Hypovitaminosis D: comparison between patients with hip fracture and patients with vertebral fractures.

This study analyses the difference in 25OH-vitamin D values between two groups of patients both affected by severe osteoporosis with fragility fractures, but one group has vertebral fractures and the other one has hip fractures. Patients with hip fractures have vitamin D values lower than patients with vertebral fractures. INTRODUCTION: The purpose of this study was to evaluate 25OHD levels in patients with fragility vertebral fractures (VF) and hip fractures (HF) and make a comparison between the groups. METHODS: In the first group were enrolled ambulatory patients with 3 or more moderate to severe VF; in the second group were enrolled patients hospitalized in the Department of Orthogeriatrics undergoing surgery for HF. For all patients, we collected values of 25OHD and PTH. The group of patients with VF was further subdivided into pre-existing VF or recent VF treated within 30 days with vertebroplasty. RESULTS: The sample consists of 180 subjects divided into two groups: 90 with VF and 90 with HF. The average value of 25OHD in the total sample was 13.2 ± 9.6 ng/ml, Vitamin D was significantly lower in the HF group than the VF group (p < 0.001)(VF 18.6 ± 9.7 ng/ml, HF 7.9 ± 5.7 ng/ml). The mean PTH value in the total sample was 67.5 ± 54.9 pg/ml and PTH was significantly higher in the HF group compared to the group with VF (p < 0.001) (VF 55.6 ± 27.2 pg/ml, HF 78.7 ± 70.2 pg/ml). The mean 25OHD value in the recent VF group is 16.0 ± 6.6 ng/ml while in the pre-existing VF group is 19.5 ± 10.4 ng/ml with a statistically significant difference (p < 0.001). CONCLUSIONS: Patients of the same age with severe osteoporosis have a lower 25OHD value when the fracture occur at the hip and is recent, probably this is due to the inflammation caused by fracture and/or surgical intervention.

Atrial reservoir function by strain rate imaging in asymptomatic mitral stenosis: prognostic value at 3 year follow-up.

AIMS: Assessment of left and right systolic atrial reservoir function in asymptomatic mitral stenosis (MS) by strain and strain rate imaging (SRI) and their prognostic power at 3 year follow-up was the purpose of this study. There is clear indication to treat (by surgery or percutaneous valvotomy) symptomatic patients with MS, whereas for the asymptomatic ones, the question is much debated. So, we need new echocardiographic parameters helpful for the management of asymtomatic patients. Atrial reservoir function by SRI could help in evaluation of these patients. METHODS AND RESULTS: Fifty-three asymptomatic patients with MS and 53 healthy controls were evaluated by the standard echo-Doppler study [mitral valve (MV) area, mean gradient, systolic pulmonary pressure, left atrial (LA) width, LA volumes, LA compliance index] and by Doppler myocardial imaging (velocity, strain, and SR of both atria). The endpoint at 3 year follow-up was symptoms, hospitalization for cardiac cause, atrial fibrillation, thrombo-embolic events, valvular surgery, or percutaneous commissurotomy. LA width, volumes, and systolic pulmonary pressure were significantly increased in MS patients (P < 0.001). Atrial myocardial velocities and deformation indices were significantly compromised in MS patients (P < 0.0001). Significant correlation was found between atrial myocardial velocity and MV area (by pressure half-time method: P = 0.019, R = 0.41; by planimetric method: P = 0.016, R = 0.43). Peak systolic LA myocardial strain and SR were significantly correlated with atrial volumes (strain: P = 0.03, R = -0.28; SR: P = 0.0008, R = -0.42), with atrial compliance index (strain: P = 0.04, R = 0.26; SR: P = 0.04, R = 0.16), with atrial ejection fraction (strain: P < 0.0001, R = 0.56; SR: P = 0.03, R = 0.43). At 3 year follow-up, 22 (41%) patients had events. Comparing the MS patients who had events during the 3 year follow-up with those who did not, the former had bigger LA volumes, although these parameters did not reached a significant value, whereas atrial myocardial systolic SR was significantly impaired in patients with events. In multivariate analysis, the best predictor of adverse events was LA peak systolic SR average (P = 0.04; coefficient: 0.113; SE: 0.055; cut-off value of 1.69 s(-1) for LA peak systolic SR average) with a sensitivity of 88%, specificity of 80.6%, area under the receiver operating characteristic curve of 0.852 (SE: 0.048; 95% CI: 0.74-0.93, P = 0.0001). CONCLUSION: Atrial myocardial deformation properties, assessed by SRI, are abnormal in asymptomatic patients with rheumatic MS. The degree of this impairment is predictor of events in a 3 year follow-up. SRI could be helpful in decision-making of asymtomatic patients with MS.

Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a case report.

BACKGROUND: There are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients. We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device's optimization at 6-month follow-up. DISCUSSION: The degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity. CONCLUSION: This clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle.

Left atrial myocardial function in either physiological or pathological left ventricular hypertrophy: a two-dimensional speckle strain study.

BACKGROUND: Atrial function is an integral part of cardiac function that is often neglected. The presence of left ventricule hypertrophy (LVH) due to arterial hypertension may impair atrial function. However, it has also been suggested that physical training attenuates the age-associated impairment of diastolic filling. This study investigated whether mechanical dysfunction in the left atrium (LA) is present in patients with either physiological or pathological LVH, using two-dimensional strain rate imaging (2D strain echocardiography; 2DSE). METHODS: Standard echocardiography, exercise stress echo and 2DSE of the left atrium were performed in 40 patients with arterial hypertension, 45 age-matched elite athletes (>40 years) and 25 healthy sedentary controls. Atrial longitudinal strain was performed from the apical views for the basal segments of the LA septum, lateral wall and roof. RESULTS: LV mass index and ejection fraction were comparable between patients with either physiological or pathological LVH. Elite athletes showed increased LV end-diastolic diameter, end-diastolic volume and stroke volume, whereas circumferential end-systolic stress was higher in patients with hypertension. LA diameter and maximum volume were increased but similar between the two groups of patients with LVH. LA active emptying volume and fraction were both higher in patients with hypertension. Conversely, peak systolic myocardial atrial strain was significantly reduced in patients with pathological LVH compared with controls and athletes for all the analysed atrial segments (p<0.0001). Using multivariate analysis, LV end-diastolic volume/body surface area (BSA) (beta coefficient 0.52; p<0.0001) and LV mass (beta = 0.48; p<0.001) in athletes emerged as the only independent determinants of LA lateral wall peak systolic strain. In contrast, in patients with hypertension, an independent negative association of LA lateral wall peak systolic strain with both LV mass (beta = -0.42; p<0.001) and circumferential end-systolic stress (beta = -0.43; p<0.001) was found. In addition, in the overall population of patients with LVH, LA lateral wall systolic strain (beta = 0.49; p<0.0001) was a powerful independent predictor of maximum workload during exercise testing. CONCLUSIONS: 2DSE represents a promising, non-invasive, simple and reproducible technique to assess LA myocardial function in patients with either physiological or pathological LVH. LA myocardial deformation is impaired in patients with hypertension compared with age-matched sedentary controls and elite athletes, and is closely associated with functional capacity during effort.

WITHDRAWN: Prognostic Value of Pharmacologic Stress Echocardiography in Diabetic Patients.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 202-208, . The duplicate article has therefore been withdrawn.

Prognostic value of intra-left ventricular electromechanical asynchrony in patients with mild hypertrophic cardiomyopathy compared with power athletes.

OBJECTIVES: We sought to assess the indexes of myocardial activation delay, using Doppler myocardial imaging (DMI), as potential diagnostic tools and predictors of cardiac events in patients with hypertrophic cardiomyopathy (HCM) compared with power athletes. BACKGROUND: the distribution and magnitude of left ventricular (LV) hypertrophy are not uniform in patients with HCM, which results in heterogeneity of regional LV systolic function. METHODS: The study population comprised 70 young patients with HCM (mean (SD) age 29.4 (5.9) years) with mild septal hypertrophy (15-19 mm) and 85 age and sex matched athletes with septal thickness >12 mm, followed up for 44.4 (10.8) months. Using pulsed DMI, myocardial peak velocities, systolic time intervals, and myocardial intraventricular and interventricular systolic delays were measured in six different basal myocardial segments. RESULTS: DMI analysis showed in HCM lower myocardial both systolic and early diastolic peak velocities of all the segments. Patients with HCM also showed significant interventricular and intraventricular delay (p<0.0001), whereas athletes showed homogeneous systolic activation of the ventricular walls. During the follow up, seven sudden deaths occurred in the HCM group, while no cardiovascular event was observed in the group of athletes. In patients with HCM, intraventricular delay on DMI was the most powerful independent predictor of sudden cardiac death (p<0.0001). An intraventricular delay >45 ms identified with high sensitivity and specificity patients with HCM at higher risk of ventricular tachycardia and cardiac events (test accuracy 90.6%). CONCLUSIONS: DMI may be a valid supporting tool for the differential diagnosis between HCM and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up. Accordingly, such patients may benefit from early intensive treatment and survey. MINIABSTRACT: Doppler myocardial imaging may represent a valid supporting tool for the differential diagnosis between mild hypertrophic cardiomyopathy (HCM) and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up.

Myocardial diastolic impairment caused by left ventricular hypertrophy involves basal septum more than other walls: analysis by pulsed Doppler tissue imaging.

OBJECTIVE: To assess regional diastolic function in patients with hypertension with or without left ventricular hypertrophy using Doppler tissue imaging, a new tool that analyzes myocardial wall motion 'on-line'. METHODS: Ten normotensive subjects, 20 hypertensive patients without hypertrophy and 20 with hypertrophy (left ventricular mass index >50 g/m2.7), all men, underwent Doppler echocardiography and Doppler tissue imaging, which was performed in apical view by placing pulsed sample volume at the level of the basal and middle septum, basal and middle lateral wall, and infero-posterior wall. Peak velocities and time-velocity integrals of myocardial early (Em) and late (Am) waves and their ratios, regional deceleration time and regional relaxation time were measured in each segment. RESULTS: Transmitral peak E/A ratio was 1.37 in normotensive subjects, 1.01 in hypertensive patients without hypertrophy and 0.77 in those with hypertrophy (P < 0.00001). The myocardial diastolic indexes derived by Doppler tissue imaging worsened at all levels in hypertensive patients without hypertrophy compared with normotensive subjects. In hypertensive patients with hypertrophy, the majority of myocardial diastolic indexes were further impaired at the basal septal level, but only marginal differences were found in other regions, compared with indexes in hypertensive patients without hypertrophy. The main diastolic indexes were found, using separate intra-group analyses, to be more compromised at the basal septum than at other levels only in hypertrophic hypertensive patients. The prevalence of regions having peak Em/Am ratios < 1 increased significantly from normotensive subjects to hypertensive patients without hypertrophy, but not significantly from these to the hypertrophic group. Among pooled hypertensive patients, after adjusting for heart rate and diastolic blood pressure using multivariate models, the septal wall thickness was shown to be an independent determinant of the diastolic indexes of the basal and middle septum. CONCLUSIONS: In hypertensive patients without hypertrophy, diastolic dysfunction is uniform along the ventricular walls, whereas in those with hypertrophy it is more evident at the basal septal level than in other walls. Overall among hypertensive patients, the diastolic properties of the interventricular septum worsen as the thickness of the septal wall increases, in the presence and in the absence of hypertrophy.

Use of pulsed Doppler tissue imaging to assess regional left ventricular diastolic dysfunction in hypertrophic cardiomyopathy.

In this study, regional diastolic patterns and their relations with transmitral Doppler inflow were investigated in hypertrophic cardiomyopathy (HC) by pulsed Doppler tissue imaging (DTI). Doppler echocardiography and DTI of basal septum and lateral wall (apical 4-chamber view) were performed in 20 patients (15 men and 5 women) with HC and in 10 healthy subjects (7 men and 3 women). Diabetes, hypertension, coronary artery and valvular disease, mitral regurgitation, New York Heart Association functional classes III to IV, sinus tachycardia, atrial fibrillation, and inadequate echocardiograms were exclusion criteria. Peak velocity and time-velocity integral of early and late waves and their ratios, and deceleration and isovolumic relaxation times were determined by standard Doppler and by DTI at the septal and lateral wall levels. The 2 groups were comparable for age, heart rate, blood pressure, and ejection fraction. Transmitral peak velocity and time-velocity integral E/A ratios were reduced (both p <0.05) and deceleration and isovolumic relaxation times prolonged (both p <0.00001) in HC. Septal DTI showed lower peak velocity and time-velocity integral e/a ratios (p <0.00001 and p <0.001, respectively) and lengthened regional deceleration (p <0.01) and isovolumic (p <0.001) relaxation times. DTI of the lateral wall showed a prolongation of deceleration and isovolumic relaxation times (both p <0.01). By dividing HC according to transmitral E/A, 8 patients with E/A <1 had lower DTI septal e/a ratio (p <0.01) and prolonged septal deceleration and isovolumic relaxation times (both p <0.01) but no changes in DTI pattern of lateral wall than 12 patients with E/A > 1. In conclusion, DTI is useful and complementary to standard Doppler imaging to characterize diastolic properties in HC, reflecting a typical pattern of intramyocardial impaired relaxation at the level of hypertrophied septum and also providing information about the degree of this regional impairment. The lateral wall presents minor changes in diastolic times, which indicate how diastolic asynchrony is not confined to the hypertrophied segment in HC.

Pulsed Doppler tissue imaging in endurance athletes: relation between left ventricular preload and myocardial regional diastolic function.

The aim of this study was to assess the effects of endurance training on myocardial regional systolic and diastolic function by pulsed Doppler tissue imaging (DTI). Twenty male water polo players and 20 male control subjects underwent standard Doppler echocardiography and pulsed DTI, performed in apical views by placing a sample volume on left ventricular (LV) basal septal and inferior walls. Age, body surface area, and blood pressure were comparable between the 2 groups, with lower heart rate in athletes (p <0.001). They had significantly increased LV mass index (due to both higher wall thickness and end-diastolic diameter), greater endocardial fractional shortening, higher transmitral early/atrial (E/A) peak velocities ratio. In athletes, DTI analysis showed significantly prolonged myocardial deceleration time and greater myocardial E/A peak velocity ratio of septal and inferior walls, whereas myocardial early peak velocity was increased (p <0.01) only at the inferior wall. In the overall group, we found univariate relations of septal and inferior E/A peak velocity ratio and myocardial deceleration time with LV mass levels, and, in particular, with the sum of wall thickness. By separate multivariate analyses, however, these relations disappeared, being dependent on heart rate degree. Another association found between LV end-diastolic diameter and myocardial early diastolic wave peak velocity of the inferior wall (r = 0.68, p <0.0001) remained significant (standardized beta coefficient 0.60, p <0.00001), even after adjusting for heart rate, body surface area, age, and stroke volume (R(2) = 0.71, p <0.00001). In conclusion, DTI is a useful tool for detecting regional changes in myocardial function induced by training, because athletes present with an improvement in diastolic passive properties of myocardium. The higher early diastolic velocity of the inferior wall and its relation to increased preload may represent an indicator of aerobic training, allowing quantification of the degree of LV adaptation to endurance exercise.

Echocardiographic identification of infective endocarditis within a congenital left sinus of Valsalva-right atrial communication.

A rare case is described of infective endocarditis within a congenital left sinus of Valsalva aneurysm to right atrial communication diagnosed by a combination of precordial and transesophageal echocardiography. The respective roles of precordial and transesophageal echocardiography in this case are discussed with regard to both diagnosis and surgical decision making.

Noninvasive assessment of left and right internal mammary artery graft patency with high-frequency transthoracic echocardiography.

OBJECTIVES: The aim of this study was (1) to visualize internal mammary artery grafts (IMAG) on coronary artery by transthoracic echocardiography and (2) to assess the patency of the grafts. METHODS: Twenty-three patients (21 men, 56 +/- 6 years) with previous coronary artery bypass grafting were studied at baseline and after they underwent low-dose dipyridamole infusion. The parameters obtained were systolic (SPV) and diastolic (DPV) peak velocities and their ratio (DPV/SPV); the dipyridamole infusion to baseline ratio of DPV was an index of IMAG blood flow reserve (FR). Two groups of patients were selected at baseline: group A, (n = 12) with a DPV/SPV >1, and group B (n = 11), with a DPV/SPV <1. RESULTS: The IMAG was identified in all patients. Intraluminal flow signals obtained with pulsed wave Doppler showed a biphasic pattern (1 systolic and 1 diastolic wave). After dipyridamole infusion was administered, flow velocities increased in 11 of 12 patients in group A and in 5 of 11 patients in group B. In group A the DPV/SPV increased from 1.79 +/- 0.47 to 1.8 +/- 0.43 (P = not significant), and the FR was 1.8 +/- 0.4. In group B the DPV/SPV increased from 0. 46 +/- 0.05 to 0.5 +/- 0.09 (P = not significant), and the FR was 1. 3 +/- 0.41. Coronary angiography showed the graft patency in all patients in group A and in 5 patients in group B with increased flow velocity after dipyridamole infusion. In the identification of graft stenosis at baseline, DPV/SPV showed 100% sensibility and 58% specificity, and FR showed 92% sensibility and 84% specificity. CONCLUSION: Doppler echocardiographic evaluation of the IMAG is a simple noninvasive method to assess the functional impairment of the vessel.

Association between myocardial right ventricular relaxation time and pulmonary arterial pressure in chronic obstructive lung disease: analysis by pulsed Doppler tissue imaging.

This study assessed right ventricular function in chronic obstructive lung disease and pulmonary hypertension by Doppler tissue imaging. Doppler echocardiography of the right ventricle and Doppler tissue imaging of the tricuspid annulus were performed in 63 subjects: 20 healthy controls, 20 with lung disease, and 23 with both lung disease and pulmonary hypertension. Two-dimensional tricuspid systolic plane excursion was lower in patients with pulmonary hypertension than in the other 2 groups. Doppler tricuspid inflow measurements distinguished patients in both of the diseased groups from the control subjects, but they did not differentiate patients with pulmonary hypertension from those without it. The ratio of peak E-wave to peak A-wave velocities derived by Doppler tissue imaging was significantly lower and the myocardial acceleration time longer in both groups of lung disease than in the control group. Only myocardial relaxation time distinguished the 3 groups (all P <.01); a gradual increase in time occurred, with the shortest time seen in controls, a longer time in patients with chronic obstructive lung disease without pulmonary hypertension, and the longest time in patients with lung disease and pulmonary hypertension. In the overall population including subjects with at least minimal tricuspid regurgitation, myocardial relaxation time was positively related to pulmonary systolic pressure. In conclusion, Doppler tissue imaging distinguishes subsets of patients affected by lung disease with or without pulmonary hypertension and identifies patients with different levels of pulmonary artery systolic pressure.

Right ventricular myocardial dysfunction in adult patients late after repair of tetralogy of fallot.

AIM OF THE STUDY: To detect in adult patients late after repair of Tetralogy of Fallot (TOF) possible correlation between myocardial parameters assessed at rest by Tissue Doppler (TD) and cardiac performance during physical effort. METHODS: Doppler echo, treadmill test and pulsed TD of both mitral and tricuspid annulus were performed in 25 healthy subjects and in 40 adult patients who had undergone surgery for TOF at a mean age of 1.4+/-0.5 years. Exclusion criteria were echocardiographic evidence of residual pulmonary, either stenosis or regurgitation. By use of TD, the following parameters were assessed: systolic peak velocities (Sm), pre-contraction time, contraction time, early (E(m)) and late (A(m)) diastolic velocities, E(m)/A(m) ratio, relaxation time. By treadmill test, we measured: maximal heart rate (HR), systolic blood pressure (SBP), rate-pressure product, maximal workload, time duration of the exercise. RESULTS: the two groups were comparable for left ventricular measurements and for all transmitral and transtricuspid Doppler indexes, while tricuspid ring diameter was increased in TOF. TD analysis showed in TOF lower S(m), E(m) and E(m)/A(m) ratio and prolonged PCT(m) and Rt(m) at tricuspid annulus level, despite comparable TD mitral annulus indexes. By treadmill test, TOF showed reduced time of exercise, number of METS reached and rate-pressure product. Multiple linear regression models evidenced in TOF independent positive association between tricuspid Em velocity and time of exercise (p<0.0001), achieved METS at peak effort (p<0.001) and rate-pressure product (p<0.001). An E(m) peak velocity of tricuspid annulus lower than 0.13 m/s showed 90% sensitivity and 93% specificity in identifying TOF patients unable to perform maximal exercise test. CONCLUSIONS: despite normal Doppler parameters, adult patients late after correction of TOF showed impaired right ventricular myocardial function. In these patients pulsed TD may be taken into account as a valuable supporting tool to predict the effort response and possibly to assess long-term follow-up of cardiac functional reserve.

Usefulness of Doppler tissue imaging for the assessment of right and left ventricular myocardial function in patients with dual-chamber pacing.

The aim of the study was to evaluate by Doppler tissue imaging (DTI) the combined effects of atrio-ventricular (AV) delay and heart rate (HR) changes on global and segmental right (RV) and left (LV) ventricular diastolic function in 15 patients with dual-chamber pacemakers paced in the DDD mode. RV and LV inflow velocities and regional systolic and diastolic pulsed-wave (PW) DTI parameters were analyzed at four different pacing modes: (1) HR 70 beats/min, AV delay 125 ms; (2) HR 70 beats/min, AV delay 188 ms; (3) HR 89 beats/min, AV delay 125 ms; (4) HR 89 beats/min, AV delay 188 ms. For each pacing mode selected, RV diastolic filling velocities always prevailed over LV ones. As for RV and LV adaptation to the four different stimulation protocols, a higher paced rate and a prolonged AV delay caused across both the AV valves a decrease of E wave and of E/A ratios. The intersegmental comparison of PW-DTI parameters outlined that RV free wall exhibited significantly higher peak systolic (Sm) and early-diastolic (Em) wall velocities, and longer systolic ejection time. Considering separately RV and LV segmental physiology at the four programmed pacing modes, an increase in HR determined a progressive shortening of systolic ejection times in all the segments analyzed. Moreover, in each region the Em/Am ratio decreased with higher HR and longer AV delay. Conversely, Em encountered a progressive reduction in RV free wall, while remaining quite unchanged in all the LV regions. Both ventricles shared a similar pattern of global and regional adaptation to programmed HR and AV delay modifications, consisting in a progressive greater contribution of late diastole to ventricular filling at higher HR and more prolonged AV delay. However, at a regional level the right ventricle exhibited higher systolic and diastolic wall velocities than all left ventricular regions.

Percutaneous mitral commissurotomy versus open mitral commissurotomy: a comparative study.

OBJECTIVE: Although many studies in medical literature are comparing percutaneous trans-septal mitral commissurotomy (PTMC) and open mitral commissurotomy (OMC), very few long-term comparative follow-ups are available. METHODS: Between January 1991 and December 1997, 193 patients with isolated mitral stenosis were assigned either to PTMC (111 cases) or to OMC (82 cases). PTMC was performed in all cases with Inoue Ballon, OMC was performed with standard techniques. Categorical values were compared by chi square analysis, whereas continuous data were compared by Mann-Whitney test. Univariate survival and event free analysis (Kaplan-Meier+/-SE and log rank) were performed. Recurrent stenosis was classified any mitral valve area (MVA) less than 1.2 cm2 and whenever post-op. echo showed a loss more than 50% of the initial gain. Data were reported as mean+/-SD. Data concerning late echocardiographic assessment were studied with linear and logistic regression analysis. RESULTS: The two groups were homogenous as far preoperative variables as sex, mean age, MVA, echo score and incidence of left atrial thrombosis were concerned. Mean NYHA was preoperatively higher in OMC (2.79+/-0.58) versus PTMC (2.42+/-0.5) (P = 0.001). There was no hospital mortality in both groups. Incidence of hospital complications was similar (4/ 111 after PTMC and 1/82 after OMC; P = 0.3). Seven year survival: 95.41+/-0.02 (PTMC) and 98.05+/-0.01 (OMC) (P = 0.3) and freedom from late complications did not show statistical differences: Embolism 98.78+/-0.01 in PTMC and 98.78+0.01 in OMC (P = 0.8); Recurrent stenosis 71.89+/-0.13 in PTMC versus 82.89+/-0.08 in OMC (P = 0.2); Reoperation 88.43+/-0.08 in PTMC versus 96.25+/-0.02 in OMC (P = 0.4). A larger MVA was found in patients undergone to OMC (2.05+/-0.35) versus PTMC (1.81+/-0.33) (P = 0.001). Furthermore mean NYHA was lower in OMC (1.14+/-0.3) versus PTMC (1.39+/-0.7) (P = 0.001). CONCLUSIONS: Both techniques achieve with a low operative risk and low incidence of complications a good palliation of rheumatic mitral stenosis. Incidence of complications in the follow-up is similar. OMC allows a larger mitral valve area, a better functional recovery and a lower incidence of late mitral regurgitation.

Doppler myocardial imaging vs. B-mode grey-scale imaging: a comparative in vitro and in vivo study into their relative efficacy in endocardial boundary detection.

Doppler myocardial imaging (DMI) is a new ultrasound imaging modality in which colour Doppler algorithms are adapted to visualise the myocardium. It allows measurement of regional intramyocardial velocities and quantification of intramural left ventricular function. However promising the technique is, to date the accuracy of endocardial boundary detection by DMI has not been validated. As Doppler velocity estimation is based on measurement of phase shift rather than signal strength, the technique is relatively independent of chest wall attenuation. In the current study, a series of in vitro and in vivo studies was performed to compare standard B-mode grey-scale imaging (GSI) and DMI techniques in endocardial boundary detection. In vitro, the minimum and maximum volumes of a single-chamber tissue-mimicking phantom were calculated using both imaging techniques. In vivo, left ventricular end-diastolic (ED) volume and end-systolic (ES) volume indices were measured from GSI and DMI images in a group of 40 volunteers. All images were obtained in the freeze-frame mode with the Doppler display turned on and off so that simultaneous DMI and GSI information was obtained. In vitro, the limits of agreement between the minimum volume of the phantom and the minimum volume measured by GSI and DMI was 4% and 3%, respectively. For maximum volumes, limits of agreement were 3% for GSI and 2% for DMI. In vivo, the limits of agreement between the two imaging techniques in volume measurements were 6 mL (9%) for ED and 4 mL (11%) for ES. The comparison of the endocardial boundary detection by GSI vs. DMI showed DMI to be significantly superior: ED (72 +/- 16% vs. 85 +/- 8%, respectively; p < 0.05) and ES (71 +/- 13% vs. 88 +/- 7%, respectively; p < 0.05). The results of the study show that: (1) in vitro, based on two-dimensional algorithms, DMI provides as accurate volume measurements as GSI; and (2) in vivo, there is a very good agreement of left ventricular volume measurements between GSI and DMI. However, the endocardial boundary is more reliably displayed and visually easier to detect using DMI than GSI.

Dipyridamole thallium-201 perfusion imaging for the study of ischemic heart disease in hemodialysis patients.

To assess the usefulness of dipyridamole thallium perfusion imaging in the evaluation of myocardial perfusion in hemodialysis (HD), we studied 29 HD patients divided into three groups: A) 13 patients with clinical angina, B) 8 patients without angina but similar in age, sex, time on HD and hematocrit and C) 8 young asymptomatic patients (mean age 33 +/- 9.7 years). Dipyridamole thallium-201 (Tl-201) perfusion imaging revealed myocardial perfusion defects in 8 patients (61%) from group A, 4 (50%) from group B and 1 (12.5%) from group C. These defects were localized in the inferior, posterior and septal segments of the left ventricle. Abnormal myocardial perfusion was associated with age over 50 years and aortic calcifications (p less than 0.05). Eight patients died within the following four years. All had aortic calcifications (p less than 0.001). Our results show that myocardial perfusion defects are frequent even in non-symptomatic HD patients. This suggests that ischemic heart disease could be more frequent than estimated by clinical symptoms alone. Tl-201 scintigraphy may be a useful non-invasive procedure in cardiological evaluation of HD patients.

Reduction of coronary flow reserve non-invasively determined by transthoracic Doppler echocardiography as a predictor of left anterior descending coronary artery stenosis.

BACKGROUND: The aim of this study was to evaluate if a reduced coronary flow reserve determined by transthoracic echocardiography alone or combined with contrast agents may represent a predictive index of significant left anterior descending coronary artery (LAD) stenosis. METHODS: Thirty-four patients (mean age 59+/-9 years) undergoing coronary angiography for coronary artery disease were studied. Coronary stenosis was classified (according to visually determined percent narrowing) as severe (> 75%), moderate (40 to 75%) and mild (< 40%). Coronary blood flow velocities were recorded in each patient at baseline and after low-dose dipyridamole administration by use of a 3.5 MHz transducer with a machine equipped with second harmonic capability and nondirectional color Doppler software. Coronary flow reserve was defined as the ratio of hyperemic to basal diastolic peak velocity. RESULTS: Adequate Doppler recordings in the LAD were obtained by transthoracic echocardiography in 26/34 patients (76%); the infusion of Levovist allowed for the visualization of LAD flow in a further 7 patients, with an overall feasibility of 97%. Coronary flow reserve was significantly higher in the group of patients with mild coronary lesions (2.3+/-0.3) than in patients with moderate (1.68+/-0.29, p = 0.0004) or severe (1.49+/-0.39, p = 0.0005) LAD stenosis. CONCLUSIONS: By use of transthoracic echocardiography combined with contrast agents it is possible to visualize blood flow velocities in the LAD and to evaluate coronary flow reserve after dipyridamole infusion with a non-invasive approach. Combined with angiographic findings, this diagnostic approach could be useful in giving additional information to assess the functional significance of a stenotic coronary lesion.

Risk predictors of paroxysmal atrial fibrillation following aortic valve replacement.

BACKGROUND: Atrial fibrillation (AF) is the most frequently encountered arrhythmic complication associated with cardiac surgery. The aim of this paper was to identify the clinical predictors of AF occurrence following aortic valve replacement. METHODS: Three hundred and two patients were included in this study and divided into two groups according to the absence (SR group, 243 patients, mean age 55.6 +/- 15 years) or the evidence (AF group, 59 patients, mean age 63.8 +/- 11 years) of post-aortic valve replacement AF. Sixty-five perioperative variables (37 preoperative, 8 intraoperative and 20 postoperative) were considered. RESULTS: Post-aortic valve replacement paroxysmal AF occurred in 59 out of 302 patients (19%). At univariate analysis, post-aortic valve replacement AF was associated with advanced age, left atrial enlargement, preoperative episodes of paroxysmal AF, the use of a warm blood cardioplegic solution and normothermia, administration of inotropic agents, prolonged assisted ventilation but also with postoperative acidosis, electrolyte imbalance and atrioventricular and intraventricular conduction disorders. Stepwise forward multivariate logistic regression analysis identified age (p = 0.002, odds ratio--OR 1.04), left atrial enlargement (p = 0.004, OR 2.6), a prior history of paroxysmal AF (p = 0.0003, OR 10.9), and postoperative electrolyte imbalance (p = 0.01, OR 2.3) as independent correlates of AF, whereas the use of hypothermia appeared to be a protective factor (p = 0.0004, OR 0.26). CONCLUSIONS: According to our findings, post-aortic valve replacement AF seems to be associated with well-defined anatomical and electrical substrates generated by advanced age, increased left atrial dimensions, and a possible electrical remodeling consequent to prior repetitive episodes of paroxysmal AF. On these grounds, external factors such as postoperative electrolyte imbalance might enhance atrial ectopic activity and trigger postoperative sustained tachyarrhythmias, while the use of hypothermia might allow for better protection of the atrial myocardium against intraoperative ischemia.

Impact of myocardial diastolic dysfunction on coronary flow reserve in hypertensive patients with left ventricular hypertrophy.

BACKGROUND: The aim of the study was to assess the possible association, in hypertensive patients, between left ventricular myocardial diastolic dysfunction and coronary flow reserve (CFR) in relation to the presence of left ventricular hypertrophy (LVH). METHODS: Twenty-eight untreated hypertensives (22 males, 6 females, mean age 53.1 years), free of coronary artery disease, were enrolled in the study. Standard Doppler echocardiography, color Doppler tissue imaging of the posterior septum during dobutamine stress and second harmonic Doppler of the distal left anterior descending coronary vessel, at baseline and after maximal hyperemia induced by dipyridamole, were performed. CFR was estimated as the ratio between hyperemic and baseline diastolic velocities. Hypertensives were divided into two groups according to the left ventricular mass index: 15 without LVH (left ventricular mass index < 51 g/m2.7) and 13 with LVH (left ventricular mass index > 51 g/m2.7). The two groups were comparable for sex prevalence, age, body mass index, baseline heart rate and blood pressure. RESULTS: Color Doppler tissue imaging did not show any significant difference of both the baseline and high-dobutamine septal systolic peak velocities between the two groups. The ratio between myocardial early and atrial peak velocities (Em/Am ratio) was lower in patients with LVH, either at baseline (p < 0.01) or at high-dose dobutamine (p < 0.0001). Also, CFR was lower in the presence of LVH (p < 0.01). After adjusting for age, body mass index, left ventricular mass index, diastolic blood pressure and high-dose dobutamine heart rate by a multiple linear regression analysis, the high-dose dobutamine Em/Am ratio was an independent contributor of CFR in the overall hypertensive population (beta = 0.65, p < 0.0001) (cumulative r2 = 0.38, p < 0.0001). CONCLUSIONS: The combined use of second harmonic Doppler and color Doppler tissue imaging identifies, in arterial hypertension, an association between myocardial diastolic properties and CFR, independent of the presence of LVH. In hypertensive patients free of coronary artery stenosis, left ventricular myocardial diastolic dysfunction may be a determinant in the impairment of the coronary microvessel vasodilation capacity or a marker of silent ischemia involving the microvascular circulation.