Rapid three-dimensional echocardiography : clinically feasible alternative for precise and accurate measurement of left ventricular volumes.

BACKGROUND: Clinical applicability of conventional ultrasonographic systems using mechanical adapters for 3D echocardiographic imaging has been limited by long acquisition and processing times. We developed a rapid (6-s) acquisition technique that collects apical tomograms using a continuously internally rotating transthoracic transducer. This study was performed to examine the clinical feasibility of rapid-acquisition 3D echocardiography to estimate left ventricular end-diastolic and end-systolic volumes using electron-beam computed tomography as the reference standard. Methods and Results-We collected a series of 6 to 11 apical echocardiographic tomograms, depending on heart rate, in 11 patients. There was good correlation, low variability, and low bias between rapid 3D echocardiography and electron-beam computed tomography for measuring left ventricular end-diastolic volume (r=0.96; standard error of the estimate, 21.34 mL; bias, -4.93 mL) and left ventricular end-systolic volume (r=0.96; standard error of the estimate, 14.78 mL; bias, -6.97 mL). CONCLUSIONS: The rapid-acquisition 3D echocardiography extends the use of a multiplane, internally rotating handheld transducer so that it becomes a precise and clinically feasible tool for assessing left ventricular volumes and function. A rapid-image acquisition time of 6 s would allow repeated image collection during the course of a clinical echocardiographic examination. Additional work must address rapid and automated data processing.

Electron beam computed tomographic coronary calcium score cutpoints and severity of associated angiographic lumen stenosis.

OBJECTIVES: We sought to determine a range of cutpoints for coronary calcium scores measured by electron beam computed tomography (EBCT) in predicting the likely severity of associated angiographic coronary artery stenoses. BACKGROUND: EBCT can quantify coronary calcium and allow the estimation of atherosclerotic plaque burden, but use of the calcium score to define lumen narrowing is controversial. METHODS: A total of 213 patients (mean [+/- SD] age 50 +/- 9 years) underwent coronary angiography and EBCT. Maximal percent diameter stenosis in any artery was paired with total coronary calcium score. Receiver operating characteristic (ROC) curve analysis was done using definitions of "disease" for maximal stenosis from > or = 20% to 100%, and the corresponding score cutpoints were determined for 90% sensitivity, 90% specificity or "optimal" sensitivity and specificity. RESULTS: ROC curve areas ranged from a mean (+/- SE) of 0.91 +/- 0.02 for > or = 20% stenosis to 0.83 +/- 0.03 for 100% stenosis. Optimal calcium score cutpoints consisted of nonoverlapping values ranging from 15 for > or = 20% stenosis to 327 for 100% stenosis, whereas sensitivities and specificities ranged from 78% to 84%, depending on maximal stenosis severity. Calcium score cutpoints for 90% sensitivity and 90% specificity were also nonoverlapping and ranged from 3 and 27, respectively, for > or = 20% stenosis to 154 and 945, respectively, for 100% stenosis; corresponding specificities and sensitivities ranged from 40% to 78%. CONCLUSIONS: These data define the ranges for EBCT coronary calcium score cutpoints that predict the likely severity of associated maximal angiographic stenosis severity to a high sensitivity, high specificity or optimal sensitivity/specificity. These cutpoints potentially can be used in conjunction with clinical variables to predict the severity of lumen narrowing in patients undergoing assessment for coronary artery disease.

Coronary calcification by electron beam computed tomography and obstructive coronary artery disease: a model for costs and effectiveness of diagnosis as compared with conventional cardiac testing methods.

OBJECTIVES: The purpose of this study was to determine if electron beam computed tomography (EBCT) has potential as a cost-effective approach to diagnosis of obstructive coronary disease. BACKGROUND: Coronary calcification quantified by EBCT is closely related to the extent of atherosclerosis. METHODS: A model based upon published sensitivities (Se)/specificities (Sp) for diagnosis in an ambulatory patient of obstructive coronary disease (> or =50% stenosis) and population prevalence was tested for angiography alone, or treadmill exercise, stress echocardiography, stress thallium or predetermined EBCT calcium score outpoints, followed by angiography if indicated. RESULTS: Total direct testing costs increased in proportion to disease prevalence whereas cost-effectiveness, direct costs/patient diagnosed correctly with disease, decreased as a function of prevalence. Using an EBCT calcium score of 168 (Se/Sp = 71%/90%) provided for the least costly and most cost-effective noninvasive pathway. Calcium scores of 80 (Se/Sp = 84%/84%) and 37 (Se/Sp = 90%/77%) were also cost-effective when prevalence of disease was < or =70%; but results for a >0 calcium score (Se/Sp = 95%/46%) cutpoint were not superior to conventional methods. Calcium score cutpoints of 37, 80 or 168 provided similar or superior overall negative and positive predictive values to conventional noninvasive testing pathways across all prevalence subgroups. CONCLUSIONS: In ambulatory patients evaluated for obstructive coronary disease, a testing pathway utilizing quantification of coronary calcium by EBCT as an initial noninvasive testing approach minimized direct costs, and maximized cost-effectiveness in population groups with low/ moderate disease prevalence (< or =70%); as expected, direct angiography as the first and only test proved most cost-effective in patients with a high prevalence (>70%) of disease.

Contrast echocardiography improves the accuracy and reproducibility of left ventricular remodeling measurements: a prospective, randomly assigned, blinded study.

OBJECTIVES: We sought to assess the impact of contrast injection and harmonic imaging, on the measure by echocardiography of left ventricular (LV) remodeling. BACKGROUND: Left ventricular remodeling is a precursor of LV dysfunction, but the impact of contrast injection and harmonic imaging on the accuracy or reproducibility of echocardiography is unclear. METHODS: We prospectively collected LV images by using simultaneous methods. Then, LV volumes were measured off-line, in blinded manner and in random order. The accuracy of echocardiography was determined in comparison to electron beam computed tomography (EBCT) in 26 patients. The reproducibility of echocardiography was assessed by three blinded observers with different training levels in 32 patients. RESULTS: End-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV) and ejection fraction (EF), as measured by EBCT (195 +/- 55, 58 +/- 24 and 137 +/- 35 ml and 71 +/- 5%, respectively) and echocardiography with harmonic imaging and contrast injection (194 +/- 51, 55 +/- 20 and 140 +/- 35 ml and 72 +/- 4%, respectively), showed no differences (all p > 0.15) and excellent correlations (all r > 0.87). In contrast, echocardiography using harmonic imaging without contrast injection underestimated the EBCT results (all p < 0.01). Reproducibility was superior with rather than without contrast injection for intraobserver and interobserver variabilities (all p < 0.001). Values measured by different observers were different without contrast injection, but were similar with contrast injection (all p > 0.18). Consequently, intrinsic patient differences represented a larger and almost exclusive proportion of global variability with contrast injection for EDV (94 vs. 79%), ESV (93 vs. 82%), SV (87 vs. 53%) and EF (84 vs. 41%), as compared with harmonic imaging without contrast injection (all p < 0.005). CONCLUSIONS: For assessment of LV remodeling, echocardiography with harmonic imaging and contrast injection improved the accuracy and reproducibility, as compared with imaging without contrast injection. With contrast injection, variability was almost exclusively due to intrinsic patient differences. Therefore, when evaluation of LV remodeling is deemed important, assessment after contrast injection should be the preferred echocardiographic approach.

Noninvasive definition of anatomic coronary artery disease by ultrafast computed tomographic scanning: a quantitative pathologic comparison study.

OBJECTIVES: The aim of this study was to determine the relation between coronary artery calcification detected by ultrafast computed tomographic scanning and histopathologic coronary artery disease. BACKGROUND: Recent studies suggest that discrete coronary artery calcification as visualized by ultrafast computed tomographic scanning may facilitate the noninvasive detection or estimation, or both, of the in situ extent of coronary disease. Such quantitative relations have not been established. METHODS: Thirteen consecutive perfusion-fixed autopsy hearts (from eight male and five female patients aged 17 to 83 years) were scanned by ultrafast computed tomographic scanning in contiguous 3-mm tomographic sections. The major epicardial arteries were dissected free, positioned longitudinally and scanned again in cross section. Coronary artery calcification in a coronary segment was defined as the presence of one or more voxels with a computed tomographic density > 130 Hounsfield units. Each epicardial artery was sectioned longitudinally, stained and measured with a planimeter for quantification of cross-sectional and atherosclerotic plaque areas at 3-mm intervals, corresponding to the computed tomographic scans. A total of 522 paired coronary computed tomographic and histologic sections were studied. RESULTS: Direct relations were found between ultrafast computed tomographic scanning coronary artery calcium burden and atherosclerotic plaque area and percent lumen area stenosis. However, the range for plaque area or percent lumen stenosis, or both, associated with a given calcium burden was broad. Three hundred thirty-one coronary segments showed no calcification by computed tomography. Although atherosclerotic disease was found in several corresponding pathologic specimens, > 97% of these noncalcified segments were associated with nonobstructive disease (< 75% area stenosis); if no calcification was determined in an entire coronary vessel, all corresponding coronary disease was found to be nonobstructive. To determine the relation between arterial calcification and any atheromatous disease, computed tomographic calcium burden for each segment was paired with the histologic absence or presence of disease. Ultrafast computed tomographic scanning had a sensitivity and specificity of 59% and 90% and a negative and positive predictive value of 65% and 87%, respectively. A direct correlation was found (r = 0.99) between total calcium burden calculated from tomographic scans of the heart as a whole and scans of the arteries obtained in cross section. CONCLUSIONS: The detection of coronary calcification by ultrafast computed tomographic scanning is highly predictive of the presence of histopathologic coronary disease, but the use of this technique to define the extent of coronary disease may be limited. However, the absence of coronary calcification at any site is highly specific for the absence of obstructive disease.

Pericardial thickness measured with transesophageal echocardiography: feasibility and potential clinical usefulness.

OBJECTIVES: This study assessed the reliability of transesophageal echocardiographic measurements of pericardial thickness and the potential diagnostic usefulness of this technique. BACKGROUND: Transthoracic echocardiography cannot reliably detect thickened pericardium. The superior resolution achieved with transesophageal echocardiography should allow better pericardial definition. METHODS: Pericardial thickness measured at 26 locations in 11 patients with constrictive pericarditis who underwent intraoperative transesophageal echocardiography was compared with pericardial thickness measured with electron beam computed tomography. Intraobserver and interobserver variabilities were determined. Pericardial thickness was then measured in 21 normal subjects. With these values as a guide, two observers reviewed 37 transesophageal echocardiographic studies to determine whether echocardiographic measurement of pericardial thickness could be used to distinguish diseased from normal pericardium. RESULTS: The correlation between echocardiographic and computed tomographic measurements (r > or = 0.95, SE < or = 0.06 mm, p < 0.0001) was excellent. The +/-2 SD limits of agreement were +/-1.0 mm or less for pericardial thickness < 5.5 mm and +/-2.0 mm or less for the entire range of thicknesses. Intraobserver and interobserver agreements were good. Mean normal pericardial thickness was 1.2 +/- 0.8 mm (+/-2 SD) and did not exceed 2.5 mm. Pericardial thickness > or = 3 mm on transesophageal echocardiography was 95% sensitive and 86% specific for the detection of thickened pericardium. CONCLUSIONS: Measurement of pericardial thickness with transesophageal echocardiography is reproducible and should be a valuable adjunct in assessing constrictive pericarditis.

Inhibition of yeast phagocytosis in macrophage cultures treated with slime polysaccharide purified from Pseudomonas aeruginosa.

This study was initiated to determine whether purified slime polysaccharide(PSP) from P aeruginosa inhibits the ingestion of heat killed Saccharomyces cerevisiae particles in macrophage cultures. Relative to controls, direct phagocytosis assays revealed that the percentages of phagocytes and the numbers of ingested yeast particles per phagocyte decreased in a dose-dependent manner in PSP-treated cultures. Thus, PSP may act as a virulence factor in vivo by impairing the phagocytic capacity of macrophages.

Right ventricular assessment in patients presenting for lung transplantation.

Chronic pulmonary disease is associated with varying degrees of cardiac dysfunction. Because of the potentially predominant effect of severe lung disease on right ventricular (RV) size and function, a reliable method to assess RV mechanics before and after lung transplantation may provide information of long-term significance and/or prognosis. Conventional invasive and non-invasive imaging methods have a number of limitations in evaluating RV function. Ultrafast computed tomographic (ultrafast CT) scanning has been shown to provide quantitative assessment of RV and left ventricular (LV) function in individuals with and without cardiac disease. Twenty-two patients presenting during evaluation for possible lung transplantation with end-stage pulmonary disease formed the basis of this study. There were 14 patients with chronic obstructive pulmonary disease and 8 with pulmonary fibrosis. Conventional transthoracic echocardiography and ultrafast CT were used for the assessment of RV and LV function. All patients had invasive assessment of right-sided hemodynamics and pulmonary function studies performed within 7-10 days of cardiac imaging. A qualitative assessment of RV size or function was possible in all but two patients by echocardiogram, but in 45%, the echocardiographic examination was described as suboptimal. In contrast, a quantitative assessment of ventricular volumes and systolic function was obtained in all patients by ultrafast CT. Pulmonary function parameters or hemodynamic measurements obtained during cardiac catheterization did not correlate with any assessment of RV function. We concluded that (1) ultrafast CT provides measurement of the RV and LV cavity dimension and systolic function; (2) invasive right-sided hemodynamics or pulmonary function studies do not predict RV function; and (3) echocardiography does not uniformly provide assessment of RV function in patients with chronic pulmonary disease.

Calcified left ventricular mass: unusual clinical, echocardiographic, and computed tomographic findings of primary cardiac osteosarcoma.

Primary cardiac osteosarcomas are rare and usually originate in the left atrium. In contrast, osteosarcomas metastatic to the heart most commonly involve the right cardiac chambers. This case report describes an unusual primary cardiac osteosarcoma, initially observed as a slowly growing, densely calcified mass of the left ventricle with subsequent secondary pulmonary metastasis. Although cardiac tumors may be asymptomatic, this patient had recurrent bouts of ventricular tachyarrhythmia. We describe the clinical, echocardiographic, and radiological observations spanning 6 years and the gross and microscopic features at autopsy.

Ultrafast computed tomographic scanning to assess patency of coronary artery stents in bypass grafts.

Anginal chest pain after implantation of coronary stents in bypass grafts is a concern because it suggests the possibility of occlusion. Coronary angiography is the definitive method for determining patency of a stent; however, this procedure is relatively contraindicated in a patient receiving warfarin sodium, who has a therapeutic international normalized ratio. An alternative method for determining patency of a stent is by ultrafast computed tomography. This new, minimally invasive technique shows promise for determining blood flow within the large vessels of the thorax. Herein we describe a case in which a metallic stent placed in a vein graft was noninvasively established to be patent, despite chest pain in the patient. This method may be clinically applicable for determining patency of stents in vein grafts in the setting of patients with chest pain who have undergone complete anticoagulation.

Telemedicine consultations in congenital heart disease: assessment of advanced technical capabilities.

OBJECTIVE: To assess the value of adding remote pointer and dynamic display capabilities to a telemedicine system designed to provide consultative services for patients with congenital heart disease. MATERIAL AND METHODS: Independent observations by the referring physician and the consulting physician provided the data for the assessment. Fifty-four teleconsultations involving 38 patients with 21 different congenital heart diseases were analyzed. The teleconsultations were based on previously obtained cineangiograms that were digitized and then transmitted by combined satellite and terrestrial-based technology. The observations, recorded by each physician at his workstation at the time of each teleconsultation, were summarized and analyzed statistically. RESULTS: In 108 observations, the pointer was believed to be helpful in 72 (67%), and dynamic display was helpful in 96 (89%). CONCLUSION: This study suggests that use of a pointer and dynamic display enhances teleconsultations for patients with congenital heart disease.

Ventricular remodeling after orthotopic cardiac transplantation.

OBJECTIVE: To determine quantitative changes in ventricular chamber volumes and left ventricular mass after orthotopic cardiac transplantation. MATERIAL AND METHODS: Right ventricular and left ventricular chamber volumes and left ventricular muscle mass were quantified by electron beam computed tomography in 10 patients at 1 month and 12 months after orthotopic cardiac transplantation. RESULTS: During the study period, the mean right ventricular end-diastolic volumes increased from 117 +/- 26.1 cc to 143 +/- 25.3 cc (P < 0.005), and the mean left ventricular end-diastolic volumes increased from 90 +/- 20.6 cc to 117 +/- 27.3 cc (P < 0.001). Left ventricular stroke volume increased from 63 +/- 16.5 cc at 1 month to 78 +/- 19.8 cc by 12 months (P < 0.005). These changes were associated with a concurrent reduction in global left ventricular muscle mass from 168 +/- 25.2 g to 145 +/- 16.3 g (P < 0.01). The left ventricular end-diastolic volume/mass ratio, an index of wall tension, was abnormally low at 1 month but was in the normal range by 12 months (P < 0.0005). Both left ventricular and right ventricular ejection fractions were normal at all times and not significantly changed between the 1-month and 12-month studies. CONCLUSION: Significant right and left ventricular remodeling occurs between 1 month and 12 months after orthotopic cardiac transplantation, with progressive cavity dilatation but reduction in global left ventricular muscle mass. These adjustments, especially in the left ventricle, tend to reduce the volume/mass ratio by 1 year and are compatible with normalization of ventricular wall tension between the early and late scan dates. Routine clinical measurements of ejection fraction alone mask the almost parallel increases in stroke volume and end-diastolic volume during the first 12 months after orthotopic cardiac transplantation.

Electron beam computed tomography and coronary artery disease: scanning for coronary artery calcification.

OBJECTIVE: To review the association of coronary artery calcification with coronary atherosclerosis and its potential clinical application as detected on electron beam computed tomography (EBCT). DESIGN: A literature review of coronary artery calcification, coronary artery disease, and EBCT is presented, and clinical applications of EBCT are discussed. RESULTS: Recent studies have confirmed that arterial calcification is an active process intimately associated with atherosclerotic plaque evolution. Clinical investigations with use of EBCT have shown that a scan "negative" for coronary calcification is common in patients with normal or near-normal findings on coronary angiography, whereas patients with severe obstructive disease most commonly have "positive" scans--greater amounts of coronary artery calcium are associated with more severe luminal disease. Coronary artery calcium as evaluated on EBCT follows patterns that reflect the development of coronary atheromatous disease as a function of age and gender. Although histologic studies have confirmed that not all atherosclerotic segments have detectable calcification, the area of coronary artery calcification quantified on EBCT has a direct, positive relationship with the histopathologic coronary plaque area. CONCLUSION: The long-held notion of "degenerative" calcification of the coronary arteries with aging is incorrect. Although the incidence of coronary artery calcification increases with patient age, this relationship simply parallels the increased incidence of coronary atherosclerosis with advancing age. Data suggest that EBCT is a highly sensitive and specific test for coronary atherosclerosis and provide a basis for clinical applications when EBCT is viewed as a noninvasive method to estimate human coronary atherosclerotic involvement and "plaque burden."

Congenital partial and complete absence of the pericardium.

Between 1952 and 1991, 15 Mayo patients were found to have partial or complete absence of the pericardium at the time of a cardiovascular surgical procedure. One patient with complete absence of the left pericardium had symptoms possibly related to the pericardial abnormality. This 42-year-old man had severe insufficiency of the tricuspid valve attributable to chordal rupture of the anterior leaflet, possibly precipitated by complete displacement of the heart into the left pleural space. Excision of the ruptured chordae and plication of the anterior flail leaflet rendered a competent tricuspid valve. In two patients, a small defect in the pericardium was repaired. Three patients who underwent operation for complex congenital heart disease died: two early postoperatively and one late after a reoperation. In the other 12 patients, no early or late postoperative complications were encountered. Although rare and usually asymptomatic, complete and partial deficiency of the pericardium may lead to serious complications such as cardiac valvular insufficiency or incarceration of cardiac tissue.

Determination of ventricular ejection fraction: a comparison of available imaging methods. The Cardiovascular Imaging Working Group.

Knowledge of left ventricular ejection fraction has been shown to provide diagnostic and prognostic information in patients with known or suspected heart disease. In clinical practice, the ejection fraction can be determined by using one of the five currently available imaging techniques: contrast angiography, echocardiography, radionuclide techniques of blood pool and first pass imaging, electron beam computed tomography, and magnetic resonance imaging. In this review, we discuss the clinical application as well as the advantages and disadvantages of each of these methods as it relates to determination of ventricular ejection fraction.

Quantity of coronary artery calcium detected by electron beam computed tomography in asymptomatic subjects and angiographically studied patients.

OBJECTIVE: To determine the prevalence and quantity of coronary artery calcium (CAC) in asymptomatic subjects from the general population, to identify asymptomatic subjects without risk factors for coronary artery disease (CAD) with CAC scores in the top quartile of the distribution, and to compare CAC scores in patients who underwent angiography with percentiles in asymptomatic subjects of the same age and sex. DESIGN: We studied two samples from Rochester, Minnesota, which consisted of 772 asymptomatic subjects from the general population and 145 patients who underwent angiography, all of whom were 20 to 59 years of age. METHODS: Asymptomatic subjects were classified on the basis of their CAD risk profile. All subjects in both study samples underwent electron beam computed tomography. Age- and sex-specific calcium score percentiles were calculated in the asymptomatic sample. RESULTS: CAC prevalence in the asymptomatic subjects was lower in female than in male subjects and increased with advancing age. Of the asymptomatic sample, 8% had a low-risk profile with calcium scores in the top quartile of the distribution. More patients than expected in the angiography sample had calcium scores above the 50th through 95th score percentiles. CONCLUSION: The quantity of CAC was substantially increased in patients who underwent angiography. Subjects with large amounts of CAC but without known CAD risk factors may be a valuable subset of the population to investigate for previously unidentified CAD risk factors.

Aprotinin for coronary bypass operations: efficacy, safety, and influence on early saphenous vein graft patency. A multicenter, randomized, double-blind, placebo-controlled study.

The purpose of this study was to evaluate the efficacy and safety of aprotinin in a U.S. population of patients undergoing coronary artery bypass grafting. Early vein graft patency rates were assessed by ultrafast computed tomography. A total of 216 patients at five centers were randomized to receive either high-dose aprotinin or placebo during the operation; 151 patients underwent primary operation, and 65 underwent repeat procedures. Total blood product exposures in the primary group were 2.2 per patient receiving aprotinin as compared with 5.7 per patient receiving placebo (p = 0.010). The repeat group had 0.3 exposures per patient receiving aprotinin as compared with 10.7 per patient receiving placebo (p = < 0.001). Consistent reductions in the percent of patients requiring donor red blood cells and in the number of units of platelets, fresh frozen plasma, and cryoprecipitate required were associated with the use of aprotinin in both primary and repeat groups. Mortality was 5.6% in the aprotinin group and 3.7% in the placebo group (p = 0.517). In the primary group, clinical diagnoses of myocardial infarction were made in 8.9% of patients receiving aprotinin as compared with 5.6% of the patients receiving placebo (p = 0.435). In the repeat group, infarctions occurred in 10.3% of patients receiving aprotinin and 8.3% of patients receiving placebo (p = 1.000). Secondary analysis of electrocardiograms and available enzyme data showed no significant difference in infarction rates between the treatment groups. There was no difference in clinically significant renal dysfunction. The early vein graft patency rates were 92.0% in the aprotinin group and 95.1% in the placebo group (p = 0.248). In this study, aprotinin was effective in reducing bleeding and blood product transfusion rates, and its use was not associated with an increase in complications. An adverse effect on early vein graft patency rates was not demonstrated, but the number of grafts assessed was insufficient for absolute conclusions in this regard.

Right and left ventricular remodeling after orthotopic single lung transplantation for end-stage emphysema.

BACKGROUND: Orthotopic single lung transplantation (LTX) is now an established treatment modality for patients with end-stage emphysema. LTX has been shown to cause unloading of the right ventricle with improvement in right ventricular (RV) structure and function both immediately and up to weeks after surgery, mostly in patients with severe pulmonary hypertension and decreased RV function. Long-term effects of lung transplantation on both RV and left ventricular (LV) anatomy and function, however, are not well known. METHODS: Seventeen patients undergoing LTX for end-stage emphysema and preserved RV function underwent serial electron beam computed tomography RV and LV function studies before, 3 months after, 1 year after, and 2 years after transplantation. Right-sided heart catheterization was performed before transplantation and at 1 and 2 years follow-up. RESULTS: RV end systolic volume decreased significantly (-15.5%), and RV ejection fraction increased significantly (+16%) in the first 3 months after LTX. This change was paralleled by a decrease in pulmonary pressure and vascular resistance, indicating a permanent RV unloading. This improvement was maintained up to 2 years after LTX. LV end-diastolic volume (+25%), LV stroke volume (+29%), and LV muscle mass (+28%) increased significantly in the first 3 months after LTX. This remodeling was maintained during the 2-year follow-up. CONCLUSIONS: Significant changes in cardiac anatomy and function occur shortly after LTX, most likely as a consequence of adaptation to a new hemodynamic state in patients with well preserved RV function before LTX. Furthermore, these acute changes persist for at least 2 years after LTX.

Replicate studies comparing the relative efficacies of aspirin and indoprofen in oral surgery outpatients.

The results from the present studies confirm that indoprofen is an orally effective analgesic drug. Both the 100- and 200-mg dosages of indoprofen demonstrated superior analgesic activity when compared to 600 mg aspirin.

Localized aortic dissection: unusual features by transesophageal echocardiography.

Transesophageal echocardiography relies on the presence of an undulating intimal flap for the diagnosis of aortic dissection. Furthermore, to distinguish true dissection from echo artifacts, the flap has to be identified in more than one view, and it must have a motion independent of the aortic wall. We describe the transesophageal echocardiography appearance of a localized aortic dissection with atypical features for an intimal flap. Awareness of this unusual echocardiographic appearance of an intimal flap will avoid misdiagnosis of the potentially serious acute aortic dissection.