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.

Transoesophageal echocardiography beyond the echo-laboratory. An expert consensus paper of the working group of echocardiography of the hellenic society of cardiology.

Transoesophageal echocardiography (TOE) is a well-established and valid imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for several specific diagnoses and recently a useful guide of an increasing number of catheter-based and surgical interventions. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Society of Cardiology to state the essential steps of the TOE exam performed beyond the echo lab: a) in the operating rooms intraoperatively during either transcatheter interventions, or cardiothoracic surgery and b) in the intensive care unit for critically ill patients' monitoring. This paper includes information and tips and tricks about the pre-procedural evaluation, the procedural echocardiographic guidance, and post-procedural evaluation of the result and potential complications.

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.

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.

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.

Handgrip-enhanced myocardial fractional flow reserve for assessment of coronary artery stenoses.

BACKGROUND: Fractional flow reserve (FFR) may yield false-negative results in up to 12% of lesions tested, and there is a zone of uncertainty at borderline values. METHODS: Forty-eight patients were investigated by means of dobutamine stress echocardiography (DSE), coronary angiography, and FFR assessment of 48 coronary lesions before, during, and immediately after handgrip exercise. RESULTS: Mean FFR values were lower during and immediately after handgrip exercise as compared with baseline (0.86 +/- 0.09 vs 0.87 +/- 0.08 vs 0.88 +/- 0.08, P < .05, respectively). The sensitivity of FFR < or = 0.75 for predicting myocardial ischemia on DSE was 17.6% before handgrip exercise, 52.9% during, and 35.5% immediately after exercise. The specificity of FFR < or = 0.75 before, during, and immediate after exercise was 100%, 93.5%, and 96.8%, respectively. In 10 patients, FFR values > 0.75 before handgrip became < or = 0.75 during or immediately after handgrip exercise (P = .01). All these patients had angina and/or DSE indicating ischemia in the territory of the vessel studied, and underwent coronary intervention. At 6 months follow-up, all patients were asymptomatic with negative DSE tests. CONCLUSIONS: The addition of handgrip exercise can significantly lower the FFR and potentially improve its ability to detect physiologically significant stenoses.

Microalbuminuria: a strong predictor of 3-year adverse prognosis in nondiabetic patients with acute myocardial infarction.

BACKGROUND: The aim of this study is to evaluate the significance of microalbuminuria (MA) as a 3-year prognostic index in nondiabetic patients with acute myocardial infarction (AMI). METHODS: One hundred seventy-five patients with AMI were followed prospectively for 3 years. The study end point was cardiac death or rehospitalization for an acute coronary event. RESULTS: Forty-two patients (24%) developed a new cardiac event during the follow-up. Microalbuminuria (P < .001), pulmonary edema during initial hospitalization (P < .001) and postinfarction angina (P = .0364), advanced age (P = .001), severe atherosclerosis (high Gensini score) (P = .036), ejection fraction <50% (P = .0013), history of bypass surgery (P = .0265), and early conservative management (P = .0214) were all associated with adverse prognosis. Cox proportional hazards regression analysis showed that MA was an independent predictor of 3-year adverse prognosis in all the models tested, with an adjusted relative risk for the development of a cardiac event ranging from 2.1 to 4.3. CONCLUSIONS: In nondiabetic patients with AMI, MA is a strong and independent predictor of an adverse cardiac event within the next 3 years.

Comparison of the effects of ramipril versus telmisartan in reducing serum levels of high-sensitivity C-reactive protein and oxidized low-density lipoprotein cholesterol in patients with type 2 diabetes mellitus.

The effect of ramipril (an angiotensin [AT]-converting enzyme inhibitor), telmisartan (an AT-II type 1 receptor blocker), or their combination on inflammation and lipid peroxidation was assessed in 37 patients with type 2 diabetes who were free of coronary artery disease. All regimens were associated with a significant reduction of C-reactive protein and oxidized low-density lipoprotein cholesterol serum levels (p <0.001). These results further enlighten the mechanisms underlying the cardiovascular beneficial effect of renin-AT system inhibition.

Latent arterial hypertension in apparently lone atrial fibrillation.

INTRODUCTION: Longitudinal studies on lone AF are rare and the incidence of hypertension in this population unknown. This study aimed at investigating the incidence of arterial hypertension in patients with apparently lone atrial fibrillation (AF). METHODS AND RESULTS: Out of 292 consecutive patients presented with permanent or paroxysmal AF, 32 patients were diagnosed as having lone AF according to strict criteria. Three patients were subjected to ablation of the ligament of Marshall, 14 patients to pulmonary vein isolation, and the remainder were treated with beta blockade. Patients were followed-up for a 1-3 year period. During follow-up, 14 patients were diagnosed as having arterial hypertension. Thirteen of them had recurrent AF despite ligament of Marshall ablation (1 patient), pulmonary vein isolation (4 patients) and beta blockade (8 patients). Cox regression analysis revealed that the only significant predictor of development of hypertension was complete or partial response to antiarrhythmic therapy (beta=3.82, S.E.=1.22, exp(b)=45.63, 95% C.I.=4.17-499.2, p=0.001), independent of age (beta=-0.01, p=0.74), sex (beta=-0.91, p=0.28), left ventricular ejection fraction (beta=0.06, p=0.52), left atrial size (beta=0.58, p=0.7) and kind of antiarrhythmic therapy (ablation or drug therapy) (beta=1.36, p=0.09). In patients with lone AF that did not respond at all to antiarrhythmic therapy, there was a 45.6 times higher risk of diagnosing hypertension during the next 3 years as compared to responders. CONCLUSION: Approximately 44% of patients with an initial diagnosis of lone AF may represent occult cases of arterial hypertension. In these patients hypertension may affect AF recurrence and treatment outcomes, regardless of the mode of antiarrhythmic therapy used.

Impaired systolic dysfunction of left ventricular longitudinal fibers: a sign of early hypertensive cardiomyopathy.

BACKGROUND: Atrioventricular plane displacement (AVPD) study by M-mode echocardiography can supply useful clinical information about left ventricular (LV) long-axis function. HYPOTHESIS: We assessed the hypothesis that AVPD estimation could be used to detect early hypertensive cardiomyopathy. METHODS: The study population included 81 hypertensive patients with normal LV ejection fraction and fractional shortening, and 50 age- and gender-matched healthy controls. By utilizing M-mode and apical views, the following parameters were estimated: early mitral flow peak velocity (E) and deceleration time (DT), peak velocity of late mitral flow (A), A/E ratio, isovolumic relaxation time (IVRT), total AVPD, AVPD motion during atrial systole (At), systolic AVPD (total AVPD-At), and At/total AVPD ratio. RESULTS: Of 81 hypertensive patients, 16 (19.7%) had a normal (Group 1) and 65 (80.3%) an impaired LV relaxation filling pattern (Group 2). Mean total AVPD-At was significantly lower in Group 2 than in Group 1 (7.1 +/- 2 vs. 10.3 +/- 3 mm, p<0.001) and in Group 1 compared with healthy subjects (10.3 +/- 3 vs. 13.1 +/- 1 mm, p<0.001). Mean At and At/total AVPD were significantly higher in Group 2 than in Group 1 (46.9 +/- 8.6 vs. 37.7 +/- 8.7%, p<0.001), but not in Group 1 compared with healthy subjects (37.7 +/- 8.7 vs. 36 +/- 6%, p>0.05). CONCLUSIONS: Hypertensive patients without overt systolic dysfunction demonstrate LV long-axis systolic dysfunction, while long-axis diastolic dysfunction always coexists with abnormal diastolic filling patterns. This suggests that long-axis systolic dysfunction precedes diastolic dysfunction at the same axis in hypertensive patients.

Right and left inferior extensions of the atrioventricular node may represent the anatomic substrate of the slow pathway in humans.

OBJECTIVES: The purpose of this study was to investigate the electrophysiologic characteristics of the inferior extensions of the human atrioventricular (AV) node and their possible relationship to slow pathway conduction. BACKGROUND: The human heart contains right and left inferior extensions of the AV node that relate to right and left atrial inputs. METHODS: Fourteen patients admitted for catheter ablation of left-sided accessory pathways were studied. Atrial pacing was performed from multiple sites in both atria, and simultaneous His-bundle recordings from right and left sides of the septum were made. RESULTS: Significant differences of A-H and stimulus to His (St-H) intervals with pacing at various sites were found. St-H intervals were similar during constant pacing from the low right atrium or the left inferoparaseptal area (112 +/- 28 ms vs 112 +/- 26 ms, P = .8, for right His recordings and 114 +/- 23 ms vs 111 +/- 25 ms, P = .9, for left His recordings). At maximum decrement, there were significantly shorter St-H intervals during left inferoparaseptal pacing compared to low right atrial pacing (201 +/- 24 ms vs 218 +/- 44 ms, P = .02, for right His recordings, and 200 +/- 24 ms vs 219 +/- 41 ms, P = .009, for left His recordings). Differences on right His recordings between St-H intervals at maximum decrement and at constant pacing from the low right atrium were significantly higher than corresponding differences on left His recordings during pacing from the left inferoparaseptal area (P = .035). CONCLUSIONS: Our findings support the concept that the right and left inferior extensions of the human AV node may represent the anatomic substrate of the slow pathway as defined electrophysiologically.

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.

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.

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.