Alternative explanations to the differences of femoral and brachial saline contrast injections for echocardiographic detection of patent foramen ovale.

Patent foramen ovale (PFO) of the interatrial septum is a cardiac foetal remnant, which frequent persistence in adulthood has important implications in a variety of clinical conditions. Echographic diagnosis of PFO is based on detection of interatrial shunt by means of contrast microbubbles identification after venous injection of a first-generation echographic contrast agent. Current recommendations propose venous femoral injection of contrast for enhanced echographic detection of PFO instead of venous brachial administration, as femoral injection has been shown to have higher sensitivity for PFO detection. Inferior vena cava inflow directed toward interatrial septum has been considered the explanation for increased sensitivity of femoral delivery of contrast. In the present paper, it is hypothesised that the main determinants of these differences between injection sites are technical factors related to right atrial contrast opacification and proper transient right atrial pressure rise, rather than intraatrial flow streaming. Effects of inferior vena cava inflow stream, although significant during foetal life, would be negligible after birth. Rationale and evidence, basis for further research, and practical implications leading to a simpler and safer routine technique for echographic detection of PFO are presented and discussed.

[Agreement between centers on the interpretation of exercise echocardiography]. / Concordancia intercentros en la interpretación de la ecocardiografía de ejercicio.

INTRODUCTION AND OBJECTIVES: A low-to-moderate level of agreement on the interpretation of dobutamine echocardiography has been reported, but there are no similar findings on exercise echocardiography. The objectives of this study were to assess the level of agreement between centers on the use of exercise echocardiography and to evaluate the accuracy of the technique when used in a blinded manner. PATIENTS AND METHOD: Six institutions with experience in exercise echocardiography each sent 25 study results to the other centers. Of these, 15 were positive or negative studies on consecutive patients undergoing coronary angiography, and 10 were on non-diabetic patients who had non-coronary chest pain or were asymptomatic and whose pretest probability of coronary artery disease was < 10%. Each institution evaluated 150 studies: 125 blinded and 25 of their own with knowledge of clinical data. RESULTS: For 116 patients (78%), four or more of the five centers blindly evaluating each study agreed with the positive or negative result. The average kappa coefficient was 0.48 (intercenter range 0.45-0.52). The percentage agreement was higher with three-vessel disease (93%, range 85%-95%), with left anterior descending coronary artery disease (83%, range 80%-86%), and when the referring institution reported baseline dyssynergy (86%, range 82%-90%), dyssynergy in left anterior descending coronary artery territory (81%, range 76%-84%), or a peak wall motion score index > 1.50 (88%, range 85%-90%). When the technique was used blinded to detect > or = 50% coronary narrowing in > or = 1 vessel, its sensitivity, specificity and accuracy were 68%, 66% and 67%, respectively, with wide variability between centers. CONCLUSIONS: There was moderate agreement between centers on the interpretation of exercise echocardiography. When used blinded, the technique's accuracy was lower than that reported when clinical data is known.

Intraoperative myocardial rupture heralded by contrast echocardiography.

This case report shows the use of bedside transthoracic contrast echocardiography in the diagnosis of subacute myocardial rupture after acute myocardial infarction and indication of urgent surgery. Usefulness of intraoperative transesophageal echocardiography for detection of sudden complete myocardial rupture leading to pericardial tamponade during anesthetic induction, and prompt lifesaving surgical procedure are also presented.

[Comparison of the degree of right atrial opacification seen on intracardiac echocardiography following femoral or antecubital injection of saline contrast]. / Comparación del grado de opacificación auricular derecha con ecocardiografía intracardiaca tras inyecciones femoral y antecubital de contraste salino.

It is thought that femoral injection of agitated saline contrast is better for detecting patent foramen ovale than antecubital injection mainly because of the nature of intraatrial flow where the venae cavae enter the heart. Our aim was to investigate the effect of the contrast injection site on the degree of right atrial opacification seen on intracardiac echocardiography. The degree of right atrial opacification after each femoral or antecubital injection of saline contrast was scored from 0-4 in 21 patients. It was shown that the degree of right atrial opacification was greater after femoral than antecubital injection (3.76 vs. 1.62; P<.001). Future studies comparing the two routes of saline contrast injection should control for the degree of right atrial opacification.

Comparación del grado de opacificación auricular derecha con ecocardiografía intracardiaca tras inyecciones femoral y antecubital de contraste salino / Comparison of the degree of right atrial opacification seen on intracardiac echocardiography following femoral or antecubital injection of saline contrast

Se asume que la superioridad de la inyección femoral de suero salino agitado para la detección del foramen oval permeable comparada con la antecubital se debe principalmente al efecto de las corrientes intrauriculares de la desembocadura de las cavas. Nos propusimos evaluar la influencia del lugar de inyección de contraste en el grado de opacificación auricular derecha en ecografía intracardiaca. Se puntuó de 0 a 4 el grado de opacificación obtenido tras inyecciones venosas por vía antecubital y femoral de contraste salino en 21 pacientes. Se comprobó que el grado de opacificación auricular derecha es mayor tras la inyección femoral que la antecubital (3,76 frente a 1,62; p < 0,001). Los futuros estudios que comparen ambas vías de inyección de salino deberían controlar el grado de opacificación auricular derecha (AU)

It is thought that femoral injection of agitated saline contrast is better for detecting patent foramen ovale than antecubital injection mainly because of the nature of intraatrial flow where the venae cavae enter the heart. Our aim was to investigate the effect of the contrast injection site on the degree of right atrial opacification seen on intracardiac echocardiography. The degree of right atrial opacification after each femoral or antecubital injection of saline contrast was scored from 0­4 in 21 patients. It was shown that the degree of right atrial opacification was greater after femoral than antecubital injection (3.76 vs. 1.62; P<.001). Future studies comparing the two routes of saline contrast injection should control for the degree of right atrial opacification (AU)

Concordancia intercentros en la interpretación de la ecocardiografía de ejercicio / Agreement between centers on the interpretation of exercise echocardiography

Introducción y objetivos. Se ha demostrado un acuerdo bajo-moderado en la interpretación de la ecocardiografía con dobutamina, pero no se ha realizado un estudio similar con ejercicio. El objetivo fue evaluar la concordancia intercentros de la ecocardiografía de ejercicio y la precisión de la técnica realizada de forma «ciega». Pacientes y método. Cada uno de los 6 centros remitió 25 casos a los demás centros: 15 eran pacientes consecutivos en los que se había realizado una coronariografía y 10 eran no diabéticos, asintomáticos o con dolor precordial atípico y con una probabilidad pretest 1,50 (88%; rango, 85-90%). La sensibilidad, la especificidad y la precisión diagnóstica media de la técnica «a ciegas» para estenosis coronaria ≥ 50% en ≥ 1 vaso fue del 68, el 66 y el 67%, respectivamente, pero con una amplia variabilidad intercentros. Conclusiones. La concordancia intercentros de la ecocardiografía de ejercicio es moderada. La precisión diagnóstica «a ciegas» es inferior a la comunicada cuando se conocen los datos clínicos

Introduction and objectives. A low-to-moderate level of agreement on the interpretation of dobutamine echocardiography has been reported, but there are no similar findings on exercise echocardiography. The objectives of this study were to assess the level of agreement between centers on the use of exercise echocardiography and to evaluate the accuracy of the technique when used in a blinded manner. Patients and method. Six institutions with experience in exercise echocardiography each sent 25 study results to the other centers. Of these, 15 were positive or negative studies on consecutive patients undergoing coronary angiography, and 10 were on non-diabetic patients who had non-coronary chest pain or were asymptomatic and whose pretest probability of coronary artery disease was 1.50 (88%, range 85%-90%). When the technique was used blinded to detect =50% coronary narrowing in =1 vessel, its sensitivity, specificity and accuracy were 68%, 66% and 67%, respectively, with wide variability between centers. Conclusions. There was moderate agreement between centers on the interpretation of exercise echocardiography. When used blinded, the technique's accuracy was lower than that reported when clinical data is known

Diagnóstico de miocardiopatía hipertrófica apical con ecocardiografía de contraste / Diagnosis of Apical Hypertrophic Cardiomyopathy Using Contrast Echocardiography

La miocardiopatía hipertrófica apical es una enfermedad con unas características electrocardiográficas y ecocardiográficas muy definidas. Sin embargo, la falta de definición del endocardio apical por mala ventana acústica limita el diagnóstico ecocardiográfico. Presentamos el caso de una paciente con electrocardiograma típico en el que el diagnóstico se realizó mediante ecocardiografía de contraste. Se discute el papel de la ecocardiografía de contraste en el diagnóstico de la miocardiopatía hipertrófica apical (AU)