Utility of stress echocardiography in the triage of patients with atypical chest pain from the emergency department.

We followed 108 patients presenting to the emergency department with atypical chest pain and triaged with stress echocardiography. One-year cardiac event-free survival was 100% with a negative stress echocardiogram and 25% with a positive study.

Prognostic value of stress echocardiography in the evaluation of atypical chest pain patients without known coronary artery disease.

Patients with atypical chest pain frequently lack significant coronary artery disease (CAD) and are, therefore, at low risk for future adverse cardiovascular events. We hypothesized that in this group of patients, stress echocardiography could identify those at risk for cardiac events. We retrospectively reviewed (mean follow-up 23.0 +/- 7.2 months) the prognostic value of stress echocardiography for major (cardiac death, myocardial infarction, congestive heart failure, and unstable angina) and total (major events plus coronary revascularization) cardiac events in 661 patients with atypical chest pain, normal global left ventricular (LV) systolic function, and no history of CAD. A positive stress echocardiogram was defined as the development of new or worsening wall motion abnormalities with exercise stress (80%) or dobutamine (20%). A total of 41 cardiac and 16 major events were noted. The event-free survival for total cardiac events was 97% for a normal stress echocardiogram and 93% for a normal stress electrocardiogram (ECG) at 30 months. A positive stress ECG predicted an event-free rate of 86% compared with 74% for stress-induced wall motion abnormalities and 42% if stress-induced LV dysfunction accompanied the wall motion abnormalities. A strategy recommending invasive studies based on positive stress echocardiogram results increased the per-patient cost, but led to greater savings per cardiac event predicted and provided incremental prognostic value for future cardiac events beyond clinical and stress electrocardiographic data. Thus, stress echocardiography in low-risk patients for CAD appears to be more cost effective than a stress ECG.

Benefits of reducing the cardiac cycle-triggering frequency of ultrasound imaging to increase myocardial opacification with FSO69 during fundamental and second harmonic imaging.

BACKGROUND: Recent work has shown significant enhancement in myocardial contrast intensity with brief ultrasound pulsing gated to a discrete portion of the cardiac cycle over conventional 30 Hz imaging. We hypothesized that limiting ultrasound imaging to less than every cardiac cycle would further intensity the myocardial echo-contrast effect. We therefore sought to determine the best pulsing frequency for ultrasound imaging to achieve optimal myocardial perfusion after the intravenous administration of FSO69 using fundamental and second harmonic imaging. METHODS AND RESULTS: In 13 male mongrel dogs, myocardial contrast opacification was determined while varying the cardiac cycle-triggering frequency of ultrasound imaging after intravenous injections of FSO69. Resulting myocardial echo-contrast intensities with a cardiac cycle-triggering frequency of every beat during end-diastole were compared with those with a cardiac cycle-triggering frequency of every third and fifth beat. Myocardial opacification, measured by background-subtracted peak intensity and visual scoring, was significantly greater when ultrasound imaging was triggered to every third and fifth beats compared with every beat. These benefits were seen with imaging in both the fundamental and second harmonic modes. Optimal myocardial opacification with FSO69 was achieved with injections as low as 0.1 ml, a dose that produced significant acoustic shadowing in only 24% of the injections. The degree of myocardial opacification was not significantly affected when the images were acquired during end-systole or end-diastole. CONCLUSIONS: Electrocardiogram-gated ultrasound imaging to every third or fifth cardiac cycle greatly improves myocardial opacification compared with imaging each cardiac cycle. This benefit was increased twofold to threefold with the use of second harmonic imaging as compared with fundamental imaging.

Percutaneous bailout therapy of a perforated vein graft using a stent-autologous vein patch.

A 74-yr-old man with two prior coronary bypass surgeries experienced perforation of an occluded aortocoronary vein graft during a transluminal extraction catheter (TEC) procedure for unstable angina. The perforation was successfully closed using a Palmaz 154 stent covered with a short segment of autologous antecubital vein.