Early evaluation of coronary microcirculation by echocardiography with contrast medium in patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty.

AIM: In about 30% of patients with ST elevated myocardial infarction (STEMI), in which a TIMI 3 flow is obtained in the infarct related artery (IRA) after primary percutaneous transluminal coronary angioplasty (PTCA), it's not possible to obtain a good perfusion of coronary microcirculation (no reflow). Aim of the study is to estimate the prognostic value of microcirculation study by echocardiography with contrast medium (MCE) within 48 h from procedure and to point out if there're clinical or procedural factors correlated with no reflow. METHODS: From February 2002 to June 2003 we have analyzed the integrity of microcirculation by MCE in patients with STEMI treated with PTCA. We have included in this study 62 patients with anterior myocardial infarction (MI) (first event), within 12 h from symptoms onset, with great echocardiographic window and TIMI 3 flow in the IRA after PTCA, excluding shock. We have obtained the evaluation of myocardial perfusion by MCE within 48 h from the treatment. We have used Sonovue as contrast medium, infused through peripheral vein. In each patient we have measured: perfusion index (PI) (sum of single segments scores divided by total number of myocardial segments) and regional perfusion index (RPI) (number of normal perfused segments between the diskinetic ones divided by diskinetic segments). RPI varies from 0 to 1: when >0.5 it has been considered index of good perfusion. Ejection fraction (EF) and wall motion score index (WMSI) have been calculated within 48 h and at 6 weeks follow up. ST resolution (STR) has been evaluated at 90 min from procedure and it was considered significant when >70%. RESULTS: Patients have been divided into 2 groups by myocardial perfusion: group R (33 patients with RPI>0.5) and group NR (29 patients with RPI =/<0.5). The 2 groups were similar for age (group R: mean age 61 years old; group NR: mean age 64 years old, P=n.s.), glycoprotein inhibitors use (group R 90%, group NR 97%, P=n.s.), diabetes (group R 12%, group NR 17%, P=n.s.), hypertension (group R 22%, group NR 23%, P=n.s.), incomplete revascularization (group R 12%, group NR 10%, P=n.s.). Group NR has shown a major women percentage (33%) than group R (9%) P=0.026. In group R we have appreciated a trend to a major percentage of TIMI 2-3 flow preprocedure (66% vs 36%, P=n.s.), a shorter ischemic time (209 min vs 258 min, P=n.s.) and a major STR at 90 min (72% vs 53%, P=n.s.), not statistically significant. Echocardiographic analysis and MCE show a better myocardial perfusion in group R (RPI 0.7 vs 0.14 and PI 0.96 vs 0.86, P<0.0001); better left ventricular kinetics at 6 weeks follow up (EF 54.2% vs 50.8%, P=n.s. and WMSI 1.07 vs 1.2, P=0.014) but not in the acute phase (EF 46.8 vs 42.9 and WMSI 1.3 vs 1.34, P=n.s.) 30 days mortality is similar in the 2 groups (both 3%). CONCLUSIONS: Myocardial perfusion evaluation correlates with left ventricular contractility measured at 6 weeks from acute MI, but doesn't correlate with contractility in the acute phase or 30 days mortality.

Cardiac performance and mass in adults with hypopituitarism: effects of one year of growth hormone treatment.

We studied the effects of GH administration on myocardial structure and function in 20 patients with hypopituitarism (14 males and 6 females; mean +/- SE age, 47.2 +/- 2.6 yr; range, 31-59 yr) developed in adulthood because of pituitary or parapituitary tumors. All patients had GH deficiency (GHD), as assessed by a GH response of less than 4 micrograms/L to a standard insulin tolerance test (0.05 U kg, iv) and the combined pyridostigmine (120 mg, orally, at -60 min) plus GHRH (1 microgram/kg, iv, at 0 min) test. Patients received either placebo (n = 10) or GH substitution therapy (n = 10; 0.05 U/kg.day GH for 1 yr; 0.03 U/kg.day during the first month). M- and B-mode echocardiography and pulsed Doppler examination of transmitral flow were performed before treatment, 6 months and 1 yr after starting GH or placebo administration, and 15 days and 3 months after GH or placebo withdrawal. Twenty healthy subjects, matched for age, sex, body mass index, and physical activity, served as controls. Left ventricular dimensions, mass, and systolic function were normal in patients with adult-onset GHD; however, diastolic function, specifically E wave deceleration time, was altered. GH administration markedly increased left ventricular performance and reversed diastolic abnormalities at 6 and even more so at 12 months. On the other hand, a clear increase in left ventricular mass was seen after 12, but not after 6, months of GH administration (P < 0.01 vs. pretreatment values). In addition, although all changes induced by GH treatment disappeared within 3 months after GH withdrawal, at that time the increase in left ventricular mass was still detectable (P < 0.05 vs. pretreatment values). These data indicate that augmented left ventricular contractility is not strictly related to cardiac muscle growth, supporting the hypothesis that GH treatment increases the inotropic activity of myocardial fibers. In conclusion, GH treatment enhances cardiac function, increases cardiac mass, and reverses diastolic abnormalities in adults with hypopituitarism and GHD. However, long term studies are required to demonstrate that GH replacement therapy reduces cardiac death rate in these patients.

Noninvasive evaluation of cardiovascular hemodynamics during multiple follicular stimulation, late luteal phase and early pregnancy.

A noninvasive hemodynamic study in three moments of the gamete intrafallopian transfer (GIFT) cycle was carried out on 25 patients: before beginning multiple follicular stimulation (MFS) (study I); after rapid increase of serum estradiol (E2) (study II); and 12 days after GIFT (study III). In the 25 patients, the rapid increase in E2 proved to be combined with a significant increase in the left ventricular end diastolic dimension (LVEDD), the left ventricular end systolic dimension, the heart rate (HR), the systolic index, the cardiac index, and a significant reduction in the mean arterial pressure, in the systolic arterial pressure and in the systemic vascular resistence index. In the 14 pregnant patients in study III, all of the hemodynamic parameters studied proved to be significantly modified with respect to study I. In the 11 nonpregnant patients between Studies I and III were no significant cardiovascular modifications except for a significant increase in LVEDD in Study III. It is concluded that, during MFS, the rapid increase in E2 is combined with hemodynamic modifications and that, in pregnancy, the cardiovascular adaptation modifications occur in the very early stages.

[Effects of hypertrophy on cardiac systolic and diastolic performance in athletes with mild hypertension]. / Effetti dell'ipertrofia sulla performance cardiaca sistolica e diastolica in atleti con ipertensione lieve.

Aims of the study has been the evaluation of morphological and functional aspects of left ventricle in subjects undergoing mild hypertension and sport adaptation effects. These evaluations have been carried out by Echo-Doppler both at rest and during sharp increase in after load induced by isometric stress. Together with the morphological parameters represented by mass index and by radius to thickness ratio, we have studied stroke volume and transmitral flow pattern assessing the maximum flow velocity during rapid filling phase (E), during atrial contraction phase (A) and their ratio (E/A). We have studied 31 male subjects from 39 to 60 (average 47) exercising twice or three times a week (in the main, aerobic sports such as road cycling). They were subdivided into two groups, the first included 16 subjects with mild hypertension (AP = 155 +/- 9/97 +/- 5 mmHg) the second included 15 normotensive subjects without known pathologies, comparable for age and body surface (AP = 125 +/- 15/77 +/- 10 mmHg). Hypertensive subjects exercising regularly, showed a mass index (164 +/- 42 g/m2) significantly higher than the controls (139 +/- 35 g/m2, P less than 0.01) but they ke a normal filling pattern at rest and similar stroke volume values. During isometric exercise instead, the velocities of E and A waves showed a different trend in the two groups with a higher reduction in E/A ratio in hypertensive subjects. The per cent decrease in this ratio turned out to be 15% in the control group and 33% in hypertensive subjects (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiocirculatory adaptations during the initial phases of pregnancy. An echo-Doppler assessment]. / Adattamenti cardiocircolatori durante le fasi iniziali della gravidanza. Valutazione eco-Doppler.

During pregnancy the cardiovascular apparatus meets an important process of morphofunctional adjustment. However the very moment when this happens is not very well known. We observed thirty patients during the various GIFT phases (Gamete Intrafallopian Transfer) that consists in the intratubal transfer of male and female gametes and that represents also an ideal model for the study of pregnancy in the early phases. With echo-Doppler technique morphological and functional parameters of the left ventricle have been evaluated and at the same time estradiol and progesterone blood variations have been determined. In all the thirty patients to the increase of E2 corresponds a significative increment of telediastolic (Dd) and telesystolic (Ds) diameter and of systolic index (SI) and cardiac index (CI). At the same time a significant reduction of mean arterial pressure and of the index of a systemic vascular resistance has been observed. These data say that the systolic flow increment is not due to an increase of the ejection fraction but to an increase of the diastolic filling. The utilised mechanism has nothing to do with inotropism but to the preload reserve according Starling principle. The increase of the systolic output is the almost unique cause of the cardiac capacity increment because there is only a light increase of heart rate. Those patients in which GIFT gave a positive results, these variations are sustained while in the group of those patients not pregnant one can see a rapid return to basic values of the various parameters (except the presence of a significative Dd increment) together with the reduction of plasmatic E2. In conclusion our work results say that significative cardiovascular adjustments are evident from the earliest pregnancy phases and that these changes one can related to E2 plasmatic variations.

[Non-fistulized aneurysm of the right sinus of Valsalva. Pre- and postoperative echocardiographic aspects]. / Aneurisma non fistolizzato del seno di Valsalva destro. Aspetti ecocardiografici pre e post-operatori.

The case considered concerns as 57 year-old patient who was submitted for heart tests because of a slight diastolic aortic murmur and hypertension. Echocardiographic investigation diagnosed an aneurysm of the sinus of Valsalva. The patient underwent a surgical intervention to reconstruct, on a dacron piece, the right sinus of Valsalva from which the aneurysmal cavity originated, retaining the aortic valve. After a short description of the etiology and the natural history of this condition we explain the importance of echocardiographic tests for the diagnosis and post-operative follow-up of these patients who run a high risk of severe and often lethal complications.

[Malfunctioning of the Meadox bioprosthesis placed in mitral position. Description of 2 clinical cases]. / Malfunzionamento della bioprotesi di Meadox posizionata in sede mitralica. Descrizione di due casi clinici.

The Meadox valve, made up by a single bovine pericardial leaflet fixed in glutaraldehyde, is a "new-generation" bio-prostheses. In two patients those bio-prostheses revealed early malfunction with abnormal stretching of the valvular tissue. In both cases the beginning symptom was a strong fremitus caused by the vibration, during systole, of valvular leaflet. In the first case mechanical solicitation onsed partial laceration of valvular leaflet with subsequent regurgitation into the left atrium and cardiac failure. In both cases, the evaluation by Doppler Echocardiography and polygraphic examination, allowed the diagnose of malfunction which was confirmed at surgery. The replacement of a new prosthesis was successful in both cases.

Madness and method in stress echo reading.

AIM: To assess whether 'eye education' through short-term, high-intensity joint reading sessions may improve diagnostic accuracy and inter-observer agreement among beginners. METHODS AND RESULTS: Seventeen cardiologists with absent to minimal (<100 studies performed) previous stress echo experience independently and blindly read 18 stress echo studies, nine at the beginning ('pre-training' set) and nine at the end ('post-training' set) of a 2 day stress echo school which included a joint reading session of 50 tapes. The two sets were balanced as far as type of stress and image quality. The 17 observers had an average accuracy score of 51+/-16.4 before and 64.3+/-8.7% after the training (P<0.005). Concordant (i.e. >14 readers giving the same response) interpretation occurred in three out of nine studies before and in eight out of nine studies after the training (33% vs 88%, P<0.01). Kappa values went from 0.14 (poor) before to 0.39 (fair, close to moderate) after the training. CONCLUSION: Short-term, high-intensity dedicated training in stress echo, with joint reading sessions and consensus development of reading criteria significantly increased accuracy and markedly reduced the inter-observer variability in the reading of stress echoes by beginners. If there is a Shakespearean madness in stress echo reading, 'yet there is a method in't' (Hamlet, II, II, 205-206).

Diagnostic and prognostic value of vasodilator stress echocardiography in asymptomatic Type 2 diabetic patients with positive exercise thallium scintigraphy: a pilot study.

AIM: To assess the diagnostic and prognostic value of vasodilator stress echocardiography in Type 2 diabetic patients with positive exercise perfusion scintigraphy. METHODS: Of an initial cohort of 50 asymptomatic Type 2 diabetic patients undergoing exercise single photon emission computed tomography (SPECT) thallium scintigraphy, 24 had a positive thallium scan, with a reversible perfusion defect. All these 24 underwent high dose (up to 0.84 mg/kg in 10 min) dipyridamole echocardiography and coronary angiography independently of stress echocardiography results. All patients were then followed for 61+/-22 months. RESULTS: Coronary angiography showed normal coronary arteries in 11 patients and significant (> 50% visually assessed diameter reduction in a major vessel) coronary artery disease in 13. Stress echocardiography showed 92% sensitivity and 100% specificity for non-invasive detection of coronary artery disease. During follow-up, five patients experienced cardiac events: heart failure in one, angina with subsequent revascularization in two, and myocardial infarction in two. Event-free survival was 100% in the 12 patients with negative and 58% in the 12 patients with positive stress echocardiography (P = 0.08 by Mantel-Cox test). CONCLUSIONS: In asymptomatic Type 2 diabetic patients with stress-induced perfusion defects, vasodilator stress echocardiography is an excellent diagnostic and prognostic tool proven with long-term follow-up.