Electrocardiographic evolutionary changes and left ventricular remodeling after acute myocardial infarction: results of the GISSI-3 Echo substudy.

OBJECTIVES: The aim of this study was to describe the electrocardiographic (ECG) evolutionary changes after an acute myocardial infarction (AMI) and to evaluate their correlation with left ventricular function and remodeling. BACKGROUND: The QRS complex changes after AMI have been correlated with infarct size and left ventricular function. By contrast, the significance of T wave changes is controversial. METHODS: We studied 536 patients enrolled in the GISSI-3-Echo substudy who underwent ECG and echocardiographic studies at 24 to 48 h (S1), at hospital discharge (S2), at six weeks (S3) and six months (S4) after AMI. RESULTS: The number of Qwaves (nQ) and QRS quantitative score (QRSs) did not change over time. From S2 to S4, the number of negative T waves (nT NEG) decreased (p < 0.0001), wall motion abnormalities (%WMA) improved (p < 0.001), ventricular volumes increased (p < 0.0001) while ejection fraction remained stable. According to the T wave changes after hospital discharge, patients were divided into four groups: stable positive T waves (group 1, n = 35), patients who showed a decrease > or =1 in nT NEG (group 2, n = 361), patients with no change in nT NEG (group 3, n = 64) and those with an increase > or =1 in nT NEG (group 4, n = 76). The QRSs and nQ remained stable in all groups. Groups 3 and 4 showed less recovery in %WMA, more pronounced ventricular enlargement and progressive decline in ejection fraction than groups 1 and 2 (interaction time x groups p < 0.0001). CONCLUSIONS: The analysis of serial ECG can predict postinfarct left ventricular remodeling. Normalization of negative T waves during the follow-up appears more strictly related to recovery of regional dysfunction than QRS changes. Lack of resolution and late appearance of new negative T predict unfavorable remodeling with progressive deterioration of ventricular function.

Validation of the ejection fraction-velocity ratio: a new simplified "function-corrected" index for assessing aortic stenosis severity.

A new echocardiographic method for the evaluation of aortic stenosis (AS) severity has recently been introduced: the fractional shortening-velocity ratio (FSVR = fractional shortening/4 Vmax(2)). An important advantage of the method is the possibility of avoiding the difficulties related to the measurement of left ventricular outflow tract in calcific AS for assessing the continuity equation. FSVR, however, also shows some significant limitations especially in patients with regional wall motion abnormalities and conduction defects. To overcome this problem, we developed a new index: the ejection fraction-velocity ratio (EFVR = ejection fraction/4 Vmax(2)), where percent ejection fraction and Vmax have been obtained with an apical echocardiographic approach. In 343 consecutive patients with AS, aortic valve area was measured by cardiac catheterization (Gorlin), whereas FSVR and EFVR were calculated by echo-Doppler examination performed within 24 hours. Mean valve area was 0.70 +/- 0.30 cm(2), mean EFVR was 0.78 +/- 0.41, and mean FSVR was 0.45 +/- 0.26. The linear correlation area-EFVR was highly significant (r = 0.88). Correlation valve area-FSVR was also significant (r = 0.82). EFVR allowed identification of patients with severe AS (area

Role of transesophageal echocardiography in evaluation of pulmonary venous obstruction by paracardiac neoplastic masses.

From 71 consecutive patients with paracardiac neoplastic masses who underwent transesophageal echocardiography (TEE), obstruction of individual right upper pulmonary venous flow by compression by contiguous mass was detected by TEE in 4 patients before and disappeared after anti-neoplastic treatments. Pulmonary vein, contiguous neoplastic mass and their relation could be clearly visualized and assessed by TEE. Pulmonary venous obstruction was assessed as moderate degree by combination of Doppler flow characteristics and diameter of pulmonary vein. Before therapy, peak velocities and time-velocity integrals in obstructed right upper pulmonary venous flow were increased, whereas deceleration times of systolic flow were prolonged. After therapy, peak velocities and time-velocity integrals were reduced and deceleration times of systolic flow were shortened, with normalization of the diameter of the right upper pulmonary veins. Thus, TEE may be used to detect and evaluate pulmonary venous obstruction by neoplastic masses and its changes after antineoplastic treatments.

Reproducibility of wall motion score and its correlation with left ventricular ejection fraction in patients with acute myocardial infarction.

The inter- and intraobserver variability, as well as the relation to left ventricular (LV) function indexes, of LV wall motion score calculated using the 16- and 11-segment models of LV segmentation were assessed in 105 patients with acute myocardial infarction who were examined at 36 +/- 7 hours from onset of symptoms. In these patients, the use of the 16-segment model of LV segmentation portends to a significantly higher inter- and intraobserver reproducibility of segmental wall motion score than the use of the 11-segment model. In addition, wall motion score assessed with the more detailed 16-segment model of LV segmentation showed a significantly higher correlation with LV ejection fraction than the wall motion score assessed using the 11-segment model.

Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis.

Pulmonary hypertension (PH) has been reported in patients with valvular aortic stenosis (AS) and has been found to be associated with a more severe clinical picture and a poor prognosis after aortic valve replacement. The aim of this study was to assess the prevalence of PH in adult patients with symptomatic AS undergoing cardiac catheterization, and to evaluate the relation between pulmonary artery (PA) systolic pressure and hemodynamic and clinical variables to further clarify the pathogenetic mechanisms. We assessed right-sided heart hemodynamics during cardiac catheterization in 388 patients with symptomatic isolated or predominant AS. PA systolic pressure between 31 and 50 mm Hg was used to define mild to moderate PH, whereas PA systolic pressure >50 mm Hg was used to define severe PH. PA systolic pressure showed no significant difference according to age and sex, although it was significantly higher in patients in New York Heart Association functional classes III and IV and in patients with coexistent systemic hypertension than in the others. PH was absent in 136 patients (35%, group 1), mild to moderate in 196 patients (50%, group 2), and severe in 58 patients (15%, group 3). Only the prevalence of overt heart failure was significantly higher in group 3 patients. AS severity was similar among the 3 groups, and PA systolic pressure showed no relation to aortic valve area in the entire population. Also, a poor correlation was found between PA pressure and left ventricular (LV) ejection fraction (r = -0.28), with several patients having moderate or severe PH despite a preserved LV systolic function. PA systolic pressure significantly correlated with LV end-diastolic pressure (r = 0.50) and with PA wedge pressure (r = 0.84). Furthermore, transpulmonary pressure gradient, an index of resistance across the pulmonary vascular bed (obtained as the difference between PA mean and PA wedge pressure), was significantly higher in patients with PH, especially in those with a marked increase in PA systolic pressure, suggesting a reactive component of PH.

Relation between three-dimensional geometry of the inflow tract to the orifice and the area, shape, and velocity of regurgitant color Doppler jets: an in vitro study.

The relation between three-dimensional geometry of the inflow tract to the orifice and the area, shape, and velocity of regurgitant jets was studied in a pulsatile in vitro color Doppler flow model. A 2.5 MHz transducer connected to a diagnostic ultrasound machine was placed in a water tank facing pulsatile jets (duration, 0.5 second) obtained by a calibrated injector. Flow rate from 6 to 52 ml/sec were tested through a 5 mm diameter circular orifice. Four different three-dimensional inflow tract geometries were compared: (A) sharp-edged, (B) Venturi (funnel), (C) converging conical, and (D) diverging conical. Mean velocities of jets were measured by continuous-wave Doppler echocardiography. Driving pressures were also measured by means of a fluid-filled catheter. Two observers independently digitized contours of maximal color jet areas by computer system from two separate sets of experiments. Results are given as the mean values of the four measurements for each parameter. Jet areas were correlated to flow rate, with no difference from A through D. The shape (eccentricity) of jets was different between A and B (p less than 0.05), between B and D (p less than 0.01), and between C and D (p less than 0.01). The shape of jets was correlated with flow rate, continuous-wave velocity, and pressure gradient in B, C, and D but not in A. Measured pressure gradients and estimated gradients by continuous-wave Doppler echocardiography were similarly correlated from A through D.(ABSTRACT TRUNCATED AT 250 WORDS)

Can short-term verapamil therapy reduce the recurrence of atrial fibrillation after successful low energy intracardiac cardioversion?

BACKGROUND: Calcium-lowering drugs seem to be able to reduce the recurrences of atrial fibrillation (AF) after cardioversion by preventing electrical remodeling of atrial cells. The aim of our study was to prospectively evaluate the efficacy of short-term verapamil therapy associated with propafenone or amiodarone in reducing recurrences of AF after low energy intracardiac cardioversion. METHODS: Eighty-two patients with chronic AF (mean duration 6.1 months, range 1-96 months) underwent low energy intracardiac cardioversion. Forty-one patients (Group A) were instructed to suspend antiarrhythmic therapy 48 hours before the procedure (only chronic amiodarone was allowed). The subsequent 41 patients (Group B), in addition to previous prescriptions, had to take verapamil (120 mg twice daily) for 3 days before low energy intracardiac cardioversion and for 7 days after cardioversion. A right atrium-coronary sinus or right atrium-left pulmonary artery electrode configuration was indifferently utilized. Propafenone (450-900 mg daily) or amiodarone (200 mg daily) was prescribed to all patients after cardioversion. RESULTS: Sinus rhythm was acutely restored in 80 patients (97.6%): the mean number of shocks delivered was 2.3 (range 1-5); the mean energy required was 10.5 J (range 7.2-19.8 J). No statistically significant differences were found between the right atrium-coronary sinus vs right atrium-left pulmonary artery electrode configuration regarding the energy required and the number of shocks delivered. Group A and Group B showed the same number of AF recurrences at the first month of follow-up. CONCLUSIONS: In our study, short-term verapamil treatment associated with propafenone or amiodarone seems to be useless for the prevention of recurrent AF after low energy intracardiac cardioversion.

Low energy intracardiac cardioversion of chronic atrial fibrillation by single femoral approach: safety and effectiveness of the procedure.

BACKGROUND: Low energy intracardiac cardioversion has recently been introduced into clinical practice to treat both acute and chronic atrial fibrillation. It has also been suggested that low energy intracardiac cardioversion has a higher efficacy rate in restoring sinus rhythm than conventional external cardioversion. METHODS: A prospective study was started in 41 patients (mean age 64.5 years) with chronic atrial fibrillation (mean duration 6.5 months), in order to obtain more data on low energy intracardiac cardioversion concerning: 1) time required to perform low energy intracardiac cardioversion by single venous femoral approach; 2) acute efficacy; 3) incidence of complications; 4) persistence of sinus rhythm after 1 month. RESULTS: Twenty patients had right atrium-coronary sinus (Group A) and 20 right atrium-left pulmonary artery (Group B) electrode configuration for defibrillation. In 1 patient the configuration was not available. In all patients (100%) sinus rhythm was acutely restored. No statistically significant differences were found between the two groups concerning mean energy and impedance required to obtain cardioversion. With mild sedation the discomfort induced by the electrical shock was minimal or mild. Only 44% of patients were in sinus rhythm 1 month after low energy intracardiac cardioversion, in spite of adequate pharmacological therapy. CONCLUSIONS: Low energy intracardiac cardioversion by single venous femoral approach may be considered a very effective and not time consuming procedure in acutely restoring sinus rhythm, with low complication rate; in addition the procedure was well accepted by all patients.

[Digital signature: new prospects for the information of the cardiologic clinical card]. / Firma digitale: nuove prospettive per l'informatizzazione della cartella clinica cardiologica.

In the last few years, remarkable improvements have been made in computerized database systems used in cardiology. However, they will not easily lead to further relevant improvements unless the weaknesses and the gaps deriving from the obligation of forming and storing case sheets, according to law, are faced and resolved in an original way. This article covers the topic of the digital signature and how it could form the basis for a new powerful impulse to the process of informatization of cardiology records. The proposal of elaborating a totally computerized case sheet involves the need of rationalizing the flow of clinical information and of implementing a management system integrated with the hospital information system. The elimination of paper support will probably lead to an advantageous cycle that will involve the entire hospital, both clinically as well as administratively.

Right ventricular functional recovery after acute myocardial infarction: relation with left ventricular function and interventricular septum motion. GISSI-3 echo substudy.

OBJECTIVE: To evaluate the pattern of right ventricular (RV) functional recovery and its relation with left ventricular (LV) function and interventricular septal (IVS) motion in low risk patients after acute myocardial infarction (AMI). DESIGN AND SETTING: Multicentre clinical trial carried out in 47 Italian coronary care units. PATIENTS: 500 patients from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico) -3 echo substudy, who underwent serial echocardiograms 24-48 hours after symptom onset and at discharge, six weeks, and six months after AMI. RESULTS: Tricuspid annular plane systolic excursion (TAPSE) increased significantly during follow up (mean (SD) 1.79 (0.46) cm at 24-48 hours to 1.92 (0.46) cm at six months, p < 0.001) and the increase was already significant at discharge (1.88 (0.47) cm, p < 0.001). LV ejection fraction (LVEF) was the best correlate of TAPSE at 24-48 hours (r = 0.15, p = 0.001). TAPSE increased significantly in patients both with reduced (< 45%) and with preserved (> or = 45%) LVEF, but the magnitude of increase was higher in patients with lower initial LVEF (p = 0.001). Improvement in IVS wall motion score index (IVS-WMSI) was the only independent predictor of TAPSE changes during follow up (r = -0.12, p = 0.007). CONCLUSIONS: In low risk patients after AMI, RV function recovered throughout six months of follow up and was already significant at discharge. TAPSE was significantly related to LVEF at 24-48 hours. The magnitude of RV functional recovery was higher in patients with lower initial LVEF. RV functional recovery is best related to IVS-WMSI improvement, suggesting that IVS motion has an important role in RV functional improvement in this setting.

[Cardiologic application of a clinical database with graphic extension and its utilization in inter-hospital teleconsultation]. / Applicazione in cardiologia di un database clinico con estensione grafica e sua utilizzazione in teleconsulto interospedaliero.

A local area network of personal computers has been operative in our Cardiology Department for seven years, to collect and retrieve on-line character-based data. At present, the network is based on 2 servers and 21 workstations. DBF and DOS files are used by a Clipper 5.2d compiled program to handle demographic data, clinical reports (32,000/year) and diagnostic codes of more than 52,000 patients. In the last two years, we started entring ECG tracings using: RS232 connection, floppy disk transfer, and modem connection with commercially available machines as well as by image scanner. We integrated our clinical database with three dedicated subsystems, written in Assembly and C languages, to manage drawings, digital ECGs and complete reports. Mass storage is provided by a 10 Gbyte magneto-optical disk autochanger physically connected to a dedicated server running an original software manager to optimize routine access to the optical disks. Interhospital network connections were established with two different institutions to allow clinical information sharing, long distance consultation and ECG transfer. The system has been found to be fast, user-friendly and suitable for daily operation of a large cardiological database. Standardized versions of the system are running in seven other cardiology institutions in Italy.

Influence of aortic regurgitation on the assessment of the pressure half-time and derived mitral-valve area in patients with mitral stenosis.

The influence of aortic regurgitation on the Doppler assessment of pressure half-time (T1/2) and on the derived calculation of the mitral-valve area has not yet been adequately evaluated in patients with mitral stenosis and associated aortic regurgitation. Therefore this study was undertaken to verify the accuracy of the T1/2 method for the noninvasive estimation of mitral-valve area in patients with mitral stenosis and associated aortic regurgitation. Data were obtained from 31 selected patients who underwent cardiac catheterization within 24 h of the noninvasive examination. From the Doppler velocity curve, T1/2 was calculated as the interval between the peak transmitral velocity and velocity/ square root of 2. Mitral-valve area was measured from the T1/2 with a computerized system using the equation: 220/T1/2, in cm2. Calculation of the mitral-valve area at catheterization was derived applying the modified Gorlin formula. Mean mitral-valve area, as determined at catheterization, ranged from 0.5 to 2.8 cm2 (1.3 +/- 0.6). Mean mitral-valve area, as calculated by continuous-wave Doppler, ranged from 0.7 to 2.7 cm2 (1.5 +/- 0.6). Linear-regression analysis of data revealed a good correlation between Gorlin and Doppler measurements of the mitral-valve area (r = 0.90, SEE = 0.28 cm2, P less than 0.001, y = 1.0x + 0.2). Doppler showed a systematic overestimate of the mitral-valve area (26%) in patients with mitral stenosis and aortic regurgitation as compared to the Gorlin formula. The overestimate of continuous-wave Doppler was even greater (39%) in a subgroup of patients with 2+ or 3+ angiographic aortic regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Modification of the characteristics of regurgitant jets when impinging upon a surface: an in-vitro investigation using Doppler colour flow mapping.

Free jets were compared in vitro by colour Doppler flow mapping with jets striking a flat and a hemispherical surface, located 3 and 6 cm from a circular orifice (5 mm in diameter). The angles of the impinging jets were 45 degrees and 90 degrees. Flow rates from 6-52 ml.s-1 were tested (pulsatile jets, 0.5 s duration). Free jet areas (21.7 +/- 9.6 cm2) were larger (P less than 0.01) than that of impinging jets (14.3 +/- 5.6 cm2). The distance of the target was a significant factor for reducing areas of striking jets (P less than 0.001). The angle of incidence of the striking jet and the shape of the target surface were not independent factors, but they were important when interacting with flow rate (P less than 0.001). The percentage of total jet area of impinging jets occupied by swirling flow was larger for targets located at 3 cm (P less than 0.01), for a 90 degrees angle of incidence (P less than 0.01), for a flat target surface (P less than 0.05). We conclude that jets visualized in vitro by colour Doppler flow mapping are significantly modified when impinging a surface, with the interplay of several factors. This can be of importance in clinical settings.

Analysis of interobserver and intraobserver variation of interpretation of the echocardiographic and Doppler flow determination of cardiac output by the mitral orifice method.

The variability of the interpretation by two individuals of a combined echocardiographic and Doppler method of calculating output was studied in 30 normal adults. In each subject three separate cardiac cycles were recorded to calculate maximal mitral valve orifice, the ratio of mean to maximal mitral valve leaflet separation, and the mean flow velocity through the mitral valve. The recordings were digitised twice by two independent observers. Estimates of cardiac output ranged from 3.2 to 8.11 1/min. Analysis of variance showed that interobserver and intraobserver variability for these measurements was 5.8% and 6.1% respectively. It is concluded that the reproducibility for interpreting this non-invasive method is adequate for clinical use in adults with cardiac outputs within the normal range.

Feasibility and variability of six methods for the echocardiographic and Doppler determination of cardiac output.

The feasibility and the intrinsic variability of six different methods of echocardiographic and Doppler flow determination of cardiac output were analysed in 34 healthy volunteers. Four were excluded because of poor quality echocardiograms. The mean (range) age of the remaining 30 (12 women, 18 men) was 21 years (13-36 years). Cardiac output was calculated by six methods as a product of echocardiographically determined cross sectional area of the aorta (apical and suprasternal views), pulmonary trunk, tricuspid annulus, and mitral annulus (circular and corrected for diastolic variations), and the flow velocity integral measured by Doppler. Cardiac output ranged from 2.79 to 6.56 1/min (4.45 (1.29) 1/min) (mean (SD)). The feasibility of the methods ranged from 87% (26 patients) for the aorta from the suprasternal notch to 100% (30 patients) for the mitral orifice corrected for diastolic variations and for the tricuspid valve. The corresponding results for all 34 individuals were 76% and 88% respectively. Three way analysis of variance was performed in the 23 healthy volunteers in whom all six methods were feasible. Interobserver and intraobserver interpretative variabilities were 6.8% and 5.9% respectively. The intrinsic variability of each single measurement of cardiac output, independently of the observer and the method used, was 25%. Provided the image was suitable for analysis echocardiographic and Doppler flow determination of cardiac output was feasible in most healthy volunteers. But there was significant intrinsic variability for each of different methods. A single value of cardiac output in an individual should be interpreted with caution.

Heterogeneity of left ventricular wall dynamics in normal hearts and in chronic aortic regurgitation. A two-dimensional echocardiographic study.

The variation in shape, in the global and regional function of the left ventricle (LV) was quantitated by using Two-Dimensional Echocardiography (TDE) in 20 normal subjects (N) (17 males, 3 females, with a mean age of 21.2 years, age range 15 to 34) and compared to 20 patients with aortic regurgitation (AR) (14 males, 6 females with a mean age of 31 years, age range 16 to 51). The left ventricle was subdivided into two TDE short axis cross-sections at the papillary muscle (PM) and at the mitral valve (MV) level. Wall motion was assessed by the following indices; endocardial systolic fractional area change (FAC), wall thickening (Wth) and circumferential fiber shortening (S). The ejection fraction (EF), the diastolic (EID) and systolic eccentricity index (EIS), the end-diastolic volume (EDV), the end systolic volume (ESV) and the LV mass (M) were estimated using a 4 chamber apical view. Measurements of sectional cavity areas, muscle areas and endocardial perimeters were obtained twice independently by two observers using a computer aided system, to achieve the final results as the mean of the 4 measurements. Paired t-test showed a statistically significant variation between PM and MV for FAC in N (p less than 0.001). A statistically significant difference (p less than 0.01) was found for EID between N and AR. The EIS was not significantly different in the two groups. In AR a significant difference was found between EID and EIS (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Electrocardiographic changes and echocardiography variations in ventricular morphology in left ventricular overload]. / Alterazioni elettrocardiografiche e variazioni ecocardiografiche della morfologia ventricolare nei sovraccarichi ventricolari sinistri.

In order to compare the ECG patterns to several echocardiographic morphological indexes in different left ventricular overloadings, 15 cases of systolic left ventricular overloading (SLVO) and 17 cases of diastolic left ventricular overloading (DLVO) were analyzed. The current ECG changes of left ventricular hypertrophy and some original parameters of ventricular repolarization have been correlated with volumes, ejection fraction and mass of the left ventricle (calculated by Reichek's formula) and with left ventricular diastolic and systolic eccentricity indexes, derived by the application of Fishl's formula to the 2D echocardiographic four or two chamber apical view. In both SLVO and DLVO we found a correlation between the left ventricular mass and Romhilt-Estes point score system (p = 0.02) as well as the degree of ventricular repolarization abnormalities (p = 0.01). In SLVO we found a direct correlation between negative P wave deflection on lead V1 and diastolic as well as systolic eccentricity index: that is, the more negative P wave the more elongated left ventricular geometry. Moreover, in SLVO we found an interesting apposite correlation, compared with DLVO, between the systolic eccentricity index and the degree of ventricular repolarization abnormalities: in SLVO ST depression or T wave inversion on left limb or left precordial leads was associated with the maintenance of an elongated shape of left ventricle, while in DLVO the same ventricular repolarization abnormalities were associated with the loss of the elongated geometry of left ventricle which became spheric. Thus ECG correlates with echocardiographic left ventricular mass if poliparametric voltage indexes are considered.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of atrial fibrillation on pulmonary venous flow patterns: transoesophageal pulsed Doppler echocardiographic study.

The effect of atrial fibrillation on pulmonary venous flow patterns is still not well known. Twenty-four patients in atrial fibrillation and 21 patients in sinus rhythm were studied by transoesophageal echocardiography. In ninety-five percent (20/21) of sinus rhythm patients, the early systolic wave due to atrial relaxation or reverse wave due to atrial contraction could be distinguished on pulsed Doppler tracings by transoesophageal echocardiography. However, there was no early systolic wave and/or reverse at the end of diastole in any atrial fibrillation patients. In atrial fibrillation patients without mitral regurgitation (n = 14), the onset of systolic flow was delayed (165 +/- 38 vs 50 +/- 46 ms, P < 0.05), and systolic peak velocities, time-velocity integrals and systolic fractions were reduced (31 +/- 13 vs 54 +/- 17 cm.s-1, P < 0.05; 5 +/- 2 vs 13 +/- 6 cm, P < 0.05 and 36 +/- 8 vs 61 +/- 15%, P < 0.05, respectively) as compared to those in sinus rhythm. Significant mitral regurgitation (n = 10) reduced systolic velocity parameters considerably in atrial fibrillation patients but the diastolic flow parameters were not significantly different between sinus rhythm and atrial fibrillation patients. Stepwise multiple regression analysis identified atrial fibrillation as an important independent predictor for changes in systolic flow parameters. The R-R interval is also an important factor for diastolic flow parameters. Thus, the present study demonstrates that atrial fibrillation significantly modifies pulmonary venous flow pattern and is an important factor for systolic flow parameters. Significant mitral regurgitation can further modify systolic flow pattern in atrial fibrillation patients.