Cardiac rupture during exercise stress echocardiography: a case report.

Stress echocardiography is widely used in the evaluation of coronary artery disease. Dobutamine stress echocardiography has been the preferred method, but many centers have adopted exercise stress echocardiography, which can visualize myocardial motion during physiologic stress testing. The complications of this method in the post-myocardial infarction period are the same as those identified in conventional exercise testing. We report a case of myocardial rupture in the postinfarction period during exercise stress echocardiography.

Early and medium term results of tailored therapy for heart failure.

UNLABELLED: Patients (pts) with advanced chronic heart failure, in NYHA functional class IV, refractory to conventional medical therapy, show a poor short-term survival prognosis. Heart transplant remains the therapy of choice but it can currently be performed in only a minority of pts. Therapy tailored to hemodynamic goals has been suggested as a potential alternative for patients with advanced congestive heart failure. Intravenous and, subsequently, oral vasodilators (v) and diuretics (d) are titrated, in order to achieve specific hemodynamic parameters: systolic arterial pressure (SAP) > 80 mmHg, pulmonary wedge pressure (PWP) < 15 mmHg, right atrial pressure (RAP) < 8 mmHg, and systemic vascular resistance (SVR) < 1200 dynes.sec.cm-5. AIM: To assess short and medium term (two years) results of a tailored therapy management program for treatment of patients with advanced heart failure. METHODS: 27 pts (19 males, 61 +/- 10 years), NYHA functional class IV, with dilated cardiomyopathy (13 idiopathic, 10 ischemic, 4 hypertensive), 17 with exclusion criteria for heart transplantation, were included. Echocardiographic left ventricular end-diastolic dimension and ejection fraction were 68 +/- 8 mm and 20 +/- 9%, respectively. Initial (i) serum sodium (Na+) was 136 +/- 5 mEq/l and i serum creatinine (Cr) was 1.4 +/- 0.8 mg/dl. Baseline, at referral, hemodynamics: SAP = 125 +/- 23, PWP = 23 +/- 6, RAP = 12 +/- 6, cardiac index (CI) = 1.9 +/- 0.5 l/min/m2, SVR = 2193 +/- 670. Using bedside right heart catheterization (Swan-Ganz catheter) we set out to achieve the above hemodynamic goals. RESULTS: 1) v and d used: sodium nitroprusside--cumulative dose = 196 +/- 121 mg, captopril--daily dose (dd) = 157 +/- 95 mg, isosorbide dinitrate--dd = 91 +/- 57 mg, hydralazine--dd = 95 +/- 67 mg, and furosemide--dd = 105 +/- 70 mg; 2) final (f) hemodynamic parameters on tailored therapy: SAP = 109 +/- 20*, PWP = 12 +/- 3*, RAP = 4 +/- 3*, CI = 2.5 +/- 0.6*, SVR = 1317 +/- 340* (*: p < 0.001 vs baseline); 3) duration of invasive monitoring was 3.0 +/- 1.9 days; 4) f Na+ = 134 +/- 5, and f Cr = 1.5 +/- 0.8 (NS vs i); 5) there was one (4%) in-hospital death; functional class of discharged pts: III--4 pts, II--18 pts, I--4 pts; 6) nine pts (35%) died after discharge--three due to refractory heart failure and six (including two potential heart transplant candidates) had sudden death; 7) actuarial survival (Kaplan-Meyer method): at 6 months (m)--80%, 12 m--71%, 18 m--64%, 24 m--55%; 8) after a mean follow-up of 18 +/- 8 m, functional class in survivors was: NYHA IV--2 pts, III--4 pts, II--8 pts, and I--3 pts. CONCLUSIONS: Therapy tailored to hemodynamic goals is a valid approach for pts with advanced heart failure, showing good hemodynamic and functional short-term results, and reasonable survival at two years. The significant incidence of sudden death demands strategies for risk stratification and a search for prophylactic measures in this population.

[Recommendations for the diagnosis and treatment of unstable angina and non-Q-wave myocardial infarction (proposed revision)]. / Recomendações para o diagnóstico e tratamento da angina instável e do enfarte do miocárdio sem onda Q (proposta de revisões).

The optimal diagnostic and treatment strategies for unstable angina/non-Q-wave myocardial infarction patients will continue to be redefined as rapid progress is made in the understanding, and treatment of this syndrome. The recommendations presented here reflect, in part, discussions at the International Cardiology Forum in September 1998. Although areas of controversy remain, we have summarized major points on which a consensus could be reached and for which the weight of the clinical evidence supports a change in practice.

[Acute myocardial infarct: the prognostic significance of complex coronary lesions]. / Enfarte agudo do miocárdio: significado prognóstico das lesões coronárias complexas.

OBJECTIVE: The aim of our study was to analyze the possible influence of coronary lesion morphology on the prognosis of patients (pts) with Acute Myocardial Infarction (AMI) evaluated by coronary angiography before hospital discharge. DESIGN: Retrospective study. SETTING: Study performed at the Cardiology Department of a Central Hospital. MATERIAL AND METHODS: 141 consecutive pts admitted because of AMI were evaluated, with an age average of 53.4 +/- 9.6 years, who had hospital discharge. All pts were submitted to angiography between the 2nd and 3rd week after AMI. The ventriculography was evaluated to determine the ventricular function score, as defined by the CASS protocol. The coronarography was performed to access the number of diseased vessels and to analyze their lesion morphology. Complexity was defined by the presence of one of the following characteristics: irregularity, shoulder, ulcers, filling defects, contrast retention and ecstasy. TWO GROUPS OF PTS WERE CONSIDERED: Group I--n = 64 pts, with complex lesions, and Group II--n = 69 pts with non complex lesions. Seven pts were excluded from the study because they had no significant coronary disease. Mean time of the follow up was 21.4 +/- 8.5 months and was similar in the two groups. The cardiac events considered were angina after AMI; reinfarction; heart failure; new hospital admission, percutaneous transluminal coronary angioplasty; coronary artery bypass grafting and death. RESULTS: In relation to both groups no statistically significant difference was found concerning sex, age, left ventricular function score and number of diseased vessels. In group I a higher incidence was found for cardiac events (p 0.006) and for the occurrence of angina after AMI (p < 0.02). In this group the number of pts with cardiac events was also higher (p < 0.01). No difference was found in relation to each of the morphologic characteristics and a high risk profile could not be found. CONCLUSIONS: Besides left ventricular function and the number of diseased vessels, the analysis of coronary lesion morphology, evaluated 2 to 3 weeks after AMI, could be useful in risk stratification after AMI.

[Time integral of oxygen pulse for exercise submaximal levels in patients with heart insufficiency--correlation with maximal oxygen consumption]. / Integral tempo do pulso de oxigénio para níveis submáximos de exercício em doentes com insuficiência cardíaca--correlação com o consumo máximo de oxigénio.

UNLABELLED: Maximal oxygen consumption (VO2max) has an important prognostic value in patients with congestive heart failure (CHF). However, it requires a maximal exercise test, not often available for these patients. To overcome this limitation, we examined whether a simple time integral of oxygen pulse (OP) to submaximal exercise levels correlates with VO2max. METHODS: We performed a maximal symptom-limited treadmill exercise test, while measuring breath-by-breath oxygen consumption, using the CAEP protocol, in 24 patients with CHF (51 +/- 11 years, 18 males, sinus rhythm). No exercise was terminated due to ischemia or arrhythmias. All patients attained anaerobic threshold. Besides standard parameters, OP (ml) and time integral of OP (OPTI) were calculated at 2 minutes (OP-2 min and OPTI-2 min) and at 4 minutes (OP-4 min and OPTI-4 min) of exercise. Patients were divided in two groups according to VO2max: group I--VO2max > or = 16 ml/kg/min (14 patients) and group II--VO2max < 16 (10 patients). RESULTS: Age, sex, body surface and CHF etiology were similar in both groups. Exercise duration, maximal OP, time to anaerobic there shold, VO2 and OP at anaerobic there shold were higher in group I (p < 0.05). Comparing group I vs group II--OP-2 min: 6.2 +/- 1.5 vs 5.0 +/- 1.2 ml (p = 0.026); OP-4 min: 7.6 +/- 1.9 vs 5.4 +/- 1.2 (p = 0.001); OPTI-2 min: 3.1 +/- 1.1 vs 2.2 +/- 0.9 (p = 0.021) and OPTI-4 min: 15.2 +/- 4.4 vs 9.3 +/- 3.1 (p = 0.0007). The best correlation with VO2max was obtained for OPTI-4 min (r = 0.696). An OPTI-4 min value > or = 10 occurred in 13 patients of group I and in two patients of group II (p = 0.00013), with a predictive value of 87% for VO2max > 16 (sensitivity = 93%, specificity = 80%)--kappa index = 0.739. CONCLUSIONS: OPTI-4 min can be a useful tool for assessing cardiocirculatory functional status in patients with CHF and unable to perform a maximal exercise test.

[Comparative study of Toronto SPV prosthesis and bileaflet mechanical aortic prosthesis with 2D-Doppler echocardiography]. / Estudo comparativo entre próteses toronto SPV e próteses mecânicas bidisco em posição aórtica por ecocardiografia 2D-Doppler.

AIM: The aim of this study was to make a noninvasive comparison, by means of Doppler echocardiography, of the hemodynamic performance of biological stentless xenografts and mechanical bileaflet (MB) prostheses (P) in aortic position. METHODS: We studied 20 patients (pts) with normofunctional (nf) aortic Toronto (T) Stentless Porcine valves (SPV)--Group I--8 males, aged 69 +/- 12 years, 32 +/- 9 months after surgery, and 30 pts with nf MB aortic P (Carbomedics or St. Jude Medical)--Group II--17 males (p = NS vs G I), aged 61 +/- 12 years (p < 0.01 vs G I), 30 +/- 12 months after implantation (p = NS vs G I). Both groups were comparable with regard to body surface area and surgical indication. P diameters ranged from 21 to 25 mm (G I: 22.9 +/- 1.7; G II: 22.8 +/- 1.7 - p = NS), the number of pts with the same P diameter in each group being similar. We analysed, at rest: aortic orifice diameter (AoOd - cm), maximal (GMax) and mean (GMean) transprosthesic pressure gradients, P functional area (PFA) and P resistance (PRes). Gradients (mm Hg) were calculated by means of the Bernoulli equation, PFA (cm2) by means of the continuity equation and PRes (dynes.s.cm-5) as 1333 x Gmean x SEP/SV (SEP = systolic ejection period; SV = stroke volume). RESULTS: AoOd (G I vs G II): P 21--1.78 +/- 0.04 vs 2.00 +/- 0.10 (p < 0.001); P 23--1.91 +/- 0.10 vs 2.19 +/- 0.10 (p = 0.01); P 25--2.22 +/- 0.24 vs 2.29 +/- 0.19 (NS). Doppler parameters: [table: see text] CONCLUSIONS: P T SPV show better hemodynamic performance when compared to P MB with the same diameter, in aortic position. In addition, our results suggest that P T SPV allow the use of larger valve sizes for the same aortic orifice diameter.

[The semiquantitative evaluation of systemic vascular resistances in heart failure via an analysis of Doppler aortic flow]. / Avaliação semiquantitativa das resistências vasculares sistémicas na insuficiência cardíaca a partir da análise do fluxo Doppler aórtico.

UNLABELLED: In patients with advanced heart failure (HF) submitted to tailored therapy, monitoring of systemic vascular resistance (SVR) is essential to establish an adequate hemodynamic response, being one of the end-points to achieve SVR < 18 Wood U (WU). PURPOSE: To correlate SVR value with parameters derived from the analysis of echo-Doppler aortic flow in patients with HF on tailored therapy, in order to allow a non-invasive semiquantitative evaluation of this hemodynamic end-point. METHODS: In 13 patients with dilated cardiomyopathy (eight idiopathic, five ischemic) and advanced HF (mean age 60 +/- 10 years, 10 male, all in sinus rhythm, NYHA class IV), admitted in the ICU and submitted to tailored therapy, serial simultaneous hemodynamic and echocardiographic studies were performed (2 to 5 per patient, overall 43 evaluations). The following parameters derived from the analysis of continuous wave aortic Doppler flow were analysed: peak velocity, acceleration, deacceleration and ejection times, systolic time intervals ratio, mean acceleration, mean deacceleration, acceleration, deacceleration and overall systolic flow velocity time integrals. RESULTS: SVR ranged from 10.4 to 41.9 WU (mean = 21.7, SD = 6.9). A significant correlation was found only with mean deacceleration (MnDc)-r = -0.60. MnDc ranged from 362 to 1162 cm/s2 (mean = 667, SD = 188) and proved to be independent from heart rate, systolic, diastolic and mean blood pressure, capillary wedge pressure, cardiac output, cardiac index and ejection volume. MnDc < 700 cm.s2 occurred in 25/28 evaluations with SVR > 18 WU and only in 3/15 evaluations with SVR < 18 WU-p = 0.00003. A MnDc value < 700 cm.s2 showed sensitivity = 89%, specificity = 80%, and predictive value = 89% for SVR > 18 WU (Kappa index = 0.693). CONCLUSION: Mean deacceleration of aortic continuous wave flow is reliable for semiquantitative evaluation of systemic vascular resistance and can be particularly useful for patients with advanced heart failure submitted to tailored therapy.

[The influence of therapy (sympathomimetic amines versus vasodilators) in the indexes of ejection fraction derived from an analysis of Doppler aortic flow]. / Influência da terapêutica (aminas simpaticomiméticas versus vasodilatadores) nos indices de fase de ejecção derivados da análise do fluxo Döppler aórtico.

PURPOSE: To assess the influence of inotropic IV therapy--dobutamine and/or dopamine--versus vasodilator therapy--nitroprusside, captopril or hydralazine--in aortic flow ejection phase indexes obtained by pulsed Doppler echocardiography. METHODS: In 17 patients admitted to the ICU (11 males, 62 +/- 14 years, 9 with ischemic cardiomyopathy and 8 with dilated cardiomyopathy, all in sinus rhythm), with congestive heart failure, and submitted to tailored therapy, 53 serial pulsed Doppler and hemodynamic evaluations were made as the therapy changed the hemodynamic and clinical status. Considering serial consecutive evaluations, a hemodynamic improvement was obtained only with inotropics in 13 (group A), and with vasodilators in only 15 (group B). The following ejection phase indexes were calculated from Doppler registers: average acceleration (AvAc) and ejection force (EFor), calculated according to the formula: Efor = 1.06 x Aortic Orifice Area x AvAc x Acceleration Velocity Time Integral. RESULTS: Arterial blood pressure increased in gr A (76.2 +/- 14.1 to 81.4 +/- 14.8 mm Hg, p < 0.05) and decreased in gr B (85.1 +/- 12.6 to 76.2 +/- 9.7 mm Hg (p < 0.05). In both groups there was a significant (p < 0.05) increase in cardiac output (CO)-from 3.9 +/- 1.1 to 4.9 +/- 1.4 L/min in group A, and from 3.9 +/- 1.2 to 4.4 +/- 1.2 L/min in group B. CO increased 18.7% in group A and 13.8% in group B (NS). There was a decrease in pulmonary capillary wedge pressure (PCWP) from 19.5 +/- 6.0 to 15.1 +/- 5.8 mm Hg in group A (p < 0.05), and from (16.9 +/- 5.7 to 12.1 +/- 4.6 mm Hg in group B (p < 0.05). PCWP decreased 19.7% in group A and 27.8% in group B (NS). Systemic vascular resistance (SVR) changed from 18.2 +/- 7.0 to 16.2 +/- 7.1 Wood U in group A (p < 0.05), and from 22.3 +/- 9.3 to 17.7 +/- 5.7 Wood U in group B (p < 0.05). In group A, AvAc increased-from 1347 +/- 611 cm.s-2 (p < 0.05), as did Efor-from 15.4 +/- 10.7 to 20.2 +/- 11.0 g.cm,s-2 (p < 0.05), whereas in group B there was no significant change in either AvAc-from 1337 +/- 284 to 1277 +/- 256 cm.s-2, or Efor-from 22.7 +/- 17.0 to 23.8 +/- 15.0 g.cm.s-2. CONCLUSIONS: Vasodilator therapy, although inducing hemodynamic changes similar to inotropics, does not alter the ejection phase indexes. Therefore, AvAc and Efor, in spite of being calculated from the aortic flow, are independent of the changes in PCWP and SVR and seem to reflect changes in inotropism in the clinical setting.