Transesophageal echocardiography through nasal way as a guide to percutaneous closure of patent foramen ovale.

Percutaneous device closure of patent foramen ovale (PFO) has become an effective and safe alternative to medical or surgery treatment. Transesophageal echocardiography (TEE), as commonly used to guide this procedure, has the limitation to require general anesthesia. Recently, intracardiac echocardiography (ICE) with AcuNav probe was used to guide percutaneous PFO closure. We report a 42 year-old man with two previous cryptogenetic strokes in whom both diagnosis and guidance of PFO closure were performed by means of TEE using the AcuNav catheter introduced through nasal way (TEENW). This technique, that does not require general anesthesia, provided adequate and complete view of the Amplatzer procedure. TEENW might offer a feasible and equivalent echocardiographic alternative either to standard TEE or ICE as a guide to percutaneous PFO closure.

Noninvasive coronary flow reserve assessed by transthoracic coronary Doppler ultrasound in patients with left anterior descending coronary artery stents.

Noninvasive measurement of coronary flow reserve (CFR) (hyperemic/flow velocity ratio at rest) by transthoracic Doppler echocardiography showed normalization of flow in the left anterior descending (LAD) coronary artery early after stenting. We hypothesized that noninvasive CFR may reveal in-stent restenosis at follow-up. Therefore, we studied 134 patients, 0 to 72 months after successful proximal-middle LAD stenting, and 38 controls. LAD flow velocity was measured by transthoracic Doppler echocardiography during 90 seconds venous adenosine infusion (140 microg/kg/min). CFR was measured in diastole. According to angiography, patients who received stents were divided into 3 groups: group I, <50% LAD in-stent restenosis (n = 83); group II, nonsignificant (50% to 69%) LAD in-stent restenosis (n = 17); and group III, significant (> or = 70%) LAD in-stent restenosis (n = 34). LAD CFR was similar in group I and controls (2.90 +/- 0.58 vs 3.05 +/- 0.81; p = NS), it was slightly lower in group II (2.42 +/- 0.33) compared with controls and group I (p <0.001 vs both), and clearly abnormal (<2) in group III (1.38 +/- 0.48) compared with controls, and groups I and II (p <0.001). A CFR <2 had 91% sensitivity, 95% specificity, and 96% positive and 97% negative predictive values to detect significant stenosis in patients with LAD stents. Our data show that noninvasive Doppler assessment of CFR allows identification of significant LAD in-stent restenosis, based on a cut-off value of <2.

Measurement of coronary flow reserve in the anterior and posterior descending coronary arteries by transthoracic Doppler ultrasound.

We describe for the first time transthoracic Doppler ultrasound assessment of coronary flow reserve (CFR) in both the posterior descending (PDA) and left anterior descending (LAD) coronary arteries. CFR (hyperemic/resting diastolic flow velocity ratio) was measured by 90-second intravenous adenosine infusion (140 microg/kg/min). Baseline PDA flow was detected in 62 of 81 subjects (76%), and the CFR was measurable in 44 of them (54%) because of adenosine-induced hyperventilation. According to angiography, these 44 subjects were divided into 3 groups: group 1 (0% to 29% stenosis), group 2 (30% to 69% stenosis), and group 3 (> or =70% stenosis). PDA CFR was 2.62 +/- 0.25 in 17 patients in group 1, 2.33 +/- 0.32 in 9 patients in group 2, and 1.40 +/- 0.54 in 18 patients in group 3 (F = 41.83, p <0.0001). LAD CFR was 3.31 +/- 0.54 in 15 patients in group 1, 2.49 +/- 0.71 in 10 patients in group 2, and 1.12 +/- 0.49 in 19 patients in group 3 (F = 65.68, p <0.0001). A cut-off of <2 identified > or =70% stenosis in both of the arteries supplying the PDA and in the LAD. Noninvasive measurement of PDA CFR is feasible and may improve with technologic advancement and the use of selective adenosine receptor agonists, thus preventing hyperventilation.