Herpes zoster after COVID vaccination.

COVID-19 presents in various ways, but mainly as a pulmonary disease (Marzano, 2020). Skin manifestations have been reported, including reactivation of the varicella-zoster virus (Marzano, 2020). Our case report describes two adults developing herpes zoster after vaccination with tozinameran (the Pfizer-BioNTech COVID-19 mRNA vaccine). A possible cause for this reaction is a transient lymphocytopenia that occurs after the vaccination - similar to that in COVID-19 disease (Mulligan, 2020; Wang, 2020; Qin, 2020; Brabilla, 2020; Wang, 2020; Wei, 2017). In the context of vaccinating older and/or immunocompromised adults, our observations can be the starting point for further evaluation of a possible relationship between COVID-19, COVID vaccines, and herpes zoster.

Toxicological screening in the Amsterdam acute setting becomes more relevant if the standard panel of the drugs-of-abuse point-of-care test is expanded with GHB and ketamine.

OBJECTIVE: For diagnosis and treatment in the acute setting, it is crucial to know whether the clinical status of patients might be explained by the effects of drugs.The objective of this study was to determine how many drugs were detected by comprehensive toxicological screening, that could not be detected with a routine drugs-of-abuse point-of-care test (DOA-POCT) and which drugs of abuse (DOA) were relevant. A secondary objective was to determine in how many patients comprehensive toxicological screening provided additional clinically relevant information. METHODS: In this prospective study, patients were included in whom a DOA-POCT was performed and residual urine and serum samples were available.DOA-POCT were performed using the Triage® TOX Drug Screen. Comprehensive toxicological screening was performed using 1) the Toxtyper™ LC-MSN method and 2) two GC-FID methods for alcohols and GHB respectively.The clinical relevance of the comprehensive toxicological screening results regarding diagnosis and patient management was quantified. RESULTS: A total of 100 patients were included. In 91 of these patients, comprehensive toxicological screening identified 234 drugs that were not identified by DOA-POCT. However, DOA-POCT identified 34 DOA that were not identified by comprehensive toxicological screening.Seven percent of comprehensive toxicological screening results were found to be clinically relevant, all with regard to diagnosis. GHB and ketamine were the drugs involved. Another 38 % strengthened confidence in diagnosis and patient care decisions. CONCLUSION: GHB and ketamine should be added to the panel of drugs we screen at the point of care in the Amsterdam acute setting.

Motherhood after cancer: fertility and utilisation of fertility-preservation methods.

PURPOSE: Due to modern and individualised treatments, women at reproductive age have a high survival rate after cancer therapy. What are pregnancy and birth rates of women after cancer and how often do they use cryopreserved ovarian tissue or gametes? METHODS: From 2007 to 2015, 162 women aged 26.7 ± 6.9 years were counselled for fertility preservation at a single University Fertility Centre. A questionnaire study was performed in average 3 and 6 years after the diagnosis of cancer. The women were asked about their fertility, partnership, family planning, and pregnancy history. 72 women (51%) answered a written questionnaire in 2016. 59 women were reached again by phone in 2019 (82%). RESULTS: The preferred method of fertility preservation was ovarian tissue cryopreservation (n = 36, 50%); none of the women had ovarian hyperstimulation in order to cryopreserve oocytes. About 3 years after treatment, 37 women of 72 women (51%) of the women with a mean age of 29.9 years had a strong wish to conceive. 21/72 (29%) had actively tried to conceive after successful cancer treatment; eight women (11%) were already pregnant or had children. Six years after cancer diagnosis 16/59 (27%) women had ongoing anticancer treatment. 12/59 (20%) were pregnant or had children, while 39% (23/59) had no menstrual cycle. Only one woman used her cryopreserved ovarian tissue, but did not become pregnant. CONCLUSION: After cancer and gonadotoxic treatment, women's desire to have a child is substantial. In this study, the rate of spontaneous pregnancies and births was 20% 6 years after gonadotoxic therapies. Not every woman, however, has the opportunity to conceive: factors impairing fertility include ongoing cancer treatment or persistent disease, no partner, no menstrual cycle, as well as other reasons for infertility.

Stability of Furosemide 5 mg/mL in Polypropylene Syringes.

Furosemide parenteral solutions are routinely used in our hospital. However, the stability in transparent syringes is unknown. In this study, transparent polypropylene syringes were filled with 8 mL and 50 mL of furosemide 5-mg/mL solution. The furosemide was analyzed by high-performance liquid chromatography and assays were performed up to 35 days of storage of the syringes at 4°C protected from light, plus 24 hours at 20°C exposed to daylight. In addition, the appearance and pH of the solutions were determined. A microbiological assay using tryptic soy broth was also performed. Both types of syringes remained colorless, clear, and free from visible particles throughout the study period. The pH did not change, and concentrations remained between 95% and 105% of the stated concentration. None of the syringes filled with culture media exhibited bacterial or fungal growth. In conclusion, ready-to-administer furosemide 5-mg/mL, 8-mL, and 50-mL polypropylene syringes are stable for up to 35 days when stored in a refrigerator at 4°C protected from light, plus 24 hours at 20°C unprotected from light. These results allow maximum storage time in stock and the ability of 24-hour continuous infusion at ambient room temperature without protecting the syringe against light.

An interlaboratory study on the suitability of a gradient LC-UV method as a compendial method for the determination of erythromycin and its related substances.

A liquid chromatographic (LC) method for the analysis of erythromycin and related substances has been adapted from an isocratic method developed by Chepkwony et al. (2001). The suitability of the method for general application as a compendial (pharmacopoeia) method has been assessed by means of an interlaboratory (collaborative) study. The method involves LC separation on a XTerra C18 column kept at 65 degrees C and UV detection at 210 nm. Five laboratories, located in Europe and the United States (US), participated in the study. Four erythromycin samples were tested. The main components (erythromycin A (EA), erythromycin B (EB), erythromycin C (EC)) and the impurities were determined. The analysis of variance was carried out on the results of the five laboratories to evaluate the between-laboratory consistencies and the laboratory-sample interaction. The estimates for the repeatability and reproducibility of the method, expressed as relative standard deviation (RSD) of the result of the determination of EA, were calculated to be 0.8% and 1.4% respectively. It is concluded that the method examined is a good replacement for the methods currently described in the European Pharmacopoeia (Ph. Eur.) and the United States Pharmacopoeia (USP), especially for its enhanced selectivity.

Intracavity terahertz-wave generation in a synchronously pumped optical parametric oscillator using quasi-phase-matched GaAs.

We generated 1 mW of average output power at 2.8 THz (bandwidth of approximately 300 GHz) in a diffraction-limited beam by placing a 6-mm-long quasi-phase-matched GaAs crystal inside the cavity of a synchronously pumped optical parametric oscillator (OPO). The OPO used type-II-phase-matched periodically poled lithium niobate as a gain medium and was pumped by a mode-locked laser at 1064 nm, with a 7 ps pulse duration, 50 MHz repetition rate, and 10 W average output power. The terahertz radiation was generated by difference frequency mixing between the signal and idler waves of the near-degenerate doubly resonant OPO.

The role of shear stress in the destabilization of vulnerable plaques and related therapeutic implications.

American Heart Association type IV plaques consist of a lipid core covered by a fibrous cap, and develop at locations of eccentric low shear stress. Vascular remodeling initially preserves the lumen diameter while maintaining the low shear stress conditions that encourage plaque growth. When these plaques eventually start to intrude into the lumen, the shear stress in the area surrounding the plaque changes substantially, increasing tensile stress at the plaque shoulders and exacerbating fissuring and thrombosis. Local biologic effects induced by high shear stress can destabilize the cap, particularly on its upstream side, and turn it into a rupture-prone, vulnerable plaque. Tensile stress is the ultimate mechanical factor that precipitates rupture and atherothrombotic complications. The shear-stress-oriented view of plaque rupture has important therapeutic implications. In this review, we discuss the varying mechanobiologic mechanisms in the areas surrounding the plaque that might explain the otherwise paradoxical observations and unexpected outcomes of experimental therapies.

Imaging of coronary atherosclerosis and identification of the vulnerable plaque.

Identification of the vulnerable plaque responsible for the occurrence of acute coronary syndromes and acute coronary death is a prerequisite for the stabilisation of this vulnerable plaque. Comprehensive coronary atherosclerosis imaging in clinical practice should involve visualisation of the entire coronary artery tree and characterisation of the plaque, including the three-dimensional morphology of the plaque, encroachment of the plaque on the vessel lumen, the major tissue components of the plaque, remodelling of the vessel and presence of inflammation. Obviously, no single diagnostic modality is available that provides such comprehensive imaging and unfortunately no diagnostic tool is available that unequivocally identifies the vulnerable plaque. The objective of this article is to discuss experience with currently available diagnostic modalities for coronary atherosclerosis imaging. In addition, a number of evolving techniques will be briefly discussed.

Optical coherence tomography.

BACKGROUND: Optical coherence tomography (OCT) is a light-based imaging modality that can be used in biological systems to study tissues in vivo with near-histologic, ultrahigh resolution. The rationale for intravascular application of OCT is its potential for in vivo visualisation of the coronary artery microstructure. METHODS AND RESULTS: The principle is analogous to pulse-echo ultrasound imaging; however, light is used rather than sound to create the image. Low-coherent near-infrared light is emitted by a superluminescent diode and reflected by the microstructures within biological tissues. The echo time delay of reflected light waves is converted into a two-dimensional spatial image. The intensity of the reflected light waves is translated into an intensity map. Experimental studies confirmed the ability of intravascular OCT for plaque characterisation and accurate assessment of vascular structures that are close to the luminal surface. Preliminary clinical experience proved in vivo feasibility of intravascular OCT. A variety of atherosclerotic plaque structures including thin cap fibroatheromas can be visualized in vivo. CONCLUSIONS: Intravascular OCT allows for accurate assessment of vessel structures close to the luminal side. Clinical application is feasible. To date, however, the clinical relevance of OCT findings in coronary arteries is unclear and further validation of OCT imaging is mandatory.

Effect of temperature increase and freezing on intravascular elastography.

Intravascular ultrasound (IVUS) elastography is a technique that assesses the local strain in the vessel wall and plaque. The strain is an important parameter for characterization of different plaque components. These regions are related to plaque vulnerability. IVUS elastography was validated in vitro using human coronary and femoral arteries. These experiments were performed on specimens that were stored frozen and measured at room temperature for practical issues. The aim of this study is to determine the influence of freezing and measuring the tissues at room temperature (23 degrees C instead of 37 degrees C) on the elastic properties. Four human coronary, one carotid and one femoral arteries were first measured at 23 degrees C and next at 37 degrees C. Additionally they were stored at -80 degrees C for up to 24 h and finally measured at 23 degrees C. Acquisitions at intraluminal pressures of 80 and 100 mmHg were performed using an EndoSonics 20 MHz Visions catheter. Elastograms were determined from the IVUS rf-data (sampled at 100 MHz in 12 bits) that were obtained from a digital interface. Qualitative and quantitative analysis of the elastograms obtained from fresh and frozen specimens measured at 23 degrees C reveals that storage of the specimen at -80 degrees C has no significant influence. In vitro experiments can be performed at room temperature after storage of the tissue at -80 degrees C without significant affection of the information with respect to measuring fresh ex vivo material at body temperature.

Myocardial lactate release after intracoronary verapamil application in humans: acute effects of intracoronary verapamil on systemic and coronary hemodynamics, myocardial metabolism, and norepinephrine levels.

Coronary and systemic hemodynamic effects of verapamil have been investigated previously in detail. The acute impact of intracoronary verapamil on coronary hemodynamics has, however, not been correlated to simultaneously changes in myocardial metabolism or norepinephrine levels in humans. After bolus application of 1 mg verapamil into the left coronary artery of 52 patients scheduled for routine coronary angiography, heart rate (HR) remained unchanged, whereas mean arterial blood pressure (MAP) decreased (93.8 +/- 14.9 mmHg to 85.1 +/- 13.7 mmHg, p = 0.001). Coronary blood flow (CBF), calculated from intracoronary Doppler measurements and quantitative coronary angiography, increased after verapamil administration (28.5 +/- 16.7 ml/min to 66.2 +/- 41.8 ml/min, p < 0.001), whereas coronary vascular resistance index (CVRI) decreased (1.43 +/- 0.92 to 0.46 +/- 0.23, p < 0.001). Blood samples, taken simultaneously from the aorta (Ao) and coronary sinus (CS) at baseline and at maximal flow velocity, showed an increase in norepinephrine concentrations in Ao (209 +/- 151 ng/l to 283 +/- 195 ng/l, p < 0.001) and CS (233 +/- 162 ng/l to 323 +/- 248 ng/l, p = 0.004). Myocardial metabolism of pyruvate and free fatty acids were not affected. Glucose release was augmented and initial lactate consumption changed to a net lactate release into the CS (Ao to CS differences: glucose: -1.92 +/- 9.9 mg/dl to -12.8 +/- 22.8 mg/dl, p < 0.001; lactate: 0.07 +/- 0.2 mmol/l to -0.08 +/- 0.3 mmol/l, p = 0.001). Similar results were obtained for the extraction ratios and flux of these metabolites. There was a weak correlation between the increase in CBF and lactate release into the CS. This is the first report of unexpected myocardial lactate release following intracoronary verapamil administration in humans. This lactate release was paralleled by an increased glucose release into the CS at an unchanged metabolism of free fatty acids and pyruvate. One explanation for this unexplained lactate release during increased coronary blood flow might be a wash out phenomenon of lactate from previous ischemic areas, other explanations might be the induction of paradox myocardial ischemia and/or a steal effect. Further studies are necessary to explain these unexpected findings of increased coronary flow and myocardial lactate release. Until reliable explanations are pending, studies using only lactate release as a marker of myocardial ischemia, without taken coronary and systemic hemodynamic parameters into account, should be interpreted with caution.

Tei-index in patients with mild-to-moderate congestive heart failure.

BACKGROUND: Congestive heart failure is related to contraction and relaxation abnormalities of the ventricle. Isolated analysis of either mechanism may not be reflective of overall cardiac dysfunction. A combined myocardial performance index (isovolumic contraction time plus isovolumic relaxation time divided by ejection time, 'Tei-Index') has been described which may be more effective for analysis of global cardiac dysfunction than systolic and diastolic measures alone. It was the aim of the present investigation to evaluate the Tei-Index against invasive examination. METHODS AND RESULTS: Eighty-one subjects were included in a consecutive manner, among 125 patients undergoing left heart catheterization for invasive measurement of left ventricular end-diastolic pressure; 43 patients had congestive heart failure (35 male, 8 female, 68+/-6 years) defined by NYHA functional class >/=2 (mean 2.5+/-0.5) and left ventricular end-diastolic pressure >/=16 mmHg (mean 20+/-4) and 38 subjects (32 male, 6 female, 66+/-5 years) without symptoms of heart failure (NYHA functional class I) and with normal left ventricular end-diastolic pressure (mean 12+/-3 mmHg) served as a control group. Using conventional echo-Doppler methods, parameters assessed were: ejection fraction, peak velocities of early (E) and late (A) diastolic filling, the E/A ratio, deceleration time, isovolumic contraction time, isovolumic relaxation time and ejection time. The Tei-Index was obtained by subtracting ejection time from the interval between cessation and onset of the mitral flow. The control group and patients with congestive heart failure did not differ with respect to the E/A ratio (0.86+/-0.27 vs 0.90+/-0.44, P=ns), deceleration time (203+/-42 ms vs 206+/-36 ms, P=ns) and isovolumic relaxation time (97+/-16 ms vs 94+/-26 ms, P=ns). The ejection fraction was slightly reduced in patients with congestive heart failure (46+/-11% vs 55+/-8%, P<0.05). The Tei-Index was easily and reproducibly measured in all subjects. The mean value of the Tei-Index was significantly different between the control group and patients with congestive heart failure (0.39+/-0.10 vs 0.60+/-0.18, P<0.001). Receiver operating characteristic curve analysis for the Tei-Index yielded an area under the curve of 0.88+/-0.038. Using a Tei-Index >/=0.47 as the cutpoint, congestive heart failure was identified with a sensitivity of 86% and a specificity of 82%. No correlation was observed between the Tei-Index and heart rate (r=0.22, P=ns), systolic blood pressure (r=0.16, P=ns) or diastolic blood pressure (r=0.08, P=ns). The Tei-Index was significantly related to left ventricular end-diastolic pressure (r=0.46, P<0.01). CONCLUSION: The Tei-Index is a sensitive indicator of overall cardiac dysfunction in patients with mild-to-moderate congestive heart failure. The Tei-Index is easily obtained and may be used in the work-up of patients with suspected cardiac dysfunction.

Tissue Doppler imaging: a new technique for assessment of pseudonormalization of the mitral inflow pattern.

Left ventricular diastolic dysfunction (LVDD) is a frequent cause of heart failure. Doppler echocardiography has become the method of choice for the noninvasive evaluation of LVDD. However, pseudonormalization (PN) of the mitral inflow often presents a diagnostic challenge in clinical practice. In this setting, we sought to define the role of tissue Doppler imaging (TDI) of the septal mitral annulus. Echocardiography was performed in 36 consecutive subjects (age 59 +/- 10 years). Eighteen of these had diagnosed coronary artery disease (CAD) with recent onset of symptoms (within 3 months), 18 had clinical suspicion of CAD, and 15 had symptoms of heart failure (New York Heart Association [NYHA] Class 2.4 +/- 0.5). The mitral inflow profile (E, A, E/A) was measured by pulsed Doppler, and the deceleration time (DT) and the isovolumic relaxation time (IVRT) were calculated. Peak diastolic velocities of the septal mitral annulus (E(T), A(T), E(T)/A(T)) and the time interval from Q in the ECG to the onset of E(T) were derived from pulsed TDI. Left heart catheterization was performed for direct measurement of left ventricular end-diastolic pressure (LVEDP). PN defined by an E/A ratio > 1 and an LVEDP > or = 16 mmHg was found in nine patients. All patients with PN had symptoms of heart failure (NYHA Class 2.8 +/- 0.5). Patients with and without PN did not differ with respect to the E/A ratio (1.29 +/- 0.44 vs 1.16 +/- 0.23, P = ns), DT (182 +/- 38 msec vs 205 +/- 42 msec, P = ns), and IVRT (88 +/- 24 msec vs 92 +/- 18 msec, P = ns). In the group with PN, a significant reduction of E(T) (5.6 +/- 1.8 cm/sec vs 8.8 +/- 2. 9 cm/sec, P < 0.05) and E(T)/A(T) (0.5 +/- 0.16 vs 0.82 +/- 0.37, P < 0.05) was detected. In the PN group, the Q-E(T) interval was prolonged (404 +/- 48 msec vs 346 +/- 50 msec, P < 0.05). Receiver operating characteristic curve analysis for E(T) yielded an area under the curve of 0.78 +/- 0.06 (P = 0.034) for separating patients with versus without PN. When the combination of E(T) < 7 cm/sec and E(T)/A(T) < 1 was used as cutpoint, PN could be identified with a sensitivity of 83% and a specificity of 79%. There was no significant relation between LVEDP and either E(T) (r = 0.32, P > 0. 2) or the Q-E(T) interval (r = 0.14, P > 0.5). In conclusion, E(T) and the Q-E(T) interval appear to be useful parameters for assessing LV diastolic dysfunction in symptomatic patients with a pseudonormal mitral inflow pattern and elevated filling pressures.

[Anti-ischemic effect of verapamil within the scope of interventional recanalization]. / Antiischämische Wirkung von Verapamil im Rahmen einer interventionellen Rekanalisation.

We report on a 46-year-old male with unstable angina pectoris due to a total proximal occlusion of the left circumflex artery. At the side of a plaque rupture there was a thrombotic occlusion. With PTCA recanalization was possible, but a dissection occurred, therefore coronary stents were implanted. Besides an optimal morphological result and recurrent applications of nitroglycerin, the baseline blood flow velocity declined from initial 16 cm/s to 11 cm/s after PTCA down to 8.4 cm/s after stent implantation. Because peak flow velocity remained almost unchanged, the low baseline velocity ("slow flow phenomenon") did not lead to an impaired coronary flow velocity reserve (CFVR). Only after application of 1 mg verapamil, a sustained flow velocity on a higher baseline level was reached (17 cm/s), at the same time typical signs of ischemia in the ECG (ST-segment depressions) improved. Additionally, in the non-treated LAD there was an increase in coronary blood flow velocity from 10 cm/s up to 25 cm/s. The reduction in coronary blood flow velocity with increasing manipulations might be due to an impairment of the coronary microcirculations with increasing alpha-adrenergic vasoconstriction, a distribution of vasoactive agents and peripheral microembolizations. Only after administration of verapamil, a calcium channel blocker with non-specific anti-adrenergic effects, the slow flow was removed and ECG signs of ischemia improved. The blood flow velocity in the non-treated LAD was low at baseline and improved after verapamil. This phenomenon leads to the conclusion that mechanisms with vasoconstrictive effect are present in the whole coronary system, but these mechanisms are less pronounced in non-treated vessels.

Tissue Doppler imaging (TDI) for on-line detection of regional early diastolic ventricular asynchrony in patients with coronary artery disease.

Diastolic filling of the left ventricle is often impaired in patients with coronary artery disease (CAD) in the absence of systolic wall motion abnormalities or previous myocardial infarction. The current study was designed to assess the ability of tissue Doppler imaging (TDI) for on-line detection of regional diastolic wall motion abnormalities to identify CAD in patients with preserved systolic function. 20 normal subjects (age 51 +/- 13 years) and 17 CAD patients with normal systolic function and > or = 70% luminal narrowing of the LAD (age 56 +/- 11 years) were included. Coronary anatomy was unknown to the echocardiographer. In the parasternal short axis and the apical 4-chamber-view, peak tissue velocities of the anterior/inferior and the midseptal/midlateral LV segments during rapid ejection (RE), isovolumic relaxation (IR), rapid filling (RF) and atrial contraction (AC) were analyzed by color-M-Mode-TDI. In the apical view, in 13 of 35 (37%) patients with adequate recordings, myocardial asynchrony was detected during IR: while the septum was moving inwards (red color-coding), the lateral wall was moving outwards (blue/green coding). In the remaining 22 patients (63%) a slow, synchronous outward motion of septum and lateral wall with homogeneous color-coding (blue/green) was seen. Unblinding of the coronary status revealed a critical LAD stenosis in all 13 patients (100%) with myocardial asynchrony. Analysis of midseptal peak velocities during IR revealed positive velocities (1.22 +/- 1.64 cm/s) in CAD patients and negative velocities (-1.39 +/- 0.81 cm/s) in normal subjects. Thus, TDI allowed for the on-line detection of early diastolic asynchrony in 13 of 16 (82%) patients with critical LAD-narrowing. Due to the rapid assessment of regional wall motion abnormalities, TDI might help to identify CAD in patients with normal systolic function.

M-mode analysis of mitral annulus motion for detection of pseudonormalization of the mitral inflow pattern.

Left ventricular (LV) diastolic dysfunction is a frequent cause of heart failure. Doppler echocardiography has become the method of choice for the noninvasive evaluation of LV diastolic dysfunction. However, pseudonormalization of mitral inflow often presents a diagnostic problem in clinical practice. We sought to define the role of mitral annulus motion in this setting. We performed echocardiography in 36 consecutive subjects (age 59 +/- 10 years). Eighteen had recently (within 3 months) been diagnosed with coronary artery disease, 18 had clinical suspicion of coronary artery disease, and 15 had symptoms of heart failure (New York Heart Association class 2.4 +/- 0.5). The amplitude (E(M)) and the slope (slope E) of early diastolic motion of the septal mitral annulus were derived from M-mode analysis. Left heart catheterization was performed for direct measurement of LV end-diastolic pressure. Pseudonormalization defined by an E/A ratio > 1 and a LV end-diastolic pressure > or = 16 mm Hg was found in 9 patients. All patients with pseudonormalization were symptomatic (New York Heart Association class 2.8 +/- 0.5). Patients with and without pseudonormalization did not differ with respect to the E/A ratio (1.29 +/- 0.44 vs 1.16 +/- 0.23, p = NS), deceleration time (182 +/- 38 vs 205 +/- 42 ms, p = NS), and isovolumic relaxation time (88 +/- 24 vs 92 +/- 18 ms, p = NS). In the group with pseudonormalization, a significant reduction of E(M) (3.9 +/- 1.6 vs 5.7 +/- 1.5 mm, p = 0.008) and slope E (24.5 +/- 11.8 vs 43.9 +/- 7.7 mm/s, p <0.001) was detected. Using E(M) <4.3 mm and slope E <35 mm/s as cut points, sensitivity and specificity for the detection of pseudonormalization were 66% and 82% for E(M) and 77% and 87% for slope E, respectively. There was no significant relation between LV end-diastolic pressure as a measure of preload and either E(M) (r = 0.44, p >0.5) or slope E (r = 0.30, p >0.2). Thus, E(M) and slope E may be preload-independent tools for assessing LV diastolic dysfunction in symptomatic patients with a pseudonormal mitral inflow pattern and elevated filling pressures.

[Analysis of mitral annulus excursion with tissue Doppler echocardiography (tissue Doppler echocardiography = TDE). Noninvasive assessment of left ventricular, diastolic dysfunction]. / Analyse der Mitralringexkursion mittels Gewebedopplerechokardiographie (Tissue Doppler echocardiography = TDE). Nichtinvasive Aufdeckung einer linksventrikulären, diastolischen Funktionsstörung.

BACKGROUND: Mitral inflow velocity, deceleration time, and isovolumic relaxation time recorded by Doppler echocardiography have been widely used to evaluate left ventricular diastolic function but are affected by age, heart rate, loading conditions, and other factors. The diastolic mitral anulus velocity assessed by tissue Doppler echocardiography (TDE) was suggested to provide additional information about LV relaxation less affected by filling pressures. AIM OF THE STUDY: This study was designed to assess the clinical utility of mitral anulus velocity in the evaluation of left ventricular diastolic function. PATIENTS AND METHODS: Three groups of patients with a systolic ejection fraction > 45% were separated: 10 normal volunteers (60 +/- 10 y, CON group), 15 asymptomatic patients with known coronary artery disease (60 +/- 11 y, CAD group) and 15 patients with long-term arterial hypertension and heart failure symptoms (58 +/- 9 y, HYP group). The mitral inflow profile (E, A, E/A) was measured by pulsed Doppler, and the deceleration time (DT) and the isovolumic relaxation period (IVRT) were calculated. Systolic, early, and late diastolic velocities of the septal mitral anulus (ST, ET, AT, ET/AT) were assessed by pulsed TDE. All study subjects had invasive measurements of left ventricular end diastolic filling pressures during left heart catheterization. RESULTS: In the AH group, ET (6.9 +/- 4.8 cm/s) and ET/AT (0.71 +/- 0.28) were reduced compared to the CON group (11.7 +/- 4.7 cm/s and 1.11 +/- 0.36, p < 0.05, respectively) and the CAD group (8.9 +/- 5.4 cm/s and 0.85 +/- 0.26, respectively, p = ns). The groups did not differ with respect to the mitral E/A ratio, the deceleration time and the isovolumic relaxation time. LVED in the HYP group (16 +/- 8 mm Hg) was elevated compared to the CON group (8 +/- 3, p < 0.05) and the CAD group (12 +/- 6 mm Hg, p = ns). No correlation was found between ET and LVED (r = 0.26). When the combination of mitral E/A ratio > 1 with LVED > or = 15 mm Hg was classified as pseudonormalization, the pseudonormalization could be identified by a peak early diastolic mitral anulus velocity (ET) < 7 cm/s and an ET/AT ratio < 1 with a sensitivity of 77% and a specificity of 88%. CONCLUSIONS: The early diastolic mitral anulus velocity assessed by TDE (ET) is a preload-independent index of LV relaxation. TDE permits the detection of diastolic dysfunction in patients with a pseudonormal mitral inflow and elevated filling pressures.

[Aortic rupture after blunt chest trauma. Rapid diagnosis using transesophageal echocardiography when radiographic and computed tomographic findings are unclear]. / Aortenruptur nach stumpfem Thoraxtrauma. Rasche Diagnose durch transösophageale Echokardiographie bei unklarem Röntgen- und CT-Befund.

HISTORY AND CLINICAL FINDINGS: A 37-year-old woman who was not wearing a seat-belt while driving a car had a head-on collision at 70 km/h. On arrival of the emergency physician she was awake and responsive but complained of pain with bruising over the sternum and the epigastrium. Pressure on the sternum was painful. Arterial pressure was 95/60 mm Hg, heart rate 112/min. On admission the heart sounds were unremarkable and peripheral pulses normal. Vesicular sounds were heard over both lungs. In addition to multiple facial abrasions voluntary movements were impaired and the right knee-joint was swollen. INVESTIGATIONS: The ECG showed sinus tachycardia (103 beats/min) with left axis deviation, but was otherwise unremarkable. Initially the haemoglobin was 12.6 g/dl with normal white cell and platelet counts. Clotting tests, serum transaminases, creatine kinase, lactate dehydrogenase and other routine laboratory tests were within normal limits. TREATMENT AND COURSE: Because the haemoglobin level had fallen to 7.7 g/dl within the first 4 hours erythrocytes concentrate was infused. The chest radiogram and subsequent computed tomography showed a mediastinal and paraaortic haematoma of unclear origin. Transoesophageal echocardiography (TEE) demonstrated rupture of the descending aorta with free floating intraluminal parts of the intima in the isthmal region, just distal to the origin of the left subclavian artery, which was not occluded. Colour Doppler echocardiography revealed abnormal flow into mediastinal and paraaortic tissues. At operation the echocardiographic findings were confirmed and part of the descending aorta was replaced by a 3 cm dacron tube during an aortic crossclamping time of 37 min. The patient was discharged after a postoperative stay of average length, during which her other injuries were treated. CONCLUSION: After blunt thoracic or deceleration trauma earliest possible TEE is indicated, because it can at once provide details of extent and degree of injury to heart and/or aorta.

[Improved structure identification with tissue Doppler echocardiography]. / Verbesserte Strukturidentifizierung mittels Gewebe-Doppler-Echokardiographie.

Tissue Doppler echocardiography (TDE) has been shown to be of particular value in patients with impaired myocardial function. Recently, the technique was successfully employed to localize the ventricular insertion of accessory atrioventricular pathways. The identification of abnormal cardiac structures is coming up now as a new field of clinical interest. The purpose of this study was to differentiate anomalous cardiac and aortic from native structures by physical properties of tissue motion using transesophageal TDE. Characteristic motion patterns of anomalous structures have not been described in detail and tissue Doppler findings have not been associated with clinical features up to now. Forty consecutive patients were included after anomalous cardiac or vascular structures had been detected by conventional transesophageal echocardiography (TEE). A control group consisted of 20 subjects. Rapidity of diagnosis in anomalous structures was divided into 3 categories, and TDE signals were related to particular pathology by a blinded, 2nd observer. Three different motion patterns could be defined: incoherent motion due to free oscillation of an anomalous structure which is independent of the surrounding tissue (Figure 1b); coherent motion with a phase difference meaning that motion depends on the motion of the surrounding tissue but is out of phase (Figure 2); concordant motion showing no difference in direction, velocity, or phase of motion compared with the surrounding tissue. Incoherent motion was present in endocarditic vegetations, 4th degree aortic plaques, Chiari network, valvular prolapse, intracavitary tumors, and freely oscillating thrombi as well as in normal valve leaflets and papillary muscles. Especially if endocarditic vegetations are present its incoherent motion facilitates to recognize these small structures. The colorcode of this motion pattern demarcates the vegetation reliably from the surrounding tissue (Figure 1b). Within 15 seconds vegetations could be detected in 9 (82%) vs 2 (18%) patients employing only conventional imaging. Using conventional echocardiographic approaches detection of vegetations is frequently hindered by their small size and minor echo intensity (Figure 1a). In contrast, size and echo intensity do not affect the tissue Doppler signal. Normal papillary muscles and distal portions of the mitral and tricuspid valves were demonstrated to regularly meet the criterion of incoherent tissue motion in the control group. In part, this was also observed with respect to the aortic and pulmonary valves. In valvular tissue incoherent motion was caused by passive floating, whereas papillary muscles show an active inverse motion for short time intervals. Nevertheless, physiologic incoherent motion did not lead to any false differential diagnosis. The phase difference of coherent motion results from damped oscillation. This phenomenon was visualized by tissue Doppler M-mode in 5 thrombi of the left atrial appendage (LAA) (100%) and in 1 ventricular thrombus (50% of all clots). Concordant motion was shown in 3rd degree aortic plaques and postrheumatic and calcified vegetations. These structures were found to be completely embedded or closely attached, so that their passive motion corresponded to the motion of the surrounding regular tissue. Detection and assessment of anomalous structures are based on their motion patterns which can be synchronous or asynchronous in comparison with the surrounding tissue. Another goal of this investigation was to test if the sensitivity of TEE to spontaneous echo contrast can be improved using TDE. In 21 patients presenting with left atrial dilation (left atrial diameter > 44 mm) due to mitral stenosis (n = 8), mitral regurge (n = 5), arterial hypertension (n = 5) and multiple valvular disease (n = 3) fundamental multiplane TEE and transesophageal TDE were performed with standardized gain setting. The control group consisted of 20 randomized individuals with normal left