Dipyridamole stress echocardiography vs dipyridamole sestamibi scintigraphy for diagnosing coronary artery disease in left bundle-branch block.

STUDY OBJECTIVES: To evaluate dipyridamole stress echocardiography (DSE) for predicting coronary artery diseases (CADs) in patients with complete left bundle-branch block (LBBB). DESIGN: Comparison of DSE and dipyridamole sestamibi myocardial perfusion scintigraphy (sestamibi). SETTING: Tertiary-care cardiac referral center. PATIENTS: Fifty-four consecutive patients (26 men; mean [+/- SD] age, 59 +/- 7 years) with complete LBBB (14 patients with left ventricular [LV] dilatation) and intermediate probability of CAD. METHODS: Simultaneous single photon emission CT scan (20 mCi technetium Tc 99m stress/rest sestamibi) and echocardiography (second harmonic imaging) during a two-step (0.56 to 0.84 mg/kg) dipyridamole infusion protocol. Two sestamibi readings were performed. The first reading considered only those studies with reversible defects (sestamibi-1) to be positive. The second reading considered those studies with any defect (sestamibi-2) to be positive. CAD was defined as a >or= 50% reduction in diameter in at least one major vessel seen on coronary angiography. RESULTS: CAD was present in 17 patients (31.5%). The global predictive accuracy for CAD was significantly higher for DSE (87.0%) and sestamibi-1 (79.6%) than for sestamibi-2 (57.4%) [p < 0.01 vs DSE; p < 0.05 vs sestamibi-1]. No significant differences in sensitivity were present, but specificity was significantly higher for DSE (94.6%) and sestamibi-1 (81.1%) than for sestamibi-2 (43.2%; p < 0.01 vs both the other two tests). Of 14 patients with LV dilatation, 26.8% were falsely positive for CAD (in some cases for posterior defects) as determined by sestamibi-1 and 64.3% were falsely positive for CAD by sestamibi-2 vs none by DSE. CONCLUSIONS: DSE is at least as accurate as dipyridamole sestamibi scintigraphy for predicting CAD in patients with complete LBBB and tends to be more specific in those patients with underlying LV dilatation.

[Early diastolic sound in a patient with hepatocarcinoma]. / Un tono aggiunto protodiastolico in un paziente affetto da epatocarcinoma.

On physical examination an early diastolic sound is usually associated with mitral stenosis, prosthetic mitral valve replacement and chronic constrictive pericarditis. In case of an atrial myxoma, an early diastolic sound can be usually heard due to movement of the tumor towards the tricuspid valve (tumor plop). The following case report shows an example in which an early diastolic sound was heard in a patient presenting with a hepatocellular carcinoma. This sound was due to the presence of a thrombus that originated from the inferior vena cava and invaded the right atrium up to the tricuspid valve. It was thus similar to an atrial myxoma and produced a tumor plop.

Neuroadrenergic activation and response to dobutamine in congestive heart failure secondary to idiopathic dilated cardiomyopathy.

Detection of contractile reserve is important in heart failure patients. To determine if detection of contractile reserve is influenced by neuroadrenergic activation, we examined the relation between dobutamine stress echocardiography (DSE) findings and plasma norepinephrine levels (NE) at rest in 35 patients with nonischemic left ventricular (LV) dysfunction (New York Heart Association class >III in all; LV ejection fraction 0.27 +/- 0.5). Changes in global wall motion score (WMS), and separately in WMS of hypokinetic segments and akinetic segments, were analyzed. A patient was considered to be responsive to dobutamine if the change in global WMS was >/=4. Twenty-three patients were responsive and 12 were not responsive to dobutamine. Plasma NE and baseline heart rate were significantly higher in nonresponsive patients (p <0.001). Changes in global WMS and in hypokinetic segment WMS were inversely related to either plasma NE (r -0.68 and -0.67, respectively) or baseline heart rate (r -0.60 and -0.66, respectively). The change in akinetic segment WMS was related to plasma NE only (r -0.50). Changes in WMS were not related to age, diastolic and systolic LV volume, baseline global WMS, or number of akinetic segments at baseline. Plasma NE >602 pg/ml predicted a blunted or absent contractile reserve at DSE (sensitivity 92%; specificity 87%). Neuroadrenergic activation may influence contractile reserve found at DSE in patients with heart failure due to nonischemic LV dysfunction.

Central pulmonary artery lesions in chronic obstructive pulmonary disease: A transesophageal echocardiography study.

BACKGROUND: In patients with acute pulmonary embolism, transesophageal echocardiography (TEE) often reveals presumably thrombotic lesions within the central pulmonary arteries (CPAs). These CPA lesions, when found in patients with primary pulmonary hypertension, have been attributed to in situ thrombosis or atherosclerosis. We hypothesized that similar CPA lesions may also develop in patients with chronic obstructive pulmonary disease (COPD) in the absence of pulmonary embolism. METHODS AND RESULTS: We examined by TEE 25 patients with COPD and 27 control patients with left heart disease. None of the patients had previous pulmonary embolism or ileofemoral and popliteal vein thrombosis. By use of TEE, CPA lesions were found in 12 COPD patients (48%) and 2 control patients (7.4%) (P<0.01). When CPA lesions were subdivided into types 1 (protruding and mobile) and 2 (wall-adherent), type 1 lesions proved to be uncommon, being found within the pulmonary trunk in 12% and 3.7% of COPD and control patients, respectively (P=NS). Conversely, type 2 lesions, which were always localized in the right pulmonary artery, were frequent in COPD patients (36%) and rare in control patients (3.7%) (P<0.01). When available, helical CT and MR angiography confirmed TEE findings, supporting an atherosclerotic origin of type 2 lesions, which were different from typical thrombotic lesions. FEV(1)/FVC ratio, RV/TLC ratio, PaO(2), hematocrit value, and pulmonary artery systolic pressure were not significantly different in COPD patients with and without CPA lesions. At TEE, however, COPD patients with CPA lesions showed a larger size of the main and right pulmonary arteries. CONCLUSIONS: TEE often reveals CPA lesions in stable patients with COPD even in the absence of significant pulmonary hypertension and not in close relation with the severity of pulmonary dysfunction.

[Doppler flow-velocity analysis of the renal arteries in left ventricular dysfunction]. / Analisi della curva di flusso-velocità doppler delle arterie renali nella disfunzione ventricolare sinistra.

AIM OF THE STUDY: Chronic heart failure leads to renal hypoperfusion. Clinical methods for monitoring renal artery flow have several limitations. We analyzed the renal artery flow-velocity in patients with left ventricular dysfunction and normal controls by pulsed-wave (PW) color-guided Doppler technique. The relation between PW Doppler quantitative indexes and left ventricular ejection fraction (LVEF), creatinine clearance, and age, was also assessed. METHODS: We studied 53 patients with left ventricular dysfunction (LVEF by 2D echo < or = 40%) and no systemic hypertension, diabetes, parenchymal nephropathy, serum creatinine levels > 150 mmol/l, nor renal artery stenosis. Five patients were excluded for suboptimal renal artery PW Doppler recordings. Thus, the study group was constituted of 48 patients (mean age: 64 +/- 13 years). Twenty-eight normal subjects (mean age: 61 +/- 9 years) were the control group. By PW Doppler we measured the maximum (Vmax), the minimum (Vmin) and the mean (Vmean) velocities of both renal arteries. The resistivity index (RI), obtained from the formula (Vmax-Vmin)/ Vmax, and the pulsatility index (PI), obtained from the formula (Vmax-Vmin)/Vmed were calculated. Creatinine clearance was determined in each patient. RESULTS: RI and PI were greater in patients with left ventricular dysfunction than in normal controls. In normal controls, RI and PI were related to age (r: 0.63, p < 0.001; and r: 0.45, p < 0.05) and creatinine clearance (r: -0.44 and -0.40, respectively; both: p < 0.05), not to LVEF. In patients with left ventricular dysfunction, RI and PI were related to LVEF (r: -0.67 and -0.59; both: p < 0.001), other than to age (r: 0.57 and 0.55; both: p < 0.001) and creatinine clearance (r: -0.59, p < 0.001, and r = -0.46, p < 0.01, respectively). In this group, however, there was no sharp separation of RI and PI between patients with different degree of left ventricular dysfunction (LVEF < or = 30% and > 30%). CONCLUSIONS: In patients with left ventricular dysfunction, by renal artery PW Doppler analysis it is possible to detect noninvasively a reduction in regional flow-velocity and an increase in Doppler-derived vascular resistance indexes. These Doppler changes mainly depend on severity of left ventricular dysfunction and less on age of patients.

Regional wall motion analysis by dobutamine stess echocardiography to distinguish between ischemic and nonischemic dilated cardiomyopathy.

To distinguish between ischemic and nonischemic dilated cardiomyopathy (DCM), we studied 43 patients with left ventricular dysfunction (15 ischemic and 28 nonischemic detected by coronary angiography) by dobutamine stress echocardiography. At rest, there were more normal segments (p<0.001) and a trend toward more akinetic segments (p, not significant) per ischemic than per nonischemic DCM patient. However, either at rest or with low-dose dobutamine, individual data largely overlapped. At peak dose, in ischemic DCM, regional contraction worsened in many normal or dys-synergic regions at rest (in the latter case after improvement with low-dose dobutamine); in contrast, in nonischemic DCM, further mild improvement was observed in a variable number of left ventricular areas. Thus with peak-dose dobutamine, more akinetic and less normal segments were present per ischemic than per nonischemic DCM patient (both, p<0.001). A value of six or more akinetic segments was 80% sensitive and 96% specific for ischemic DCM. Our data show that analysis of regional contraction by dobutamine stress echocardiography can distinguish between ischemic and nonischemic DCM.

Left atrial thrombus and spontaneous echo-contrast in nonanticoagulated mitral stenosis. A transesophageal echocardiographic study.

OBJECTIVE: The aim of the study was to investigate if evidence at transthoracic echocardiography (TTE) of left atrial (LA) thrombus and LA spontaneous echo-contrast (LA SEC), which are potential precursors of embolization, can be predicted by clinical and TTE variables in nonanticoagulated mitral valve stenosis (MS). DESIGN: Clinical (age, NYHA class, rhythm, previous embolization) and TTE variables were related to transesophageal echocardiography (TEE) evidence of LA thrombus and/or LA SEC. SETTING: Nonanticoagulated MS was the setting. PATIENTS: Fifty-nine patients had MS, and they were not receiving anticoagulant or antiplatelet therapy (24 in sinus rhythm and 35 in atrial fibrillation). Previous arterial embolization had occurred in 12 patients (20.3 percent). MEASUREMENTS: The following TTE variables were analyzed: mitral orifice area (pressure half-time method), mitral gradient (Bernouilli's equation), LA end-systolic area, and mitral regurgitation (color Doppler grading). LA thrombus and LA SEC were analyzed by monoplane TEE. RESULTS: LA thrombus was found by TEE in 12 patients (20.3 percent). Of these 12, 11 (91.6 percent) were in atrial fibrillation. LA SEC was found by TTE in 2 patients (3.5 percent) and by TEE in 40 (67.8 percent) (p < 0.001). Previous embolization had occurred only in patients with LA SEC, of whom 5 had and 7 did not have LA thrombus. Patients with LA SEC, compared with those without LA SEC, were characterized by more frequent advanced NYHA class, atrial fibrillation, smaller mitral valve area, and larger LA size. By multivariate regression analysis, atrial fibrillation and LA end-systolic area were factors related to both LA thrombus and LA SEC, whereas mitral area was related only to LA SEC. However, whereas LA SEC was accurately predicted by the presence of atrial fibrillation (sensitivity: 87.5 percent; specificity: 100 percent) and a LA area > or = 30 cm2 (sensitivity: 72.5 percent; specificity: 89.5 percent), among patients with LA SEC no clinical or TTE variable accurately identified those with actual LA thrombus. CONCLUSIONS: TEE is not necessary in many patients with MS in order to recognize LA SEC. However, when actual LA thrombus detection is necessary for clinical decision making, TEE should be performed.

Systolic ejection murmurs in the elderly: aortic valve and carotid arteries echo-Doppler findings.

UNLABELLED: Two-dimensional echographic and color Doppler studies of the heart and carotid arteries (CA) were performed in 45 patients greater than sixty-five years old without aortic stenosis, 23 with (Group 1) and 22 without (group 2) precordial ejection systolic murmur (SM). Aortic cusps thickening was found in 11 Group 1 (48%) and 2 Group 2 (9%) patients (p less than 0.001). Aortic root and aortic arch size were similar in the two groups. Maximum aortic flow velocity was significantly greater in Group 1 (200 60 cm/sec) than in Group 2 (120 20 cm/sec) (p less than 0.001). Left ventricular outflow systolic maximum velocity was similar in the two groups. A bilateral neck murmur was heard in 10/23 Group 1 patients (43%); in this group, patients with cervical SM had a greater maximum aortic flow velocity than those without cervical SM (230 + 60 cm/sec vs 172 + 32 cm/sec, p less than 0.001). In Group 1, 3 patients had a cervical SM louder on one neck side; only in these 3 patients were ipsilateral obstructive CA plaques found. A unilateral neck SM was heard in 4/22 Group 2 patients (18%); in these 4, ipsilateral obstructive CA were found. CONCLUSIONS: (1) in the elderly, precordial ejection SM is related to mild increase in maximum aortic flow velocity and thickening of aortic cusps; (2) in patients with precordial SM radiated to both neck sides, maximum aortic flow velocity tends to be more markedly increased; (3) in patients with precordial SM, a cervical SM louder on one neck side should suggest coexistent ipsilateral CA stenosis.

[Diagnosis of recent posterolateral myocardial infarction: an electrocardiographic, echocardiographic and scintigraphic study]. / Diagnosi di infarto posterolaterale recente: studio elettrocardiografico, ecocardiografico e scintigrafico.

ECG and 2D echocardiography were studied in 64 patients with previous myocardial infarction and evidence of posterolateral fixed defect at 201 TI scintigraphy. The defect was isolated posterolateral in 47 patients (group 1), and posterolateral + inferoapical in 17 (group 2). Thirty subjects with no history of myocardial infarction and no 201 TI defects constituted the control group. We calculated sensitivity, specificity and predictive value of ECG and 2D echocardiography (pertinent wall motion abnormality) in the recognition of posterolateral infarction. ECG data were also analyzed using multivariate analysis. Among the ECG criteria, a positive T wave in V1 proved to be 100% sensitive and 76% specific both in group 1 and in group 2. At multivariate analysis, a 2-variable model (positive T wave inV1 + R/S ratio greater than or equal to 1 in V1-V2) had a sensitivity of 95 and 100% in group 1 and 2, respectively; the specificity was 80%. A 3-variable model (+ R wave duration in V1-V2 greater than or equal to 0.04 sec) proved to be less sensitive (70 and 88% in group 1 and 2, respectively), with a specificity of 97%. A pertinent dyssynergy at 2D echocardiography was 70% sensitive for posterolateral myocardial infarction in group 1, but only 29% in group 2, with a specificity of 100%. These results indicate: 1) standard ECG is more sensitive but less specific than 2D echocardiography in the recognition of previous postolateral myocardial infarction; 2) the recognition of posterolateral involvement can be frequently missed by 2D echocardiography in patients with associated inferior myocardial infarction.

[Forme fruste of Gorlin's syndrome with a left ventricular neoplasm]. / Forma frustra di sindrome di Gorlin con neoplasia ventricolare sinistra.

We report on a 25-year-old man, referred for atypical chest pain and negative T waves in leads V5-V6. A cardiac tumor, localized in the posterolateral left ventricular wall was diagnosed in this patient by nuclear techniques and bidimensional echocardiography. A complex form of pluridistrectual dysmorphic disorder (hypertelorism, prognathism, frontal bossing, multiple cysts of the mandible, calcification in falx cerebri, etc) was also present, suggesting a limited form of Gorlin's syndrome (nevoid basal cell carcinoma syndrome).

[Increase of plasma levels of beta-endorphin during maximum bicycle ergometry effort in sedentary and trained subjects]. / Incremento dei livelli plasmatici di beta-endorfina durante sforzo massimale al cicloergometro in sedentari ed allenati.

Plasmatic levels of beta-endorphin during maximal graded bicycle stress test were measured by RIA on extracted plasma in 10 well-trained (A group) and in 8 untrained subjects (C group). Blood samples were obtained at rest, at peak work load and at the third, 10th and 90th min of recovery. For every stress test the following were evaluated: exercise time, maximum work load, total work load, maximum double product and mean K (an index of velocity of heart rate recovery during the first three minutes after the exercise). Both groups A and C showed a significant rise in beta-endorphin activity at the third minute of recovery; the increase was significantly greater in trained rather than in sedentary subjects (p less than 0.01). Beta-endorphin release was closely related to mean K; no relationship was found between exercise time, maximum work load, total work load, maximum double product and beta-endorphin rise. Our data shows that a release of beta-endorphin occurs during the initial phase of recovery after a maximal stress test; beta-endorphin rise is greater in trained subjects and correlates with the speed of heart rate recovery, but has no relationship with the duration and the grade of the effort. Whether beta-endorphin increase plays a role in the rapid decrease of adrenergic tone which occurs after exercise or represents a secondary phenomenon remains to be determined.