Incidental visceral and renal artery stenosis in patients undergoing coronary angiography.

PURPOSE: The study aimed to examine the association between incidentally discovered mesenteric artery stenosis, renal artery stenosis (RAS) and coronary artery disease in patients undergoing coronary angiography. MATERIALS AND METHODS: We performed a prospective analysis of consecutive patients undergoing routine cardiac catheterisation. Abdominal aortograms in lateral and antero-posterior view were obtained to assess arterial stenosis of the coeliac axis, superior mesenteric artery and renal arteries. Significant arterial stenosis was defined as a narrowing of at least 50% compared with the normal artery. Demographic data and cardiovascular risk factors were analysed. RESULTS: The prevalence of visceral artery stenosis (VAS) was 63/450 (14%) including 48/450 (10.6%) cases of coeliac axis stenosis and 15/450 (3.3%) cases of superior mesenteric artery stenosis. Female sex (p = 0.01), older age (p = 0.03) and the presence of coronary artery disease (p = 0.05) were significant predictors for the presence of VAS in univariate analysis. The determinants for VAS in multivariate analysis were female sex and three-vessel coronary artery disease, while two- and three-vessel coronary artery disease was significant for RAS. CONCLUSION: Screening for VAS and RAS in female patients older than 60 years with more than two diseased coronary segments could have a high diagnostic value.

Noninvasive assessment of intrinsic ventricular load dynamics in dilated cardiomyopathy.

On the basis of hemodynamic theory, a new noninvasive method is developed to provide improved insights into the significance of depressed Doppler left ventricular ejection variables in patients with dilated cardiomyopathy. The net force (F) associated with intraventricular flow throughout ejection can be written as: F = A.dv/dt + B.v2, where v is the ejection velocity and A and B are variables related to the geometry of the ventricle and its outflow tract. Instantaneous levels of this force were calculated in 9 normal subjects and 10 patients with dilated cardiomyopathy using Doppler, M-mode and two-dimensional echocardiography. The maximal ejection force (Fmax) was 47.5 +/- 8.5 kdyn in normal subjects and 25.5 +/- 6.2 kdyn in those with dilated cardiomyopathy (p = 0.0001). Peak local acceleration and outflow velocity were severely depressed in those with cardiomyopathy compared with normal subjects (1,260 +/- 129 versus 2,671 +/- 430 cm/s2 and 71 +/- 14 versus 109 +/- 7 cm/s, respectively; p = 0.0001). Maximal ejection force was attained very early in ejection. A significant linear correlation was found between peak outflow acceleration and maximal ejection force (n = 19; r = 0.91, p = 0.0001). At the time of peak ejection velocity, the net force had decreased to 64% of its peak value in those with cardiomyopathy, whereas in normal subjects, it had decreased to only 84% of its peak value (p = 0.008). In normal subjects, the ejection force was positive during the first 75% of ejection, but in those with cardiomyopathy, it was positive only during the first 54% (p = 0.0003). Once its peak value was attained, total left ventricular systolic wall stress declined rapidly during ejection in normal subjects (to 33% of its peak value by end-ejection), whereas it remained elevated throughout ejection in patients with cardiomyopathy (at 60% of its peak value by end-ejection, p = 0.0001 versus normal). The maximal ejection force corresponded to a calculated intraventricular peak pressure gradient of 9.8 +/- 1.6 mm Hg in normal subjects and 6 +/- 1.2 mm Hg in those with cardiomyopathy (p = 0.0001). The average contribution of the intrinsic component of the left ventricular systolic load (that is, wall stress associated with the ventricular to aortic pressure gradient) to the total myocardial load was 9.1% (range 7.3% to 11.2%) in normal subjects and 6.2% (range 3.9% to 7.5%) in those with cardiomyopathy (p = 0.0001).(ABSTRACT TRUNCATED AT 400 WORDS)

Demonstration of postvalvuloplasty hemodynamic improvement in aortic stenosis based on Doppler measurement of valvular resistance.

It was recently suggested that valvular resistance, defined as the pressure gradient/flow rate ratio, may better depict the hemodynamic impairment in aortic stenosis than does valve area. The relation between aortic valve resistance and left ventricular mechanics was studied with Doppler echocardiography in 13 patients (mean age 85 years) with severe aortic stenosis who underwent percutaneous balloon valvuloplasty. The Doppler-estimated peak valvular resistance, defined as the ratio of peak transvalvular pressure gradient to peak valvular flow rate, decreased from 510 +/- 190 dynes.s.cm-5 before valvuloplasty to 300 +/- 110 dynes.s.cm-5 after the procedure (p = 0.0001). There was a close linear relation between valvular resistance measured at catheterization and Doppler-derived peak valvular resistance (r = 0.91). After valvuloplasty, left ventricular ejection fraction increased from 53 +/- 13% to 62 +/- 11% (p = 0.0001). The percent increase in ejection fraction was linearly related to the percent decrease in end-systolic wall stress (r = 0.56), which was in turn related to the percent decrease in peak valvular resistance (r = 0.75). No such linear relation existed between the percent changes in valve area and those in end-systolic wall stress. In conclusion, hemodynamic improvement after valvuloplasty is more closely related to changes in valvular resistance than to changes in valvular area. It is suggested that valvular resistance can be estimated accurately by Doppler echocardiography with use of a simple method and should be a primary consideration in assessing the hemodynamics of aortic stenosis.

Use of the continuity equation for transesophageal Doppler assessment of severity of proximal left coronary artery stenosis: a quantitative coronary angiography validation study.

OBJECTIVES: We tested the value of transesophageal Doppler echocardiography (TEDE) for quantitating proximal left coronary artery (LCA) stenosis by using the continuity equation. BACKGROUND: The continuity equation applied to a stenosis states that the ratio of the time-velocity integral (TVI) of prestenotic to stenotic flow velocities is equal to the ratio of stenotic to prestenotic cross-sectional areas. TEDE allows the measurement of coronary blood flow velocities within the proximal part of the LCA. METHODS; Forty-one patients with a stenosis of the proximal or mid left anterior descending coronary artery or with a nonostial stenosis of the left main coronary artery were studied. Coronary flow velocities were recorded by TEDE guided by color flow imaging. Prestenotic velocities were recorded by pulsed Doppler echocardiography and transstenotic velocities were recorded by pulsed or high pulse repetition frequency or continuous wave Doppler echocardiography. The prestenotic and transstenotic diastolic TVIs were calculated and the TEDE-derived percent area stenosis was calculated as (1 - TVI ratio) x 100. Quantitative angiography lesion analysis was performed using a computer-assisted automated edge-detection system. RESULTS: TEDE recordings were successful in 35 of the 41 patients. A good linear correlation was found between TEDE and quantitative angiographically derived percent area stenosis (r = 0.89, p = 0.0001, SEE 5.7). However, TEDE measurements underestimated the actual percent area stenosis (slope of regression 0.54). A better agreement (slope 1.08) was obtained after dividing prestenotic velocity by 2 in the continuity equation, based on the assumption of a parabolic cross-sectional velocity profile in the prestenotic segment. CONCLUSIONS: TEDE may be used for quantitating stenosis of the proximal part of the LCA with the use of a modified continuity equation that takes into account the parabolic velocity profile in the normal prestenotic segment.

Influence of cigarette smoking on rate of reopening of the infarct-related coronary artery after myocardial infarction: a multivariate analysis.

OBJECTIVES: This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both. BACKGROUND: In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients. METHODS: We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [+/- SD] 6.7 +/- 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade > or = 2. Four cardiovascular risk factors--smoking, hypertension, hypercholesterolemia and diabetes mellitus--and eight different variables-age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography--were recorded in all patients. RESULTS: Thrombolysis in current smokers and anterior infard location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infard vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location. CONCLUSIONS: These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas nonsmokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.

Arrhythmic cardiac arrest due to isolated coronary artery spasm: long-term outcome of seven resuscitated patients.

OBJECTIVES: Our aim was to look at the clinical features and long-term follow-up of seven patients without coronary artery disease, who had a history of life-threatening ventricular arrhythmias due to coronary spasm. BACKGROUND: Arrhythmic cardiac arrest due to isolated coronary spasm is rare, and there is limited information on the patients affected by this entity alone. METHODS: The seven patients were recruited retrospectively from a cohort of survivors of cardiac arrest. None had a history of angina pectoris, structural heart disease or significantly narrowed coronary segments. All had a positive ergonovine provocation test result. RESULTS: The patients' mean age was 44 years; three were male and four female. All were habitual cigarette smokers. No arrhythmias were induced on programmed ventricular stimulation; corrected QT interval (QTc) and corrected JT interval (JTc) dispersion were within normal ranges. After the ergonovine provocation test, treatment with calcium channel blocking agents (diltiazem, verapamil, nifedipine or amlodipine) was initiated at a dose determined by titration until a negative test result was obtained. At a mean follow-up interval of 58 months for the total group, six patients remained free of symptoms, whereas the one patient who did not stop smoking had a new cardiac arrest despite treatment for coronary spasm. CONCLUSIONS: A favorable long-term outcome may be expected in survivors of cardiac arrest due to coronary spasm, in the absence of significant coronary artery disease. Calcium channel blockers are the most appropriate therapy in these patients. These observations provide further evidence for the role of silent ischemia in cardiovascular death.

[Evaluation and surveillance of patients with an implantable defibrillator]. / Evaluation et surveillance des patients avec un défibrillateur implantable.

The implantable cardioverter-defibrillator became in some years the reference treatment of ventricular arrhythmias in association with heart disease. Recently, this technique showed its efficiency in primary prevention for patients at high risk of sudden death. The follow-up of patients with automatic defibrillator requires a detailed knowledge of both electrophysiology and stimulation. This training is based on a practical and theoretical formation. In France, a specific diploma validation is necessary and centres organisation is required. The purpose of this general review is to supply a set of updated data necessary for the coverage and the follow-up of patients with an implantable cardioverter-defibrillator.

Prevalence of factor V Leiden in patients with myocardial infarction and normal coronary angiography.

Factor V Leiden is associated with an increased risk of venous thrombosis and myocardial infarction in young women, but not in men in this latter case. The aim of this study was to evaluate the prevalence of this mutation in patients with myocardial infarction but normal coronary angiography. We compared 3 groups of patients: one group consisted of 107 patients with premature myocardial infarction but no significant coronary artery stenosis; another group of 244 patients with myocardial infarction and significant coronary artery stenosis; a third group of 400 healthy controls. Factor V Leiden was found in 13 patients (12.1%) who had a myocardial infarction without significant coronary artery stenosis, 11 patients (4.5%) who had a myocardial infarction with significant coronary artery stenosis (p = 0.01) and in 20 controls (5%) (p = 0.01). Odds ratio associated with factor V Leiden were respectively 2.93 (CI95: 1.18-7.31 ) and 2.63 (CI95: 1.19-5.78) when we compared myocardial infarction patients without significant coronary artery stenosis to controls or to patients with significant coronary artery stenosis. In myocardial infarction patients without significant coronary artery stenosis, prevalence of factor V Leiden is significantly higher than in controls. This new finding supports the hypothesis that thrombosis plays a key role in this selected situation.

Pulsed Doppler flow characteristics of ductus arteriosus in infants with associated congenital anomalies of the heart or great arteries.

Pulsed Doppler echocardiography (PDE) from the suprasternal approach was used to assess flow characteristics of ductus arteriosus (DA) in 145 infants (aged 1 day to 6 months) with major congenital heart disease. Direct ductal Doppler interrogation was possible in 138 patients and serial studies before and after medical treatment were performed in 28 infants. According to pulmonary artery pressure and associated heart lesions, 3 ductal shunting patterns were identified. An isolated left-to-right shunt, observed in isolated DA or in right ventricular outflow tract obstruction, was characterized by a continuous flow with a peak velocity in late systole. An isolated right-to-left shunt, observed in persistent fetal circulation and aortic arch abnormalities, was characterized by a continuous flow with a peak velocity in early systole. In patients with a bidirectional ductal shunt, the right-to-left shunt always occurred in systole and the left-to-right shunt began in late systole and extended into diastole. A systolic right-to-left shunt always corresponded to the presence of significant pulmonary hypertension. Ductal flow changes could be documented after prostaglandin E1 therapy in patients with ductus-dependent heart disease or after tolazoline therapy in patients with persistent fetal circulation. Thus, PDE with direct ductal Doppler interrogation is an important complement to the echocardiographic evaluation of DA. It is a safe noninvasive approach to ductal shunt and permits convenient evaluation of the effects of drugs on pulmonary artery resistance (tolazoline) and ductal patency (prostaglandin E1).

A new Doppler method of assessing left ventricular ejection force in chronic congestive heart failure.

A noninvasive method using Doppler echocardiography was developed to determine the force exerted by the left ventricle in accelerating the blood into the aorta. The value of this new Doppler ejection index in the assessment of left ventricular (LV) performance was tested in 36 patients with chronic congestive heart disease undergoing cardiac catheterization and in 11 age-matched normal control subjects. The 36 patients were subgrouped into 3 groups based on angiographic ejection fraction (LV ejection fraction greater than 60, 41 to 60 and less than or equal to 40%). According to Newton's second law of motion (force = mass X acceleration), the LV ejection force was derived from the product of the mass of blood ejected during the acceleration time with the mean acceleration undergone during that time. In patients with LV ejection fraction less than or equal to 40%, LV ejection force, peak aortic velocity and mean acceleration were severely depressed when compared with the other groups (p less than 0.001). In patients with LV ejection fraction of 41 to 60%, LV ejection force was significantly reduced (22 +/- 3 kdynes) when compared with normal subjects (29 +/- 5 kdynes, p = 0.002) and with patients with LV ejection fraction greater than 60% (29 +/- 7 kdynes, p = 0.009); peak velocity and mean acceleration did not differ between these 3 groups. The LV ejection force showed a good linear correlation with LV ejection fraction (r = 0.86) and a better power fit (r = 0.91). Peak aortic blood velocity and mean acceleration showed less good linear correlations with LV ejection fraction (r = 0.73 and r = 0.66, respectively). The mass of blood ejected during the acceleration time also showed a weak linear correlation with LV ejection fraction (r = 0.64). An LV ejection force less than 20 kdynes was associated with a depressed LV performance (LV ejection fraction less than 50%) with 91% sensitivity and 90% specificity. Thus, these findings suggest that LV ejection force is a new Doppler ejection phase index that appears to be more accurate than peak aortic blood velocity and mean acceleration for the assessment of systolic LV function.

A simplified normalized ejection phase index measured by Doppler echocardiography for the assessment of left ventricular performance.

Although useful for the assessment of directional changes in contractility in individual patients, resting peak aortic blood velocity is of limited value for differentiating among patients with different levels of basal cardiac function. A dimensional analysis based on fluid dynamics shows that peak aortic blood velocity is not only generated by the contracting myocardium but also reflects the convective acceleration of blood from the left ventricle to the aorta. The reduction of cross-sectional area from the midleft ventricle to the aorta at the time of peak aortic blood velocity generates the convective acceleration. Accordingly, a higher convective acceleration due to left ventricular (LV) enlargement as observed in cardiomyopathy may explain why peak aortic blood velocity can be maintained as normal although myocardial contractility is depressed. This study tested the hypothesis that peak aortic blood velocity normalized by the ratio of midleft ventricle to aortic cross-sectional areas might provide a reliable index of LV performance. Nine normal control subjects and 25 patients undergoing catheterization were studied by M-mode, 2-dimensional and Doppler echocardiography. The normalized peak velocity measured noninvasively showed a high correlation with angiographic ejection fraction (r = 0.90, p less than 0.0001). Peak aortic blood velocity and the ratio of midleft ventricle to aortic cross-sectional areas alone correlated less well with ejection fraction (r = 0.76 and r = 0.75, p less than 0.0001, respectively). Furthermore, peak aortic blood velocity showed a significant overlap between patients with normal and those with abnormal LV function, whereas normalized peak aortic blood velocity was a better discriminator.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive assessment of coronary flow dynamics before and after coronary angioplasty using transesophageal Doppler.

Recent invasive studies using intracoronary Doppler catheters or guide wires reported improved coronary flow dynamics after successful percutaneous transluminal coronary angioplasty. Transesophageal Doppler enables the measurement of coronary flow velocities within the left anterior descending artery. The present study was designed to test: (1) whether transesophageal Doppler may detect coronary flow velocity changes in patients undergoing angioplasty for left anterior descending artery stenosis, and (2) whether this technique may help to evaluate non-invasively the results of the procedure. Twenty-three patients undergoing angioplasty of the left anterior descending artery were studied by transesophageal Doppler before and < or = 24 hours after the interventional procedure. Coronary flow velocities were measured in the proximal part of the left anterior descending artery with the use of pulsed Doppler guided by color flow imaging. The degree of stenosis was measured by computerized quantitative coronary arteriography. Coronary flow velocity signals were successfully obtained in 19 of 23 patients (83%). In 16 successful angioplasty procedures, peak diastolic velocity increased from 37 +/- 14 cm/s before angioplasty to 51 +/- 16 cm/s after (p = 0.0001). In the 3 patients in whom angioplasty was unsuccessful, transesophageal Doppler showed no significant increase in peak diastolic coronary flow velocity. In a total of 19 angioplasty procedures, a good linear relation was found between the percent changes in coronary flow diastolic velocity and the reduction in the degree of stenosis (r = 0.85; p = 0.0001). All patients with > 20% increase in peak diastolic velocity had > 40% stenosis reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall.

A new noninvasive method using pulsed Doppler echocardiography was developed to assess left ventricular (LV) posterior wall motion dynamics. Seventeen normal subjects and 23 patients undergoing cardiac catheterization were prospectively studied. The sample volume was placed within the LV posterior wall endocardium just apical to the mitral valve sulcus using a posteriorly angulated low parasternal view. The wall filter was set at 100 Hz to record the low velocities of the LV posterior wall motion. The Doppler signal was morphologically similar to the rate of change of the LV posterior wall endocardium excursion obtained by a digitized M-mode echocardiogram, and showed 3 major waves: a systolic wave (S), an early diastolic wave (E) and a late diastolic wave (A). The peak velocities of LV posterior wall endocardium excursion were also determined by M-mode echocardiographic technique. We found a significant linear correlation between peak E-wave velocity and M-mode peak diastolic endocardial velocity (r = 0.90, p less than 0.001) and between peak S-wave velocity and M-mode peak systolic endocardial velocity (r = 0.81, p less than 0.001). M-mode peak systolic endocardial velocity showed an important overlap between control subjects and patients with normal and patients with abnormal LV posterior wall motion on the angiogram. In contrast, peak S-wave velocity was a better discriminator, and a peak S-wave velocity less than 7.5 cm/s was associated with abnormal LV posterior wall motion with an 83% sensitivity, 100% specificity and 95% accuracy. In patients with coronary artery disease but normal systolic LV posterior wall motion and normal global systolic LV function, peak S-wave velocity was not different when compared to control subjects. Peak E-wave velocity and E/A were significantly lower than in control subjects (p less than 0.01) and peak A-wave velocity was greater (p less than 0.01). In conclusion, these data suggest that pulsed Doppler echocardiography can be used for the direct analysis of LV posterior wall instantaneous low velocities and appears to be more informative than M-mode technique for systolic measurements. Thus, detection of abnormal LV posterior wall diastolic motion by pulsed Doppler echocardiography may, upon additional confirmation, be used as a new noninvasive method to gain insight into global LV diastolic performance.

Assessment of right ventricular outflow tract in children by two-dimensional echocardiography using a new subcostal view. Angiocardiographic and morphologic correlative study.

Evaluation of the right ventricular (RV) outflow tract in congenital heart disease is extremely important for surgical management. Therefore, the value of 2-dimensional echocardiography (2-D echo) to assess the RV outflow tract was studied using a new approach: the subcostal elongated right oblique view. Twenty normal children and 49 children with congenital heart disease, aged 1 day to 11 years, were studied. Significant pulmonary infundibular obstruction was present in 22 patients with conotruncal malformations. To obtain the subcostal elongated right oblique view from the short-axis view at the aortic valve level, the transducer was slightly rotated clockwise with an anterior angulation of about 30 degrees so that the ascending aorta was seen in its long axis, providing an image similar to that obtained by a right ventriculogram in the elongated right anterior oblique view. The deviation of infundibular septum was appreciated by measurement of the angle alpha, defined by the long axis of the infundibular septum and the plane of aortic cusps. This view could be obtained in 64 patients (92%). In correlation with angiographic or anatomic data, the subcostal elongated right oblique view permitted recognition of several types of RV outflow tract: type I--normally formed RV outflow tract; type II--disorganized RV outflow tract with obstruction (alpha less than 90 degrees); type III and IV--disorganized RV outflow tract with obstruction (alpha greater than 90 degrees). This view could visualize the crista supraventricularis in type I, but also the anatomic components of RV outflow tract that may contribute to obstruction in the other types: infundibular septum, septoparietal trabeculations and trabecula septomarginalis.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of an automatic and patient-triggered long-term solid memory ambulatory cardiac event recorder.

This study evaluated the R-Test Evolution, a new type of cardiac event recorder bearing both patient-triggered and automatic capabilities. Its 7-day automatic arrhythmia analysis showed promising clinical advantages, especially when investigating patients with unexplained rare events such as syncope, feeling of weakness or faintness, palpitations, stroke, or in patients inconsistent in their use of patient-triggered recordings.

Relative importance of activation sequence compared to atrioventricular synchrony in left ventricular function.

This study evaluated the relative hemodynamic importance of a normal left ventricular (LV) activation sequence compared to atrioventricular (AV) synchrony with respect to systolic and diastolic function. Twelve patients with intact AV conduction and AV sequential pacemakers underwent radionuclide studies at rest and Doppler echocardiographic studies at rest and during submaximal exercise, comparing atrial demand pacing (AAI) to sequential AV sensing pacing (DDD) and ventricular demand pacing (VVI). Studies at rest were performed at a constant heart rate between pacing modes, and the exercise study was performed at a constant heart rate and work load. Cardiac output was higher during AAI than during both DDD and VVI (6.2 +/- 1 vs 5.6 +/- 1 and 5.3 +/- 1 liters/min, p less than 0.05). LV ejection fraction was likewise higher during AAI (55 +/- 12 vs 49 +/- 11 vs 51 +/- 13, p less than 0.05). VVI with or without AV synchrony was associated with a paradoxical septal motion pattern, resulting in a 25% impairment of regional septal ejection fraction. In addition, LV contraction duration was more homogenous during AAI. Peak filling rate during AAI and VVI was higher than during DDD (2.86 +/- 1 and 2.95 +/- 1 vs 2.25 +/- 1 end-diastolic volume/s; p less than 0.05). During VVI, the time to peak filling was significantly shorter than during both AAI and DDD (165 +/- 34 vs 239 +/- 99 and 224 +/- 99 ms; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for systemic emboli in infective endocarditis.

A retrospective study was undertaken to analyse the risk factors for systemic emboli in infective endocarditis. Patients (n = 80; 70% males; mean age 65 years; range 20-91 years) with infective endocarditis, as defined by the Duke criteria and diagnosed using transoesophageal echocardiography during the period January 1995 to March 2001, were included. The average time between the start of the illness and the beginning of antibiotic treatment was 55 days (range 0-405 days). The pathogens identified were streptococci (n = 47), staphylococci (n = 11), enterococci (n = 9), and others (n = 4). In nine cases, blood cultures were sterile. Thirty patients with at least one embolic episode were compared with 50 control patients. According to univariate analysis, the main risk factor for systemic emboli was the size of the vegetation (12.4 mm vs. 7.8 mm; p = 0.0005). The risk of emboli was 57% when the vegetation measured > 10 mm and only 22% when it was < 10 mm (p = 0.003). The mobility of the vegetation was also a risk factor: 48% if the vegetation was mobile; and 9% if fixed (p = 0.003). Sex, age, pathogen, antibiotic treatment, type of valve and the number and position of the vegetations were not found to be risk factors. With multivariate analysis, only mobility was identified as a risk factor. Overall, mobile vegetations > 10 mm in size were associated with an increased risk of embolic episodes in infective endocarditis.

Prevalence of factor V Leiden (APCR) and other inherited thrombophilias in young patients with myocardial infarction and normal coronary arteries.

OBJECTIVE: To investigate the role of activated protein C resistance (APCR, factor V Leiden) in coronary artery thrombosis. METHODS: The prevalence of APCR and of congenital deficiencies of antithrombin III, protein C, protein S, plasminogen, and factor XII was investigated in adult patients under 45 years of age with acute myocardial infarction. The results were compared with those of a group of 53 age and sex matched control subjects. RESULTS: Among 75 patients under the age of 45 years who were admitted from November 1994 to April 1996 for acute myocardial infarction, 22 (29.3%) had normal coronary arteriography (group I) and 53 (70.7%) had significant coronary artery disease (group II). Inherited thrombophilia was more often found in group I (4/22, 18.2%) than in group II (4/53, 7.5%) but the difference was not significant (F test: p = 0.22). The prevalence of APCR was 9.1% (2/22) in group I, 3.8% (2/53) in group 2 (p = 0.57), and 3.8% (2/53) in the normal control group (p = 0.57). CONCLUSIONS: The prevalence of congenital thrombophilias, including APCR, does not seem to be increased in young patients with myocardial infarction and normal coronary angiograms, compared with young patients with coronary atherosclerosis and with normal control subjects. However, the statistical power of the study is too low to detect a significant difference and these results are published to allow a meta-analysis of this problem in the future.

Quantitation of the motion of the cardiac base in normal subjects by Doppler echocardiography.

Because the motion of the base of the heart plays a central role in its filling and emptying, we developed an original method to characterize the base motion dynamics throughout each cycle by use of pulsed Doppler echocardiography. A 100 Hz wall filter and low gain settings were used to record the low-frequency, high-energy Doppler signals generated by the motion of the base. From the apical four-chamber view, the sample volume was placed at the lateral margin and at the common septal margin of the tricuspid and mitral annuli. These signals were differentiated from left and right atrioventricular flows by their opposite direction, higher energy, timing, and unique audio signal. The dynamics of the cardiac base were quantitated in 17 normal subjects (31 +/- 13 years). The time relationship between transvalvular flows and the motion of the base was studied in nine normal subjects by matching recordings at the same RR interval. The Doppler signal of the motion of the cardiac base showed a succession of positive (apically directed) and negative (atrially directed) velocity waves. Differences in the dynamics of the cardiac base were demonstrated between its left and right components, probably related to different loading conditions and different myocardial mechanical properties. The relationship between the motion of the base and mitral flow as shown in this study suggests that Doppler-measured mitral flow velocity underestimates relative left ventricular inflow velocity with respect to the atrium by about 17% at peak early flow and by 20% at peak late flow. The method reported in the present study allows a more informative noninvasive quantitation of the cardiac base motion derived from measurements of its velocity, excursion, and acceleration. This new method may provide unique information on the left ventricular and right ventricular performance in the meridional direction.

Safety and tolerability of intravenous cibenzoline for acute termination of spontaneous sustained ventricular tachycardia. Cibenzoline and spontaneous VT.

STUDY OBJECTIVES: To evaluate prospectively, the tolerability and safety of intravenous cibenzoline therapy, for the cardioversion of spontaneous monomorphic ventricular tachycardia (VT). SETTING AND PATIENTS: Between February 1990 and December 1996, fifty-eight patients aged 59+/-10 years old (fifty-three males, five females), with spontaneous VT not causing cardiac arrest, received intravenous cibenzoline. Their underlying heart conditions were: ischemic heart disease [35], dilated cardiomyopathy [14], right ventricular dysplasia [3], hypertrophic cardiomyopathy [1], valvulopathy [2], Fallot's Tetralogy [1] and primary arrhythmogenic disease [2]. The left ventricular ejection fraction was 42+/-13% (range 20%-76%). RESULTS: The mean dose of cibenzoline was 70+/-12 mg. The tachycardia stopped within 6+/-3 min in 47 (81%) patients. Side effects from cibenzoline occurred in two patients. The hemodynamic complications were limited to hypotension, that required vasopressor therapy in one patient. The only apparent proarrhythmic effect consisted of an isolated change in the morphology of the VT, that resolved spontaneously on withdrawal of the drug. No mortality occurred at the hospital. CONCLUSION: With appropriate rules for its administration, intravenous cibenzoline has the potential to become one of the first-line antiarrhythmic drugs, to be used for cardioversion of patients with spontaneous VT.