Reprinted article "A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery".

OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69 ±9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p = 0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24,95% CI: 0.10-0.70; p = 0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.

Recommendations for transoesophageal echocardiography: update 2010.

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Real-time quantification and display of skin radiation during coronary angiography and intervention.

BACKGROUND: Radiographically guided investigations may be associated with excessive radiation exposure, which may cause skin injuries. The purpose of this study was to develop and test a system that measures in real time the dose applied to each 1-cm(2) area of skin, taking into account the movement of the x-ray source and changes in the beam characteristics. The goal of such a system is to help prevent high doses that might cause skin injury. METHODS AND RESULTS: The entrance point, beam size, and dose at the skin of the patient were calculated by use of the geometrical settings of gantry, investigation table, and x-ray beam and an ionization chamber. The data are displayed graphically. Three hundred twenty-two sequential cardiac investigations in adult patients were analyzed. The mean peak entrance dose per investigation was 0.475 Gy to a mean skin area of 8.2 cm(2). The cumulative KERMA-area product per investigation was 52.2 Gy/cm(2) (25.4 to 99.2 Gy/cm(2)), and the mean entrance beam size at the skin was 49.2 cm(2). Twenty-eight percent of the patients (90/322) received a maximum dose of <1 Gy to a small skin area ( approximately 6 cm(2)), and 13.5% of the patients (42/322) received a maximum dose of >2 Gy. CONCLUSIONS: Monitoring of the dose distribution at the skin will alert the operator to the development of high-dose areas; by use of other gantry settings with nonoverlapping entrance fields, different generator settings, and extra collimation, skin lesion can be avoided.

Human tissue valves in aortic position: determinants of reoperation and valve regurgitation.

BACKGROUND: Human tissue valves for aortic valve replacement have a limited durability that is influenced by interrelated determinants. Hierarchical linear modeling was used to analyze the relation between these determinants of durability and valve regurgitation measured by serial echocardiography. METHODS AND RESULTS: In adult patients, 218 cryopreserved aortic allografts were implanted with the subcoronary (85) or the root replacement technique (133), and 81 patients had root replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD 2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary implantation, and allograft diameter were independent predictors for reoperation. With repeated color Doppler echocardiography, the severity of aortic regurgitation was assessed by the jet length method and the jet diameter ratio. Multilevel hierarchical linear modeling was used to estimate initial aortic regurgitation (intercept), its change over time (slope), and the effect of 11 potential determinants of durability on aortic regurgitation. With the jet length method, the intercept was 0.94 grade and the slope was 0.11 grade per year. With the jet diameter ratio, the intercept was 0.34 and the annual increase was 0.01. Subcoronary implanted valves had more initial aortic regurgitation, but progression of aortic valve regurgitation did not differ from root replacement. At midterm follow-up, recipient age <40 years was the only independent predictor of aortic regurgitation. CONCLUSIONS: Subcoronary implantation has a learning curve, resulting in more initial aortic regurgitation and early reoperation compared with root replacement. In both techniques, progression of aortic regurgitation over time is small but accelerated in young adults.

Dobutamine stress myocardial perfusion imaging.

In patients with limited exercise capacity and (relative) contraindications to direct vasodilators such as dipyridamole or adenosine, dobutamine stress nuclear myocardial perfusion imaging (DSMPI) represents an alternative, exercise-independent stress modality for the detection of coronary artery disease (CAD). Nondiagnostic test results (absence of reversible perfusion defects with submaximal stress) do occur in approximately 10% of patients. Serious side effects during DSMPI are rare, with no death, myocardial infarction or ventricular fibrillation reported in three DSMPI safety reports for a total of 2,574 patients. On the basis of a total number of 1,014 patients reported in 20 studies, the sensitivity, specificity and accuracy of the test for the detection of CAD were 88%, 74% and 84%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 84%, 95% and 100%, respectively. The sensitivity for detection of left circumflex CAD (50%) was lower, compared with that for left anterior descending CAD (68%) and right CAD (88%). The sensitivity of predicting multivessel disease by multiregion perfusion abnormalities varied widely, from 44% to 89%, although specificity was excellent in all studies (89% to 94%). In direct diagnostic comparisons, DSMPI was more sensitive, but less specific, than dobutamine stress echocardiography and comparable with direct vasodilator myocardial perfusion imaging. In the largest prognostic study, patients with a normal DSMPI study had an annual hard event rate less than 1%. An ischemic scan pattern provided independent prognostic value, with a direct relationship between the extent and severity of the perfusion defects and prognosis. In conclusion, DSMPI seems a safe and useful nonexercise-dependent stress modality to detect CAD and assess prognosis.

Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler color flow imaging.

Three patients with a left ventricular pseudoaneurysm are presented. Doppler color flow imaging helped to establish the diagnosis and was able to show additional blood flow abnormalities. The guided continuous wave Doppler interrogation of the shunting blood flow through the communication between the pseudoaneurysm and the left ventricle allowed the identification of a specific diagnostic flow pattern. Doppler color flow imaging offers advantages in patients with equivocal two-dimensional echocardiographic findings for elucidating confusing clinical findings and demonstrating additional and unsuspected flow abnormalities.

Transthoracic three-dimensional echocardiography in adult patients with congenital heart disease.

OBJECTIVES: This study sought to assess both the feasibility and potential role of transthoracic three-dimensional echocardiography for the evaluation of adult patients with congenital heart disease. BACKGROUND: The unrestricted views with depth perception provided by three-dimensional echocardiography with dynamic volume-rendered display may enhance visualization of cardiac structures and detection of abnormalities in patients with congenital heart defects. METHODS: We studied 33 patients with various heart defects (mitral valve anomalies in 9, aortic valve anomalies in 5, subaortic membrane in 5, ventricular septal defect in 4, transposition of the great arteries in 3, tetralogy of Fallot in 2, other defects in 5). Cross-sectional images of the specific region of interest were acquired from either the parasternal or apical window with the rotational technique (2 degrees interval with electrocardiographic and respiratory gating) and postprocessed for resampling in cubic format. From these three-dimensional data sets a multitude of cut planes were selected, presented in volume-rendered dynamic display and analyzed by two observers for comparison with standard two-dimensional images to assess their additional information. RESULTS: Three-dimensional reconstruction was possible in all patients. Structures of interest were evaluated from unusual viewpoints, providing both cardiologists and surgeons with immediate feedback. When compared with standard two-dimensional images, additional information was provided for 12 patients (36%). The mitral valve, aortoseptal continuity and interatrial septum were the structures for which three-dimensional echocardiography was most useful. CONCLUSIONS: Transthoracic three-dimensional echocardiography is feasible and facilitates spatial recognition of the intracardiac anatomy in a significant proportion of patients and enhances diagnostic confidence of complex congenital heart disease.

Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography.

Large numbers of patients referred for evaluation of chest pain are unable to perform adequate, diagnostic exercise testing. In these patients, dobutamine stress echocardiography (DSE) represents an alternative, exercise-independent stress modality. Apart from the approximately 5% of patients with an inadequate acoustic window, 10% of patients referred for this test have nondiagnostic (submaximal negative) test results. Serious side effects during or shortly after DSE are uncommon, with ventricular fibrillation or myocardial infarction occurring in approximately 1 of 2,000 studies. No deaths have been reported. On the basis of a total number of 2,246 patients, reported in 28 studies, the sensitivity, specificity and accuracy of the test for the detection of coronary artery disease (CAD) were 80%, 84% and 81%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 74%, 86% and 92%, respectively. The sensitivity for detection of disease in the left circumflex coronary artery (55%) was lower, both compared with that for left anterior descending (72%) and right coronary artery disease (76%). The sensitivity of predicting multivessel disease by multiregion echocardiographic abnormalities varied widely, from 8% to 71%. In direct comparisons, DSE was superior to exercise electrocardiography and dipyridamole echocardiography and comparable to exercise echocardiography and radionuclide imaging. DSE is a useful, feasible and safe exercise-independent stress modality for assessing the presence, localization and extent of CAD.

The significance of stress-induced ST segment depression in patients with inferior Q wave myocardial infarction.

OBJECTIVES: This study was conducted to evaluate the relationship between ST segment depression (STD) during dobutamine stress tests in different electrocardiogram (ECG) leads and myocardial ischemia assessed by simultaneous single photon emission computed tomography (SPECT) imaging in patients with inferior Q wave myocardial infarction. BACKGROUND: STD is a standard electrocardiographic sign of myocardial ischemia. Although STD may represent reciprocal changes in patients with previous myocardial infarction, studies of reciprocal changes during stress tests are scarce. METHODS: Dobutamine (up to 40 microg/kg/min) stress and rest myocardial perfusion scintigraphy using technetium SPECT imaging was performed in 125 patients >3 months after Q wave inferior myocardial infarction. The location of STD at the ECG was defined as anterior (V1-4), high lateral (I, aVL) and lateral (V5,6). Ischemia was defined as reversible perfusion abnormalities. RESULTS: STD occurred in the high lateral leads in 20 patients, in the anterior leads in 12 patients and in the lateral leads in 2 patients. ST segment elevation occurred in 25 patients in the inferior leads. High lateral STD was associated with inferior ST elevation in 16 patients (80%). There was a significant inverse linear correlation between the magnitude of ST segment shift from rest to peak stress in the inferior and the high lateral leads (r = -0.8, p < 0.0005), whereas no significant correlation was found between ST segment shift in the inferior and the anterior leads (r = -0.1, p = NS) or between the inferior and the lateral leads (r = 0.15, p = NS). Ischemia was detected in 45% of patients with and in 42% of patients without high lateral STD (p = NS). Patients with high lateral STD had a higher prevalence of fixed perfusion defects in the inferior wall (100% vs. 70%) and in the posterolateral wall (55% vs. 29%) compared with other patients (both p < 0.05). Ischemia was more prevalent in patients with anterior STD than without (75% vs. 39%, p < 0.05). CONCLUSIONS: In patients with inferior Q wave myocardial infarction, stress-induced STD in high lateral leads should be recognized as a reciprocal change for ST elevation in the inferior leads, and therefore, should be interpreted with the consideration of the significance of ST elevation if present, rather than being indicative of myocardial ischemia on its own. The STD found in the anterior leads appears to be a sign of myocardial ischemia. These findings should be considered in the definition of a positive ECG stress test and in establishing the criteria for the termination of stress test.

Transesophageal echocardiography in evaluation and management after a Fontan procedure.

Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn shunt could be evaluated in eight of nine patients (precordial in three of nine). Thrombus formation was detected by transesophageal studies in three patients (precordial in one patient); repeat studies were used to evaluate thrombolytic therapy in two. Atrioventricular valvular regurgitation (11 of 18 patients) was better defined by transesophageal than by precordial studies (5 of 18). A coronary artery fistula was identified in two cases (precordial in none). Transesophageal pulsed Doppler interrogation of pulmonary artery and pulmonary vein flow patterns consistently allowed a detailed evaluation of the Fontan circulation. Transesophageal echocardiography is an important diagnostic and monitoring technique after the Fontan procedure. In this series, it was far superior to precordial ultrasound evaluation and of substantial additional value to cardiac catheterization.

Long-term follow-up after surgical closure of ventricular septal defect in infancy and childhood.

OBJECTIVES: The purpose of this study was to assess the health-related quality of life of patients who underwent surgical closure of a ventricular septal defect at a young age between 1968 and 1980. BACKGROUND: Since the beginning of open heart surgery for congenital cardiac malformations, the surgical techniques have continually improved. As a result, even infants have become eligible for surgical repair. Long-term follow-up data are not available on the health-related quality of life of nonselected patients after surgical repair at a young age. We therefore conducted a follow-up study of 176 infants and children consecutively operated on in one institution between 1968 and 1980. METHODS: Patients who were alive and could be traced through the offices of local registrars received an invitation to participate in the follow-up study, consisting of an interview, physical examination, echocardiography, exercise testing and standard 12-lead and 24-h electrocardiography. RESULTS: One hundred nine patients (78% of those eligible for follow-up) participated. The mean interval after operation (+/- SD) was 14.5 +/- 2.6 years. Eighty-four percent of the patients assessed their health as good or very good, and 89% had been free of any medical or surgical intervention since the operation. At physical examination all patients were in good health. Their mean exercise capacity was 100 +/- 17% (range 56% to 141%) of predicted values; 84% of the patients had a normal exercise capacity. Echocardiography demonstrated a small residual ventricular septal defect in seven patients (6%). There were no signs of pulmonary hypertension. No patient had symptomatic arrhythmias. CONCLUSIONS: Long-term results of surgical closure of ventricular septal defect in infancy and childhood are good. Pulmonary hypertension is absent. Personal health assessment is comparable to that of the normal population, as is exercise capacity, even though many patients have anatomic, hemodynamic or electrophysiologic sequelae.

Comparative value of transthoracic and transesophageal echocardiography in the assessment of congenital abnormalities of the atrioventricular junction.

Information obtained from transthoracic and transesophageal echocardiography (two-dimensional echocardiography with spectral Doppler and color flow imaging) was compared in 17 patients with major congenital abnormalities of the atrioventricular (AV) junction (10 discordant AV connections, 1 criss-cross connection, 5 absent right connections and 1 absent left connection). The findings by either technique were correlated with findings at cardiac catheterization (12 patients) and at surgery (5 patients). In two of six patients with an absent AV connection as defined by transthoracic echocardiography, transesophageal imaging demonstrated an imperforate AV valve. In 11 of 11 patients with a discordant or criss-cross connection, assessment of AV valve and ventricular morphology (by defining the chordal attachments of both AV valves) was possible with transesophageal echocardiography (3 of 11 patients by transthoracic echocardiography); chordal straddling was detected in 1 patient and excluded in 3 others with an associated inlet ventricular septal defect. Anomalous pulmonary venous connection (one patient), atrial septal defect (three patients) and subpulmonary stenosis (five patients) were better assessed by transesophageal imaging, and atrial appendage morphology could be demonstrated in all. The transesophageal technique was less useful in demonstrating the anterior subaortic infundibulum or aortopulmonary shunt (two patients). Although systemic ventricular function could be assessed by either method with use of short-axis M-mode scans, transesophageal pulsed Doppler interrogation of AV valve and pulmonary venous flow patterns provided clues to diastolic dysfunction of the systemic ventricle.

Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction.

Fifty consecutive patients with a newly acquired systolic murmur and severe cardiac decompensation following a recent myocardial infarction (27 with an anterior and 23 with an inferior infarct) were studied by a combination of two-dimensional echocardiography, spectral Doppler and Doppler color flow mapping. The initial ultrasound study defined a ventricular septal rupture in 43 patients and severe isolated mitral regurgitation in 7 patients (5 with papillary muscle rupture and 2 with severe papillary muscle dysfunction). All 50 patients had subsequent confirmation of the diagnosis by either cardiac catheterization or surgical inspection, or both. Two-dimensional echocardiography alone directly visualized a septal defect in only 17 (40%) of the 43 patients with ventricular septal rupture. In all 43 patients the mitral valve appeared normal on imaging. In six of the seven patients with isolated mitral regurgitation, two-dimensional echocardiography correctly demonstrated the structural abnormality of the mitral valve (five with flail anterior leaflet and one with posterior leaflet prolapse). The addition of Doppler color flow mapping greatly improved the diagnostic information in both patient groups. In all 43 patients with ventricular septal rupture, Doppler color flow mapping demonstrated both an area of turbulent transseptal flow and a diagnostic systolic flow disturbance within the right ventricle. In the seven patients with isolated papillary muscle rupture or dysfunction, Doppler color flow mapping not only demonstrated the presence of mitral regurgitation in all cases, but also identified the specific mitral leaflet abnormality by defining the direction of the regurgitant jet.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous dobutamine stress echocardiography and technetium-99m isonitrile single-photon emission computed tomography in patients with suspected coronary artery disease.

OBJECTIVES: The purpose of this study was to determine the relative value of dobutamine stress echocardiography and technetium-99m isonitrile single-photon emission computed tomography (mibi SPECT) in the detection of myocardial ischemia. BACKGROUND: Stress-induced new wall motion abnormalities and transient perfusion defects are both used for the diagnosis of myocardial ischemia. METHODS: One hundred five consecutive patients with either proved or suspected coronary artery disease, who were referred for perfusion scintigraphy, were studied by a combination of the two techniques. Both echocardiographic and mibi SPECT images were visually analyzed. Three patients were excluded from the final analysis because of unsatisfactory examinations: two with noninterpretable stress echocardiograms and one with noninterpretable mibi SPECT images. The response to stress was concordantly classified by both techniques in 68% of patients (kappa = 0.51). RESULTS: Dobutamine stress echocardiography revealed the presence of ischemia in 38 and mibi SPECT in 45 patients (overall agreement = 74%, kappa = 0.46). The agreement was higher in patients without previous myocardial infarction (84%, kappa = 0.62). When regional analysis was performed, concordance of stress echocardiography and mibi SPECT occurred in 84% of the 306 regions (kappa = 0.45). Regional agreement was also slightly higher in patients without previous infarction (88%, kappa = 0.50). In 21 patients without previous myocardial infarction who underwent coronary angiography, the overall sensitivity of dobutamine stress echocardiography and mibi SPECT for the diagnosis of coronary artery disease (diameter stenosis > 50%) was 75% and 83%, respectively, with a specificity of 89% (eight of nine patients) for both tests. CONCLUSIONS: Dobutamine stress echocardiography represents a reasonable alternative to dobutamine mibi SPECT for the functional assessment of patients with suspected myocardial ischemia and without previous myocardial infarction.

Quantitative angiographic measurements of isolated left anterior descending coronary artery stenosis. Correlation with exercise echocardiography and technetium-99m 2-methoxy isobutyl isonitrile single-photon emission computed tomography.

OBJECTIVES: This study sought to assess the value of quantitative coronary arteriography in predicting an ischemic response at exercise echocardiography and technetium-99m 2-methoxy isobutyl isonitrile (mibi) single-photon emission computed tomography (SPECT) in patients with single-vessel disease of the left anterior descending coronary artery. BACKGROUND: The relation between severity of coronary stenosis and ischemic response to exercise echocardiography and perfusion scintigraphy in patients with single-vessel left anterior descending coronary artery disease is not well established. METHODS: Thirty-one patients without a previous myocardial infarction who had isolated stenosis of varying degrees in the proximal or midportion of the left anterior descending coronary artery were studied. Quantitative arteriographic analysis was used for measurements of percent diameter stenosis and minimal lumen diameter. Exercise-induced wall motion abnormalities by echocardiography and transient perfusion defects by mibi SPECT were considered a positive response. The analysis of sensitivity/specificity and receiver operating characteristic curves was applied to establish the diagnostic power of quantitative coronary arteriography to predict an ischemic response to exercise echocardiography and mibi SPECT: RESULTS: The "best" angiographic cutoff values for predicting a positive exercise echocardiographic and scintigraphic response were similar (diameter stenosis 52%, minimal lumen diameter 1.12 mm for echocardiography; diameter stenosis 49%, minimal lumen diameter 1.20 mm for SPECT). However, the sensitivity/specificity at the cross point was slightly higher (even if not statistically significant) for echocardiography than for SPECT, both for diameter stenosis (81% vs. 67%) and minimal lumen diameter (81% vs. 74%), suggesting that quantitative coronary arteriographic measurements are more closely related to echocardiographic than scintigraphic exercise test results. CONCLUSIONS: The functional significance of a proximal/mid-left anterior descending coronary artery stenosis measured by quantitative coronary arteriography is slightly better related to echocardiographic than scintigraphic markers of exercise-induced myocardial ischemia.

Three-dimensional echocardiography of normal and pathologic mitral valve: a comparison with two-dimensional transesophageal echocardiography.

OBJECTIVES: This study was done to ascertain whether three-dimensional echocardiography can facilitate the diagnosis of mitral valve abnormalities. BACKGROUND: The value of the additional information provided by three-dimensional echocardiography compared with two-dimensional multiplane transesophageal echocardiography for evaluation of the mitral valve apparatus has not been assessed. METHODS: Thirty patients with a variety of mitral valve pathologies (stenosis in 8, insufficiency in 12, prostheses in 10) and 20 subjects with a normal mitral valve were studied. Images were acquired using the rotational technique (ever 2 degrees), with electrocardiographic and respiratory gating. From the three-dimensional data sets, cut planes were selected and presented in both two-dimensional format (anyplane echocardiography) and volume-rendered dynamic display. The data were compared with the original multiplane two-dimensional images. Different features of the mitral valve apparatus were defined and graded by three observers for clarity of visualization and confidence of interpretation as 1) inadequate, 2) sufficient, or 3) excellent. RESULTS: All the techniques provided good visualization of the mitral valve (mean global scores +/- SD for multiplane, anyplane and volume-rendered echocardiography were 2.22 +/- 0.34, 2.24 +/- 0.26 and 2.30 +/- 0.25, respectively). With volume-rendered echocardiography, the mitral valve apparatus was scored higher in pathologic than in normal conditions (2.38 +/- 0.24 vs. 2.16 +/- 0.21, p < 0.002). The spatial relationships between the mitral valve and other structures, leaflet mobility, commissures and orifice were scored higher by volume-rendered echocardiography. Prostheses were evaluated equally well by the three methods. Multiplane and anyplane echocardiography were superior for the evaluation of leaflet thickness, subvalvular apparatus and annulus. CONCLUSIONS: Transesophageal three-dimensional echocardiography facilitates imaging of some features of the mitral valve apparatus and provides additional information for comprehensive assessment of mitral valve abnormalities.

Transesophageal two-dimensional echocardiography: its role in solving clinical problems.

The diagnostic value of transesophageal two-dimensional echocardiography is described in 32 patients in whom precordial echocardiography or angiography, or both, failed to establish a definitive diagnosis. All attempted transesophageal studies were completed without complication and the referral question was definitively answered. Nineteen patients were subsequently submitted to surgery. In 18 of them, the transesophageal echocardiographic diagnoses were proven correct; in 1 patient, the diagnosis was proven partially incorrect. In the 13 unoperated patients the transesophageal echocardiographic diagnoses were not independently confirmed but were assumed correct because incontrovertible images were obtained. These results indicate that transesophageal echocardiography significantly extends the diagnostic capabilities of echocardiography.

Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography.

OBJECTIVES: This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography. BACKGROUND: Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities. METHODS: Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed. RESULTS: The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age > 70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative assessment of the extent and severity of ischemia did not provide additional prognostic information in patients with positive test results. In contrast, the heart rate at which ischemia occurred defined a high risk group with a low ischemic threshold (38 patients with 20 events [53%]) and an intermediate risk group with a high ischemic threshold (34 patients with 7 events [21%]). All 5 patients with a fatal outcome and 8 of 12 with a nonfatal myocardial infarction were in the high risk group with a low ischemic threshold. CONCLUSIONS: Clinical variables identify 33% of patients at very low risk for perioperative complications of vascular surgery in whom further testing is redundant. In all other candidates, dobutamine-atropine stress echocardiography is a powerful tool that identifies those patients at intermediate risk and a small group at very high risk. Risk stratification with a combination of clinical assessment and pharmacologic stress echocardiography has the potential to facilitate clinical decision making and conserve resources.

Prognostic value of dobutamine-atropine stress technetium-99m sestamibi perfusion scintigraphy in patients with chest pain.

OBJECTIVES: This study investigated the prognostic value of dobutamine-atropine technetium-99m (Tc-99m) sestamibi single-photon emission computed tomographic (SPECT) myocardial perfusion imaging. BACKGROUND: Dobutamine-atropine Tc-99m sestamibi SPECT imaging is an accurate method for the detection of coronary disease. However, the prognostic value of this stress modality has not been assessed. METHODS: Three hundred ninety-two consecutive patients with chest pain (mean [+/- SD] age 60 +/- 12 years; 220 men, 190 with a previous myocardial infarction) underwent a dobutamine-atropine Tc-99m sestamibi SPECT scintigraphic study. Patients were followed up for 22 +/- 13 months to determine the univariate and multivariate variables associated with hard cardiac events (cardiac death, nonfatal myocardial infarction), to define their event-free survival and to determine whether the extent and severity of reversible perfusion defects correlated with events. RESULTS: Forty-four patients (11%) had hard cardiac events. Multivariate models demonstrated that older age (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.0 to 4.4), history of heart failure (OR 2.6, 95% CI 1.3 to 5.2), abnormal sestamibi scan results (OR 10.0, 95% CI 2.3 to 43.0) and reversible perfusion defects (OR 3.2, 95% CI 1.6 to 6.4) had independent predictive value. Patients without perfusion defects, with fixed defects alone, reversible defects alone and fixed plus reversible defects had annual hard cardiac event rates of 0.8%, 6.8%, 8.1% and 11.6%, respectively. Patients with increasing reversible defect scores had increasing annual event rates of 2.1%, 5.0%, 5.5%, 13.0% and 14.6%, respectively. CONCLUSIONS: Dobutamine-atropine stress Tc-99m sestamibi SPECT imaging provides excellent prognostic information. The single most important independent predictor for future hard cardiac events is an abnormal pattern, and a reversible defect provides additional, independent prognostic information. Moreover, the extent and severity of reversible defects are major determinants for prognosis.