TAPSE/SPAP ratio stratifies mortality risk in mild-to-moderate idiopathic pulmonary fibrosis.

BACKGROUND: Due to paucity of literature data, we aimed at evaluating the prognostic role of the ratio of tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (SPAP) in idiopathic pulmonary fibrosis (IPF) patients without severe pulmonary hypertension and at assessing its correlation with effective arterial elastance index (EaI). METHODS: Multi-instrumental data obtained in 60 IPF patients (73.2 ± 6.8 years) and 60 matched controls were retrospectively analysed. Primary endpoint was all-cause mortality, while secondary endpoint was the composite of all-cause mortality and re-hospitalisations for all-causes over medium-term follow-up. RESULTS: ;At baseline, TAPSE/SPAP was significantly lower in patients with IPF than in controls (0.36 ± 0.25 vs. 0.77 ± 0.18 mm/mmHg; P < 0.001). TAPSE/SPAP was inversely correlated with EaI (r = -0.96) in IPF patients. During follow-up (3.5 ± 1.5 years), 21 patients died and 25 were re-hospitalised due to cardiopulmonary causes. TAPSE/SPAP was independently associated with both primary (HR 0.79, 95%CI 0.65-0.97) and secondary (HR 0.94, 95%CI 0.92-0.97) endpoints. A TAPSE/SPAP ratio of <0.20 and <0.44 mm/mmHg showed the greatest sensitivity and specificity for predicting primary (AUC 0.98) and secondary (AUC 0.99) endpoints, respectively. CONCLUSIONS: TAPSE/SPAP is a strong predictor of adverse outcomes in mild-to-moderate IPF. The strong correlation between TAPSE/SPAP and EaI might be an expression of a systemic fibrotic process which involves the heart, lungs and circulation.

Secondary neoplastic infiltration of the myocardium diagnosed by two-dimensional echocardiography in seven cases with anatomic confirmation.

In seven patients with different types of neoplasm, secondary myocardial infiltration was diagnosed in vivo by two-dimensional echocardiography and confirmed by direct inspection. In all patients, clinical and electrocardiographic findings were suggestive but nonspecific for myocardial involvement. Two patients had cardiac tamponade and three had pericardial effusion. In three patients, the echocardiographic diagnosis made it possible to plan specific therapy. Clinical, electrocardiographic and echocardiographic aspects are discussed. A two-dimensional echocardiographic examination should be performed in all patients when cardiac metastatic involvement is suspected from clinical electrocardiographic findings, because the in vivo diagnosis of such a condition may have important therapeutic implications for such patients.

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.

Sodium-lithium countertransport and cardiorenal abnormalities in essential hypertension.

The rate of red blood cell sodium-lithium countertransport is elevated only in a subgroup of patients with essential hypertension. We have therefore compared renal and cardiac function and morphology in two groups of hypertensive patients with high (n = 23) or normal (n = 22) sodium-lithium countertransport (mean +/- SEM: 0.61 +/- 0.10 versus 0.29 +/- 0.07 mmol/l red blood cells.hr). The two groups were similar in age, sex distribution, body mass index, smoking habit, duration of hypertension, and actual levels of untreated blood pressure. Hypertensive patients with elevated sodium-lithium countertransport activity showed elevated glomerular filtration rate (118 +/- 2 versus 109 +/- 2 ml/min.1.73 m2; p less than 0.001), albumin excretion rate (23 +/- 3 versus 14 +/- 2 micrograms/min; p less than 0.001), larger kidney volume (250 +/- 15 versus 203 +/- 13 ml.1.73 m2; p less than 0.01), lower lithium clearance rate (26.7 +/- 0.3 versus 28.9 +/- 0.3 ml/min.1.73 m2; p less than 0.01), and higher total body exchangeable sodium (2,716 +/- 33 versus 2,485 +/- 41 mmol.1.73 m2; p less than 0.01). Left ventricular mass index (139 +/- 6 versus 119 +/- 6 g/m2; p less than 0.05), relative wall thickness (0.39 +/- 0.05 versus 0.29 +/- 0.04 cm; p less than 0.001), and left posterior wall plus intraventricular septum thickness (2.02 +/- 0.04 versus 1.76 +/- 0.03 cm; p less than 0.05) were also higher in patients with high sodium-lithium countertransport. Hypertensive patients with normal sodium-lithium countertransport had renal and cardiac parameters similar to those of a normotensive control group (n = 21) except for a higher glomerular filtration rate and left ventricular mass index.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous closure of a patent foramen ovale and disappearance of impending paradoxical embolism after fibrinolytic therapy in the course of massive pulmonary embolism.

Our case suggests that a negative transesophageal contrast echocardiographic study during stable hemodynamic conditions does not definitively rule out the possibility of a functional PFO with transient right-to-left shunting in situations of increased right heart pressures. In addition, we confirm that thrombolysis can be considered as an alternative to surgery in high-risk patients with impending paradoxical embolism. The risk-to-benefit ratio of this choice, however, should be individually evaluated.

Relation of right ventricular morphology and function in pectus excavatum to the severity of the chest wall deformity.

Although pectus excavatum (PE) is thought to impair right ventricular (RV) performance, the degree of RV dysfunction, if any, produced by this chest wall deformity remains controversial. To address this issue, we performed 2-dimensional echocardiography and chest wall radiography in 28 subjects with mild-to-severe degrees of PE to assess RV morphology and function in relation to the degree of the chest wall deformity. Measurements of RV anatomy and function obtained in these patients were compared to those of 24 normal control subjects of similar age and sex. In subjects with PE, mean RV outflow tract diameter at the aortic root level was narrower (1.4 +/- 0.3 cm/m2) and end-diastolic (10 +/- 2.3 cm2/m2) and end-systolic (5.8 +/- 1.4 cm2/m2) areas were larger than those in normal controls (1.6 +/- 0.3, 8.6 +/- 1.7, and 4.5 +/- 1.2 cm2/m2, respectively; p < 0.013). The magnitude of these abnormalities was related to the degree of the chest wall deformity evaluated on the chest radiogram (r = 0.54, 0.51, and 0.49, respectively). RV planar emptying fraction, an index of RV systolic function, was reduced in subjects with PE (42 +/- 10%) compared to the normal controls (48 +/- 10%; p = 0.047). No relation could be found, however, between this index and the severity of the chest wall deformity.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of transesophageal echocardiography in evaluation of paracardiac neoplastic masses.

Mediastinal paracardiac tumors may cause both cardiovascular complications and problems in differential diagnosis of cardiac diseases. Transesophageal echocardiography (TEE) may give an additional new window to mediastinal neoplasms, but only a few studies have been reported. TEE was performed in 70 patients with paracardiac neoplastic masses. The procedure was indicated to solve particular clinical problems in 20 patients, and as a prospective study on 50 unselected patients with mediastinal neoplasms. Twenty-three patients underwent follow-up studies; a total of 101 echocardiograms were recorded. The procedure was tolerated well or very well by most patients, and provided additional anatomic or hemodynamic data in every patient in group a and in 45 of 50 in group b. The additional data were relevant for clinical management in 14 of 20 patients in group a, and in 3 of 45 in group b. Based on the results of this study, TEE is useful in association with other radiologic techniques in patients with paracardiac neoplasms. As an imaging technique, it may represent a reliable alternative to computed tomography whenever the latter is not feasible.

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.

Echocardiographic evaluation of mitral stenosis in predicting mitral valve replacement vs commissurotomy. Relation to hemodynamic measurements.

Fifty-one patients with mitral stenosis were studied by M-mode echocardiograms to verify the possibility of predicting if they will require mitral valve replacement or commissurotomy. Fifteen of 18 patients with heavy calcification and restricted or poor valvular mobility underwent mitral valve replacement. Twelve of 14 patients with normal valve amplitude underwent mitral commissurotomy regardless of the presence of valvular calcification. A newly derived measurement, the MT/ST, which is the ratio between the maximal thickness of the widest echo from the mitral valve and the maximal thickness of the left ventricular margin of the interventricular septum, was used to assess valvular calcification. Values above 1.7 were present only in valves with restricted or poor mobility and indicated mitral valve replacement in 14 of 15 cases. All of the patients undergoing mitral valve replacement who had MT/ST ratios between 1.5 and 1.7 had restricted or poor valvular mobility. Of the patients with MT/ST ratios less than 1.5, ten of 12 with normal valvular amplitude underwent mitral commissurotomy, and four of five with restricted valvular mobility underwent mitral valve replacement. We conclude that echocardiographic assessment of mitral valvular calcification and amplitude is useful in predicting patients who will require mitral valve replacement vs mitral commissurotomy.

Sensitivity and specificity of electrocardiographic ST-T changes as markers of neoplastic myocardial infiltration. Echocardiographic correlation.

We evaluated the correlations between electrocardiographic ST-T changes (negative T waves, ST segment elevation) and echocardiographic diagnosis of neoplastic infiltration of the myocardium in 95 patients with neoplastic masses in contact with the heart. We compared echocardiographic results to computed tomography, nuclear magnetic resonance, surgery or autopsy data in 49 patients: the concordance was 86 percent. Significant ST-T changes were present in 77.7 percent of the patients with myocardial infiltration at echocardiography. The "false negatives" (normal ECG, nonspecific changes) were mainly related to infiltration limited to the right side of the heart; in some of these cases, the appearance of right bundle branch block was observed. The "false positives" (ST-T changes without echocardiographic signs of infiltration) were observed in the older patients and in those with pericardial effusion or other heart diseases. The ST segment elevation was a more specific sign of myocardial infiltration as compared to negative T waves (86 vs 47 percent). A progression or the disappearance of electrocardiographic and echocardiographic abnormalities was observed during follow-up in 24 cases. Serial electrocardiograms are useful for screening in clinical settings in neoplastic patients; the appearance of ST-T changes or of conduction disturbances should suggest the need for two-dimensional echocardiography in order to define the diagnosis.

Two-dimensional echocardiographic evaluation of mitral valve calcification. Sensitivity and specificity.

The effectiveness of two-dimensional echocardiography in assessing mitral valve calcification was compared to radiography of the surgically excised valves in 43 patients affected by rheumatic disease of the mitral valve. Mitral valve calcification was graded as absent or present if single thin or multiple dense conglomerate echoes defined the valvular orifice in short axis view, provided the sensitivity of the instrumentation was adequately optimized. The radiograph of the excised valve was similarly graded. The interobserver reproducibility for both two-dimensional echocardiography and radiography was 100 percent. There were 14 true positives, 19 true negatives, 10 false positives and no false negatives, thus giving, for two-dimensional echocardiography, a sensitivity of 100 percent and a specificity of 65 per cent. It is concluded that two-dimensional echocardiography is an extremely sensitive method for assessing mitral valve calcification, and is prospectively useful also in planning reconstruction versus replacement in mitral valve surgery. Nevertheless, the consistent number of false positives affecting two-dimensional echocardiography represents a definite limit to the specificity of the technique.

M-mode and two-dimensional echocardiography in congenital absence of the pericardium.

The M-mode and two-dimensional echocardiographic features of congenital absence of the pericardium are described in two cases that had been confirmed by clinical and radiological data. The M-mode echocardiogram showed right ventricular dilatation and abnormal systolic motion of the interventricular septum. Echo contrast studies with peripheral injection of saline solution revealed normal persistence of microbubbles in the right side of the heart. Two-dimensional short axis parasternal views showed some dilatation of the right ventricle, with anterior displacement of the left ventricular cavity in systole, which appeared to be wider than the posterior motion of the interventricular septum towards the posterior wall. The resulting positive motion of the interventricular septum toward the transducer could account for the abnormal pattern seen in the M-mode echocardiogram. Congenital absence of the left pericardium has particular echocardiographic features not diagnostic for the anomaly. However, the M-mode and two-dimensional echocardiographic studies, used in conjunction with the echocontrast techniques, seem to help in the differential diagnosis and for excluding associated anomalies.

A large left ventricular thrombus evolving towards canalization and mimicking a left ventricular pseudoaneurysm: an echocardiographic study.

We describe a case of a large apical left ventricular thrombus evolving towards canalization and showing echocardiographic features mimicking a left ventricular pseudoaneurysm. Only serial echocardiographic studies allowed an appreciation of the changing morphologic features of the apical structure, permitting differential diagnosis between a canalization of an evolving thrombus and a myocardial free-wall rupture with pseudoaneurysm formation.

Direct demonstration of an air-fluid interface by two-dimensional echocardiography: a new diagnostic sign of hydropneumopericardium.

Hydropneumopericardium is an uncommon condition that requires prompt diagnosis and treatment if hemodynamic compromise is present. Chest roentgenography, computerized tomography, and echocardiography provide important information for the diagnosis. In this article a new distinctive echocardiographic sign of hydropneumopericardium is described: the direct demonstration of the air-fluid interface in the long-axis precordial view.

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)

Serum dopamine beta-hydroxylase (DBH) activity in acute myocardial infarction.

Serial serum dopamine beta-hydroxylase (DBH) activities were determined in 32 patients admitted to the Coronary Care Unit with chest pain, 9 with acute myocardial infarction and 23 with other diagnoses. The values of DBH were elevated in both groups on day one. The acute myocardial infarction group showed a slower decline and reached a baseline plateau at day five when compared to the control group whose values fell significantly by day two. The reason for the quantitative difference between the two groups is speculative and may be related to changes in plasma volume. Increases in DBH are not specific for myocardial infarction but a nonspecific responses to stress.

Echocardiography to understand remodeling and to assess prognosis after acute myocardial infarction.

Ventricular remodeling indicates a dynamic process, starting with and after acute myocardial infarction, as a result of structural and functional modifications which involve acutely and chronically both the infarcted and noninfarcted zones of the left ventricle. The most effective way to prevent or minimize post-MI cardiac remodeling is to limit the extent of the initial insult. This can be partly achieved by early myocardial reperfusion obtained by different strategies including thrombolysis. In 6405 patients of the GISSI-3 trial, 2D echocardiographic studies were available at predischarge, at 6 weeks and at 6 months after the infarction. The increase in left ventricular volumes over time was reduced by 6-week lisinopril treatment. Patients randomized to lisinopril had smaller volume also at 6 months, after withdrawal of treatment at 6 weeks. Important prognostic indications can also be derived from predischarge echocardiography, since larger quartiles of left ventricular volumes and lower quartile of ejection fraction indicates higher risk of mortality and non-fatal congestive heart failure in the 6 months after the index event, even in the relatively low risk general population of infarcts of the GISSI-3.

Hypertrophic cardiomyopathy associated with myotonic muscular dystrophy (Steinert's disease).

A 52-year-old man with myotonic dystrophy and first degree atrioventricular block, right bundle branch block and left anterior hemiblock was shown by echocardiographic examination to have hypertrophy of the posterior segment of the septum and of the anterior left ventricular wall. Myocardial involvement in this patient may represent the full expression of a genetic defect involving both skeletal and myocardial striated tissue.