Feasibility and value of two-dimensional volumetric stress echocardiography.

BACKGROUND: Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV). METHODS: We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638). RESULTS: Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume. CONCLUSIONS: Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Complexity of changes in right ventricular morphology and function in patients undergoing cardiac surgery - 3D echocardiographic study.

BACKGROUND: An impairment of standard echocardiographic parameters of right ventricular (RV) function is a known phenomenon in patients undergoing cardiac surgery, but its significance remains unclear. AIMS: This study aimed to assess changes in RV function in patients undergoing cardiac surgery using speckle tracking and 3D echocardiography. METHODS: The study population comprised 122 patients referred for cardiac surgery. Transthoracic echocardiographic (TTE) examinations were performed: before the surgery (TTE1), 1 week after surgery (TTE2), and 1 year after surgery (TTE 3). Parameters measured during these examinations included both standard and advanced indices of the RV size and function, as well as a new parameter introduced by our team - RV shortening fraction (RV SF). RESULTS: TTE1 was performed on average (standard deviation [SD]) 24 (15) hours before surgery, whereas TTE2 and TTE3 were performed on average 7.2 (3) days and 346 (75) days after the surgery, respectively. A postoperative impairment of parameters of RV longitudinal function was observed (P <0.001). However, neither the RV size assessed by both 2D and 3D techniques changed, nor the global RV function measured with the use of fractional area change and ejection fraction. Additionally, during the postoperative period, an increase in the value of an RV SF by 12.9% was observed. After 12 months we observed an improvement in the parameters of the longitudinal RV function. CONCLUSIONS: Uncomplicated cardiac surgery causes transient impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed.

Conscious sedation for transcatheter implantation of atrial septal occluders with two- and three-dimensional transoesophageal echocardiography guidance - a feasibility and safety study.

BACKGROUND: General anaesthesia may have negative impact on patient mortality and morbidity, as well as overall procedure costs, in atrial septal occluder (ASO) implantation. AIM: We sought to evaluate the safety, efficacy, and feasibility of conscious sedation for transcatheter implantation of ASOs. METHODS: A total of 122 patients referred for transcatheter implantation of ASO were included. Mean patient age was 51 ± 15 years, and 43 (35%) patients were male. The initial dose of midazolam was 2 mg and fentanyl dose was 25 µg. Additional doses of midazolam and fentanyl were administered, if necessary. Patient responsiveness was assessed every 10 min, and the sedatives doses were titrated in order not to exceed grade 3 sedation in the Ramsey scale. RESULTS: Atrial septal occluders were successfully implanted in the majority of patients (98.4%). In two (1.6%) cases the proce-dure failed because of too small patent foramen ovale (PFO) diameter (n = 1, 0.8%) or device instability (n = 1, 0.8%). The mean duration of procedure was 47.6 ± 28.4 min and was similar for ASD and PFO closure (p = 0.522). The overall mean dose of midazolam was 4.7 ± 2.2 mg (63.9 ± 32.5 µg/kg) and fentanyl was 30.0 ± 11.9 µg (0.43 ± 0.17 µg/kg). Median entrance dose of radiation at the patient plane was 25 (interquartile range: 16-57) mGy, and did not differ between ASD and PFO procedures (p = 0.614). The majority of patients were free of complications (91.0%). The following early complications were observed: transient ischaemic attack (n = 2, 1.6%), supraventricular arrhythmias (n = 4, 3.3%), left atrial thrombus formation (n = 1, 0.8%), symptomatic bradycardia (n = 1, 0.8%), and femoral venous bleeding (n = 5, 4.1%). After mean follow-up of 386 days residual shunt was observed in eight (6.6%) patients. CONCLUSIONS: Conscious sedation for transcatheter implantation of ASO is a feasible, safe, and efficient technique, allowing successful PFO and ASD closure in the majority of patients.

Conscious sedation during cryoballoon ablation of atrial fibrillation: a feasibility and safety study.

BACKGROUND: Cryoballoon ablation for atrial fibrillation (cryoAF) is relatively simple, cost-effective and easy procedure. However, general anesthesia during this procedure may have negative impact on patients' mortality and morbidity, as well as procedure costs. We sought to assess the feasibility and safety of conscious sedation during cryoAF. METHODS: Patients with paroxysmal or persistent, drug-refractory AF who underwent a first procedure of cryoAF were included in our single-center, retrospective study. The loading dose of midazolam was 2 mg and loading fentanyl dose was 25 µg intravenously. Additional doses of midazolam and fentanyl were administered, if necessary. Midazolam and fentanyl were administered to maintain amnesia and analgesia, and patients' responsiveness in Ramsay Sedation Score was assessed every 10 minutes with sedation kept at the Ramsey Sedation Scale not exceeding Ramsey 3 Grade. RESULTS: A total of 71 patients with mean age 59.5±11.1 years were enrolled (48 males, 68%). The TEE and the TEE-guided transseptal puncture was feasible in all patients. The mean duration of cryoAF procedure was 136.3±36.0 minutes. The overall mean midazolam and fentanyl used doses were: 5.1±3.1 mg (55.7±35.1 µg/kg) and 98.9±51.1 µg (1.13±0.60 µg/kg). In 3 patients (4.2%), vascular complications occurred (femoral vein bleeding with hematoma formation without communication with femoral artery). In 1 case (1.4%) transient right phrenic palsy was observed; symptoms disappeared completely within 12 hours after procedure. The overall acute procedural success rate of cryoAF (defined as electrical isolation of all pulmonary veins) was 68/71 (95.8%). CONCLUSIONS: Conscious sedation is a safe, efficacious and feasible during cryoablation of pulmonary veins for AF.

Bedside screening with the use of pocket-size imaging device can be useful for ruling out carotid artery stenosis in patients scheduled for cardiac surgery.

BACKGROUND: Patients (pts) scheduled for coronary artery bypass grafting, burdened with high risk of carotid stenosis, are recommended to undergo duplex ultrasonography (DUS) of carotid arteries. PURPOSE: To validate pocket-size imaging device (PSID) equipped with linear probe as an easily accessible tool enabling bedside screening for carotid artery stenosis (CAS). METHODS: A total of 100 pts (60 men, mean age 69±11 years) with multivessel coronary artery disease underwent bedside DUS of carotid arteries with the use of PSID performed by a cardiology resident trained in DUS. Subsequently, DUS with the use of stationary high-end ultrasound system was performed in all pts to verify findings of PSID examination. RESULTS: Initial diagnosis of atherosclerotic plaque presence obtained with PSID in 59 patients was confirmed by high-end ultrasound system examination in all cases. There was a statistically significant correlation of intima-media thickness measurements between PSID and stationary system (r=.58; 95% CI: 0.48-0.66; P<.0001), but the coefficient of agreement (κ) between the two methods in classification of intima-media as normal or thickened (>0.9 mm) was only .38 (95% CI: 0.299-0.459). During PSID examination, turbulent flow was observed in 21 pts-CAS was confirmed in all these pts-5 pts were diagnosed with significant CAS, the rest with CAS ranging from 30% to 70%. CONCLUSIONS: Pocket-size imaging device equipped with linear probe allows for identification of patients with atherosclerotic plaques and turbulent flow in carotid arteries; however, the degree of CAS cannot be reliably determined. The measurement accuracy of intima-media thickness is insufficient for a diagnostic purpose.

Optimal treatment of coronary-to-pulmonary artery fistula: surgery, coil or stent graft?

We report a case of a 57-year-old man with typical angina due to a coronary artery-to-pulmonary artery fistula, which was evident on transthoracic and transesophageal echocardiography with color Doppler flow mapping. The diagnosis was confirmed by coronary angiography. The patient underwent surgical ligation of the fistula. However, repeated transesophageal echocardiography and coronary angiography revealed persistence of the fistula with significant left-to-right shunt. The orifice of the fistula was then obliterated by stent-graft implantation, which was proven successful by angiography and echocardiography.

[Acute mitral regurgitation caused by infarction-related papillary muscle rupture with successful surgical treatment: case report]. / Ostra niedomykalnosc mitralna spowodowana zawalowym peknieciem miesnia brodawkowatego skutecznie leczona operacyjnie - opis przypadku.

We present a case of severe complication of myocardial infarction -- acute mitral regurgitation caused by papillary muscle rupture. A 69-year-old man was admitted with chest pain lasting 1 hour and pulmonary oedema. ECG revealed ST-segment depression in leads II, III, aVF, V2-V6. Soon after admission the patient experienced respiratory disorders and consequently arrest. The patient was transferred in shock to the Department of Cardiothoracic Surgery, where he underwent successful artificial mitral valve implantation. One year later the patient is in good condition (NYHA class I) and the valve is fully functional.