result occurred in 85 patients (44.7%). During follow-up, there were 62 events (14 cardiac deaths, 7 nonfatal reinfarctions, 21 cases of class III or IV angina and 20 revascularization procedures). Of these 62 events, 44 occurred among 85 patients with positive dipyridamole echocardiography and 18 among 105 patients with negative dipyridamole echocardiography (52% vs. 17%, p < 0.001). Spontaneous events (death, reinfarction, angina) occurred in 31 patients with positive and in 11 with negative dipyridamole echocardiography (36% vs. 10%, p < 0.001). Hard events (myocardial infarction or death) occurred in 14 patients with positive and 7 with negative dipyridamole echocardiography (16% vs. 6%, p < 0.05). Death occurred in 11 patients with positive and in 3 with negative dipyridamole echocardiography (13% vs. 3%, p < 0.01). The positive predictive value of positive dipyridamole echocardiography and negative predictive value of negative dipyridamole echocardiography as related to the occurrence of all events in the follow-up period (death, reinfarction, angina, revascularization procedures) were 52% and 83%, respectively. The relative risk (that is, the relative risk of occurrence of future cardiac events in the group with positive dipyridamole echocardiography compared with that in those with negative dipyridamole echocardiography) was 3 for all events and 4.4 for death. CONCLUSIONS. Dipyridamole echocardiography was well tolerated by elderly patients and proved to be very effective in prognostic stratification early after uncomplicated acute myocardial infarction, even when only survival was considered.
Abstract: OBJECTIVES. The aim of this study was to examine the ability of Dipyridamole Echocardiography Test (DET)--performed early after an acute myocardial infarction (AMI)--to assess: a) the presence of induced ischemia and its relation with coronary artery stenoses; b) the presence of myocardial viability and the comparison with late wall motion; c) the appearance of cardiac events during hospitalization and in the following period. METHODS. Ninety-five patients with AMI, subjected to thrombolytic therapy and without complications, underwent a DET on the 4th-5th day. All had a coronary angiography on the 8th-10th day; stenoses were deemed significative when > or = 70%. DET was carried out after drug discontinuance and following standard protocol; parietal kinesis was analyzed according to a 14 segment model. The myocardium was deemed viable when an improvement of a basal dyskinesis was noted; ischemia was considered when a new asynergy appeared or a basal dyskinesis worsened or enlarged; a wall motion score index (WMSI) was calculated. All 95 pts. had a clinical follow-up at 12 +/- 6 months (3-18); 62 pts. had a late echocardiographic examination at 6 +/- 3 months (3-15). RESULTS. Induced ischemia appeared in 59/95 pts. (62%): in 6/14 pts. (42%) without significative stenoses, in 29/49 pts. (59%) with a single vessel disease, and in 24/32 pts. (75%) with multivessel disease. In identifying multivessel disease, DET sensibility (SE) was 75% and specificity (SP) was 95-97%. In single or no vessel disease WMSI changed from 1.42 to 1.49 (p < 0.0001); in multivessel disease WMSI changed from 1.52 to 1.69 (p < 0.0001). As regards the assessment of diseased vessel(s), DET showed little accuracy when dyskinesis appeared in the basal segments of the inferior and lateral wall or in the mid-apical segments of the anterior and lateral wall; DET properly identified the culprit vessel when dyskinesis appeared in the remaining segments. Myocardial viability was noted in 26% of dyskinetic segments. In single or no vessel disease WMSI changed from 1.41 (basal--> B) to 1.35 (viability phase--> V) and was found 1.31 at the late echocardiography (L): p < 0.0001 between B and V, and between B and L. In multivessel disease WMSI changed from 1.5 (B) to 1.47 (V) and to 1.5 (L): p < 0.05 between B and V, NS between B and L. In comparison with late echocardiography, DET SE was 70%, SP 99%, positive predictive value (PPV) 97%, negative predictive value (NPV) 86%. As regards the prognostic value about cardiac events, DET SE was 80% and NPV was 78%; about only major cardiac events, the respective values are 91% and 97%. CONCLUSIONS. DET performed early after an AMI allows a better prognostic assessment, as it provides information about: a) the place and the severity of coronary artery stenoses; b) the presence and the extension of induced ischemia and of myocardial viability; c) the risk of subsequent cardiac events.
Abstract: BACKGROUND. Transesophageal echocardiography (TEE) is a useful means in the diagnosis of acute aortic dissection (AD), owing to its very high sensibility and specificity. In this study, TEE was performed to assess post-surgical evolution. PATIENTS. Between 1982 and 1991, 119 pts. were operated on in our institution for AD (De Bakey I and II type): 87 pts. underwent replacement of the ascending aorta with a composite tubular graft bearing a mechanical valve; 26 had a simple tubular graft and 6 had aortic reconstruction. Sixty-eight of 72 discharged pts. were followed for up to 9.5 years (mean 4.5 +/- 2.6). Nine years after surgery actuarial survival of discharged pts. was 75%. Seven pts. died after a mean period of 3.4 years from surgery: only one died from postoperative complication (dehiscence of proximal anastomosis), none for aortic rupture distal to the graft. TEE was performed in 32 of these pts. and in other two operated on elsewhere, after 4.4 +/- 2.7 years from surgery; before the operation, type I AD was diagnosed in 23 pts. and type II in 11 pts. RESULTS. In 10/11 pts. with type II AD the aortic arch and the descending aorta looked normal; in one patient a localized intimal flap was found up to the arch. The descending aorta diameter was somewhat higher than in normal subjects (25.2 +/- 2.8 vs 21.9 +/- 3.7 mm), but in only one case was it beyond 2DS (32 mm). In all type I pts. an intimal flap persisted distal to the graft, along the whole thoracic aorta. Within the false lumen a flow was detected by color-Doppler in 14/23 pts. (61%), and spontaneous echo-contrast was noted in 14 pts. (61%). A thrombus was observed in 7 pts. (30%) and it was generally localized; in only one case it was extensive with total obliteration of the false lumen. In 16 pts. (70%) communications between the two lumina were found. The descending aorta diameter ranged from 25 to 53 mm, and mean value was higher than in normal subjects (34.2 +/- 6.2 vs 21.9 +/- 3.7 mm). CONCLUSIONS. In most pts. with type II AD, surgery can be a definitive treatment, as the remaining aorta keeps to normal size and appearance. In type I AD, operation is only palliative, as the dissection persists: the false lumen is often perfused through one or more communications with the true lumen and seldom its obliteration is noted. The persistence of dissection does not necessarily seem to be an ominous finding, as the survival of the study population was high and no patient died from aortic rupture. Nevertheless, long-term prognosis can be affected by aorta dilation that often (but not always) follows the persistence of wall dissection. For its high reliability, easy feasibility and low cost TEE is a very useful method for following up patients operated on for AD and for detecting those who are at higher risk of aortic rupture because of lumen dilation.
Abstract: The purpose of the study was to assess the prevalence and the type of cardiac abnormalities in patients with HIV infection. Echocardiographic examination (M-mode, two-dimensional and Doppler) was performed in 51 patients (40 male, 11 female), whose mean age was 29 +/- 10 years; 48 of them (94%) were intravenous drug addicts, 3 (6%) homosexuals. Diagnosis was AIDS in 19 (37%) patients, AIDS related complex in 19 (37%) and asymptomatic infection in 13 (26%). Echocardiography was normal in 13 subjects. Pericardial effusion was found in 19 patients (in 8 of them, this was the only cardiac abnormality). Valve vegetations were found in 16 patients (3 of them had pericardial effusion, 5 had ventricular dilatation or wall motion abnormalities, 1 had both pericardial and myocardial impairment). Myocardial dysfunction was found in 18 patients: 11 had left ventricular dilatation (5 with wall hypokinesia), 1 had right ventricular enlargement, 1 had biventricular dilatation and 5 had only wall motion abnormalities (diffuse or localized). During the follow-up 9 patients died: 8 had AIDS, 1 was asymptomatic. Eight subjects died during hospitalization (none because of cardiac causes) and one at home for sudden unexplained death. Echocardiography had displayed myocardial dysfunction in 6 of them, thickened pericardium in 1 and was normal in 2. Pathologic examination (performed in 8 subjects) showed cardiac enlargement in 3 subjects, thickened pericardium in 2 and valve vegetation in 1. One subject had histopathologic diagnosis of myocarditis and 7 had non specific histologic abnormalities. The study shows a cardiac involvement in 75% of HIV infected patients: 35% had myocardial dysfunction, 37% pericardial disease, 31% infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Seven hundred sixty-nine patients (pts) admitted to the Coronary Care Unit (CCU) between January 1987 and January 1990 suffering from first acute myocardial infarction (AMI) were studied. The presence of left ventricular thrombosis (LVT) was evaluated by two-dimensional echocardiography (2D-echo). The relation of LVT to site, size and intra-CCU clinical outcome of AMI, in terms of systemic embolic events, Killip class and mortality, was also assessed. AMI was transmural in 707 pts (92%), anterior in 446 pts (58%) and inferior in 261 pts (34%), non-Q in 62 pts (8%). Two hundred sixty-one pts (34%) were treated with IV thrombolytic therapy followed by IV heparin 1000 IU/h over 12 hrs and then calcium heparin (CH) 12500 IU s.c. bid; 508 pts (66%) were given only antithrombotic therapy (CH 12500 IU s.c. bid). 2D-Echo was performed within 48 hours and on day 5-7 from the onset of AMI. In 41 pts (5.3%) LVT was observed: 39 had anterior AMI (8.7% of all anterior AMI pts), one had inferior AMI (0.4% of all inferior AMI pts), and one had non-Q AMI (1.6% of all non-Q AMI pts) [p less than 0.001 for anterior AMI vs inferior and non-Q AMI]. Pts with LVT had a greater infarct size (number of akinetic plus dyskinetic segments/total number of segments x 100) compared to pts without LVT (32.3 +/- 12.6% vs 16.4 +/- 5.7%, p less than 0.001). In pts treated with thrombolytic therapy, LVT incidence was not significantly different from that of pts treated with antithrombotic therapy (4.2% vs 5.9%) alone.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Using phonocardiography, continuous- and pulsed-wave Doppler, 51 patients with precordial "musical" murmurs (49 with cardiac abnormalities) and 21 patients with noisy murmurs were examined. With M-mode echocardiography, fine fluttering of the structure generating the murmur was evident in 23 patients with musical murmurs and in 5 with noisy murmurs. A continuous-wave Doppler spectral signal characterized by parallel harmonics (Doppler musical signal) was evident in all patients with musical murmurs and in none with a noisy murmur. With pulsed-wave Doppler, the musical signal had less defined spectral features because of range ambiguity. Such a signal was experimentally reproduced by activating a diapason bathed in saline solution. The source of the musical murmur was established in all 51 patients by Doppler. The musical signal was associated with a valvular regurgitation signal in 36 patients and with a ventricular septal defect in 1 patient. The musical signal always disappeared when the pulsed-wave Doppler sample volume was placed 2 cm away from the generating structure. In 11 patients with musical murmur examined by color Doppler, no abnormal bidirectional flow signal was observed in the structures generating the signal. In 6 of the patients without valvular regurgitation, no flow disturbance was found. In conclusion, Doppler is valuable in determining the source of musical murmurs, and musical murmurs are caused by a vibrating structure even in the absence of flow turbulence.
Abstract: The study was performed to assess Doppler echocardiographic features of mitral and aortic prosthetic valves of different types with both normal and abnormal function. Two hundred and twenty-three patients with 250 prostheses were studied. Two hundred eight valves (111 mitral, 95 aortic and 2 tricuspid) were considered to be functioning normally after clinical examination, phonocardiography and M-mode and 2D echocardiography. This group enabled us to define normal Doppler echocardiographic findings for different types of prosthesis. In mitral position, peak (p) and mean (m) gradients were lower for disc prostheses and higher for ball and biological prosthetic valves; values of effective orifice area (A), calculated by pressure half-time method, were lower for biological and ball prostheses and higher in disc valves. Results were as follows: St. Jude (p 10.6 mmHg, m 3.9 mmHg, A 2.7 cm2), Duromedics (p 10.6, m 4.3, A 2.8), Björk-Shiley (p 10.4, m 4, A 2.3), Omniscience (p 14.2, m 6.2, A 2.1), Starr-Edwards (p 15.9, m 5.4, A 2.1), Hancock (p 14.7, m 6, A 2), Carpentier (p 13.2, m 5.4, A 1.9). Mild regurgitation, considered "physiological", was found in 2/8 Carpentier valves and in 3/34 St. Jude prostheses. In aortic valves lower peak gradients were found in Lillehei (18.3 mmHg), St. Jude (23.8 mmHg), Björk-Shiley (26 mmHg), Duromedics (27 mmHg) and higher values in Starr-Edwards (30.2 mmHg), Hancock (30 mmHg) and Omniscience (35.5 mmHg) prostheses. Mild regurgitation, considered "physiological", was found in 17% of Omniscience valves, 21% of Hancock, 33% of Duromedics, 45% of St. Jude, 60% of Björk-Shiley prostheses. Hancock mitral valves implanted for over 7 years had a mean gradient higher than valves with a shorter period of implantation (7.6 vs 4.85 mmHg, p less than 0.1), whereas the effective orifice area was similar. Hancock aortic valves implanted for over 7 years had a peak gradient slightly higher than the other group (implantation less than 7 years previously), but the difference was not statistically significant. Forty-two valves (19 aortic and 23 mitral) were considered to be malfunctioning. Regurgitation Doppler signals of malfunctioning valves appeared different from those of "physiological" reverse flow; in the former cases forward gradient was higher than normal prostheses. In stenotic aortic prostheses, peak systolic gradient was greatly increased; in stenotic mitral prostheses, a very significant increase in mean gradient and a great decrease in effective orifice area were found. In 14 patients who underwent surgical re-operation and in the patient who died before operation, Doppler echocardiographic findings were confirmed.(ABSTRACT TRUNCATED AT 400 WORDS)
Abstract: The origin of systolic or diastolic musical murmurs was investigated by means of echo-doppler examination in 51 patients with various cardiac diseases. In all cases a typical doppler spectrum was identified, showing bi-directional clusters of frequencies which were concentric in systole and parallel in diastole. The doppler audio signal was musical. A similar echo-doppler signal was obtained by a diapason vibrating in isotonic solution. These data allowed us to identify the site of the vibrating cardiac structure causing the typical echo-doppler spectrum and characteristic audio signal.
Abstract: 29 patients with a recent myocardial infarction underwent a M-mode echocardiographic study before and after an ergometric training in order to study the training effects on the left ventricular function and on the cardiac chambers dimensions. 25 patients in the same clinical conditions and no trained acted as a control group and were evaluated with the same procedure. Our results show, in the trained group, a significant reduction of the diastolic (-5.6%) and systolic (-6.5%) diameters of the left ventricle and of the diameter of the left atrium (-7.5%). Moreover we observed an improvement of the left ventricular kinesis, as showed by the increased systolic movement of left posterior wall and of the interventricular septum and by the increased ventricular performance, as it results from increased systolic movement of the aortic root. In the control group no significant variation of the examined data was observed. The reduction of the diameters and the improvement of the kinesis and of ventricular performance could be explained by the reduced after-load and it shows the presence of direct beneficial effects of the exercise training on the heart, consisting both of improved cardiac mechanics and of a reduced MVO2.
Abstract: The Authors have examined the possibility for diagnostic and prognostic value of exercise stress test and of dynamic ecg in the identification of ventricular ectopic activity which represent a factor risk of sudden death. 41 male patients with IHD and Myocardial Infarction were given exercise stress test and Holter monitoring according to the usual methods. Both methods were useful to identify Pts with arrhythmias. The total incidence of ventricular ectopic beats was 78% with Holter and 46% with exercise test. Holter monitoring showed a major possibility to detect high degree arrhythmias (39%) against 9% of exercise test. Two methods are not comparable, not it was possible to demonstrate statistically significant incidence of ventricular ectopics with respect to the localization of M.I. 90% of Pts with positive exercise test (angina and/or ecg alterations) showed ventricular ectopic beats against 45% of Pts with negative exercise test. The association of ventricular ectopic beats in Holter and positive response to exercise test is highly predictable of sudden death. The results of investigation suggest the opportunity to evaluate Pts with MI by both methods, dynamic ecg and exercise stress test.
Abstract: 114 women with abnormal resting electrocardiograms underwent exercise test on bicycle ergometry; they were grouped as follows: --group I: 40 asymptomatic females; --group II: 67 cases with atypical chest pain; --group III: 7 cases with typical angina. The exercise test was always maximal or submaximal SL. The only criteria used for positive stress was a 1 mm or more ischemic ST segment depression below the resting level, for at least 0.08 sec. The test was positive in 11 subjects (10.7%): 5 women of group II (7.5%) and 6 of group III (85.7%). Our results suggest that repolarisation abnormalities, not caused by hypertrophy, conduction disturbances and drugs, do not modify the outcomes of stress test. Ischemic patterns during exercise test are more frequently seen when flat or diphasic T waves are present in control ECG. In the majority of patients in all groups the T wave either does not change or becomes more positive or less negative after exercise. A greater prevalence of resting hypertension and arrhythmias is present in patients with positive tests.
Abstract: The results of exercise stress test in 86 patients with intraventricular conduction troubles (BBBand or Emiblock) are discussed in order to asses the meaning of exercise induced ECG alterations and possibly of an etiopathogenetic interpretation. The AA. examined the following parameters during stress test and recovery: max heart rate, percent of teoric max heart rate, max BP, max heart rate x BP product, AQRS at rest and during recovery immediately after exercise test, QRS duration, ST depression, T amplitude. The majority (91,67%) of isolated RBBB patients had negative test; 30,43% of RBBB + LAEmiblock patients had ECG signs and clinical symptoms of myocardial ischemia. In LBBB patients the test was considered positive only if present ST depression and precordial pain. The AQRS tends during exercise to the right; in the 60% of RBBB + LAEmiblock patients it can be seen a tendency to left axis deviation; the amplitude of T-wave is increasing in more than 50% in LBBB. The conclusions are that in patients with intraventricular conduction troubles the interpretation of results is always difficult; the presence of clinical symptoms like precordial pain may give an aide when associated to the ECG variations.
