Practical guidance and clinical applications of transoesophageal echocardiography. A position paper of the working group of echocardiography of the Hellenic Society of Cardiology.

Transoesophageal echocardiography (TOE) is a well-established imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for a wide spectrum cardiac and extra-cardiac diseases. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Cardiology Society to state the essential steps of the typical TOE exam performed in echo lab. This is an educational text, describing the minimal requirements and the preparation of a meticulous TOE examination. Most importantly, it gives practical instructions to obtain and optimize TOE views and analyses the implementation of a combined two-and multi-dimensional protocol for the imaging of the most common cardiac structures during a TOE. In the second part of the article a comprehensive review of the contemporary use of TOE in a wide spectrum of valvular and non-valvular cardiac diseases is provided, based on the current guidelines and the experience of the WG members.

Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: An expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology.

Stress echocardiography (SE) is a well established and valid technique, widely used for the diagnostic evaluation of patients with ischemic and nonischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of present medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training-which focus on the preparation, the protocols used, the analysis of the SE images, and updated, evidence-based knowledge about SE applications on ischemic and nonischemic heart diseases, such as in cardiomyopathies, heart failure, and valvular heart disease.

Neutrophil count on admission predicts major in-hospital events in patients with a non-ST-segment elevation acute coronary syndrome.

BACKGROUND: Inflammation plays a key role in the pathogenesis of acute coronary syndromes (ACS). In this context we assessed neutrophil count as a predictor of major in-hospital events in patients admitted for a non-ST-segment elevation (NSTE) ACS. METHODS: We measured neutrophils on admission in 160 patients with a NSTE ACS and we correlated their count with the incidence of a combined in-hospital end point including: cardiac death, acute heart failure, ST-segment elevation myocardial infarction, and recurrent myocardial ischemia. RESULTS: Patients who had a major in-hospital event also had a higher neutrophil count (P = 0.02) and higher serum levels of troponin I (P = 0.04). In the univariate logistic regression analysis, in-hospital major events could be predicted by troponin I > 0.07 ng/mL (odds ratio [OR]: 5.65, 95% confidence interval [CI]: 1.26-25.32, P = 0.02), white blood cell count > 8650 cells/microL (OR: 2.68, 95% CI: 1.03-6.95, P = 0.04), neutrophil count > 6700 cells/microL (OR: 7.74, 95% CI: 2.79-21.47, P < 0.001), and C-reactive protein > 0.97 mg/dL (OR: 3.56, 95% CI: 1.13-11.19, P = 0.02). However, in multivariate regression, neutrophil count > 6700 cells/microL (OR: 6.52, 95% CI: 1.56-27.22, P = 0.01) was the only independent in-hospital prognostic factor. CONCLUSIONS: In patients with a NSTE ACS of moderate or high risk, neutrophil count on admission may identify those who are at risk of having an adverse in-hospital outcome.

Prevalence and potential mechanisms of sustained ventricular arrhythmias during dobutamine stress echocardiography: a literature review.

Sustained ventricular tachycardia during dobutamine stress echocardiography is a rare complication of dobutamine stress echocardiography. It may be related to reduced left ventricular function and prior myocardial infarction but cannot be used as a sensitive or specific sign for myocardial ischemia. The clinical significance of dobutamine stress echocardiography-induced sustained ventricular tachycardia is uncertain, and this condition probably does not represent an adverse prognostic sign.

Severe mitral regurgitation due to perforation of the mitral anterior leaflet.

We present a case of a 75-year-old male with a worsening dyspnea during the last month. Transthoracic echocardiography revealed a severe mitral regurgitation. Transesophageal echocardiography was evident of a 6 mm defect of the mitral anterior leaflet at the region of the anteromedial A1 and medial A2 scallops probably due to perforation, which caused a significant regurgitant jet as documented by the presence of a convergence flow over the 'hole'. As the patient had a prolonged fever of undetermined origin one and a half months ago, perforation of the mitral anterior leaflet must at least be considered to be of an infective origin.

Mahaim fibre coexisting with anomalous origin of the left main coronary artery from the right aortic sinus and an interarterial course.

We present the case of a 45-year-old female with a normal heart, who exhibited an episode of a broad QRS tachycardia that was initially suggested to be sustained ventricular tachycardia. Coronary angiography showed the left main stem originating from the right aortic sinus with an interarterial course between aorta and right ventricular outflow tract. Electrophysiological study revealed the presence of a right atriofascicular accessory pathway with decremental antegrade conduction (Mahaim bundle), which was successfully ablated.

Success, safety, and efficacy of implantation of diamond-like carbon-coated stents.

The aim of this study was to evaluate safety and clinically defined efficacy of the implantation of a new stent coated with diamond-like carbon (DLC stent), in a group of patients who underwent percutaneous transluminal coronary revascularization procedures in two hemodynamic centers. This study was an observational prospective nonrandomized study that included 196 patients with a total of 236 significant de novo atheromatous coronary lesions, in which 245 DLC stents were implanted. The primary end point of this study was a composite of major cardiovascular events (death or acute myocardial infarction with or without Q) and need for target lesion revascularization (TLR) or target vessel revascularization (TVR) procedure during the first 48 hours and at 6 months after the DLC stent implantation. All patients had a myocardial perfusion imaging study with Tl(201) at 6 months after DLC stent implantation. Only patients with a myocardial perfusion imaging study indicative of myocardial ischemia were then submitted for a new coronary angiogram. No major cardiovascular event or emergency TVR occurred during hospitalization. At 6-month follow-up no major cardiovascular event occurred either, whereas the rate for TLR was 5.6% and that for TVR was 7.65%. This preliminary study provides enough clinical evidence that implantation of intracoronary bare metal stents coated with diamond-like carbon is associated with high success rates, safety, and efficacy, both in the hospital and at the 6-month follow-up after the interventional procedure.

Spontaneous thrombus formation in a normal left ventricle following administration of large doses of epoietin.

We present a case of a thrombus formation within the left ventricle of a patient with a normal heart, who had previously been receiving high doses of erythropoietin for an inappropriately prolonged period.

Acute changes in N-terminal pro-brain natriuretic peptide induced by dobutamine stress echocardiography.

AIMS: Aim of the study was to determine the effect of dobutamine stress echocardiography (DSE)-induced ischemia on circulating levels of N-terminal fragment of B-type natriuretic peptide (NT-pro-BNP). METHODS AND RESULTS: One hundred and twenty-eight patients underwent DSE for the evaluation of known or suspected coronary artery disease. NT-pro-BNP levels were measured before and 1h after completion of DSE. NT-pro-BNP levels were similar before and after DSE regardless of whether patients had (123+/-101.8 vs. 124.2+/-108.3, p=NS) or did not have inducible ischemia (96.5+/-70.5 vs. 100.5+/-71.1, p=NS). Patients with inducible myocardial ischemia had no different NT-pro-BNP levels compared to patients without inducible ischemia both before (123+/-101.8 vs. 96.5+/-70pg/ml, p=0.37) and after DSE (124.2+/-108.3 vs. 100.5+/-71.1pg/ml, p=0.55). Patients with severe inducible ischemia had significantly higher NT-pro-BNP levels compared to patients with mild or moderate inducible ischemia and patients without inducible ischemia, both before (208.5+/-125.5 vs. 96+/-78.9 vs. 96.5+/-70pg/ml, p=0.017 and p=0.025, respectively) and after DSE (212.5+/-138.1 vs. 94.8+/-81.1 vs. 100.5+/-71.1pg/ml, p=0.015 and p=0.023, respectively). NT-pro-BNP levels before DSE could be independently predicted by age (p<0.0001), presence of diabetes mellitus (p=0.002), and ejection fraction (p=0.005), but not DSE inducible ischemia. CONCLUSION: NT-pro-BNP is not affected by DSE-induced ischemia and cannot be used in clinical practice to improve diagnostic accuracy of DSE.