Usefulness of pulmonary regurgitation Doppler tracings in predicting in-hospital and long-term outcome in patients with inferior wall acute myocardial infarction.

Right ventricular (RV) involvement is frequent during inferior wall acute myocardial infarction (AMI) and has been reported as a risk factor for in-hospital morbidity and mortality. The objectives of the present study were: (1) to evaluate in-hospital events in patients with and without RV involvement as diagnosed by abnormal flow characteristics derived from pulmonary regurgitation (PR) analysis (pressure half-time of PR, PHT(PR) < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio, Vmin/Vmax < or = 0.5); and (2) to determine the influence of RV involvement in complications at long-term follow-up. Among 126 consecutively admitted patients with inferior wall AMI (mean age, 58 +/- 13 years), 101 had PR. We determined the prognostic significance of in-hospital and long-term events for the following variables: age > or = 65 years, ST-segment elevation > or = 1 mm in lead V4R, RV dilation, PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5, thrombolytic therapy, 3-vessel disease, and diabetes mellitus. We found that the PR derived Doppler index (PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5) was the only predictor of overall in-hospital clinical events (hazards ratio, 2.7, 95% confidence interval, 1.2 to 6.1, p = 0.016). At long-term follow-up (mean: 20 +/- 12 months, range 12 to 69), event-free survival analysis showed that age > or = 65 years was the only predictor of any event (relative risk, 3.7, 95% confidence interval, 2.1 to 6.3, p < 0.0001). Thus, RV involvement diagnosed with the use of PR flow-derived variables is an accurate and independent predictor of in-hospital complications. However, RV involvement does not influence long-term prognosis.

[Quantification of longitudinal myocardial velocities by Doppler tissue imaging during dobutamine echocardiography]. / Quantification des variations de vélocités myocardiques longitudinales par doppler tissulaire au cours de l'échocardiographie sous dobutamine.

Doppler tissue imaging has been suggested to be a valuable method for the diagnosis of myocardial ischaemia during dobutamine echocardiography. The authors studied this mode of investigation in 49 consecutive patients (average age 60 +/- 12 years) referred for dobutamine stress echocardiography and who had undergone coronary angiography. The stress echo was carried out according to a standard protocol (5 to 40 m g/kg/min +/- atropine) with additional acquisition of 3 apical views (4, 2 and 3 chambers) with colour Doppler tissue imaging. Analysis of systolic and diastolic myocardial velocities was performed afterwards from digitised data. The different Doppler tissue parameters were measured in 12 left ventricular segments (excluding the apical segments) for each dosage of dobutamine: peak systolic velocity (S), Q-S duration, systolic velocity time integral (ITVS), peak early diastolic velocity (E), peak end diastolic velocity (A). These parameters were analysed throughout the stress for each segment without significant coronary stenosis to define normal values. ROC curves were constructed to determine threshold values of relative changes of velocity (between maximal dobutamine dosage and basal conditions) to improve detection of ischaemia in a segment with coronary stenosis (vessel diameter reduction > or = 70%). Similar diagnostic performances were observed with different systolic and diastolic parameters. The feasibility of measurement of diastolic velocities was, however, reduced (from 29% to 49%). The diagnostic accuracy of each parameter was the same for each vessel territory. A satisfactory concordance was observed between 2D echocardiography and Doppler tissue imaging for the detection of significant coronary stenosis in an analysis by vascular territory. The authors conclude that analysis of myocardial velocities during dobutamine stress echocardiography is feasible. It may be a useful complement for the detection of coronary stenosis during pharmacological stress echocardiography.

[Does Doppler analysis of hepatic venous flow predict increased right atrial pressure and right ventricular dysfunction?]. / L'analyse doppler du flux des veines sus-hépatiques permet-elle de prédire le niveau de pression auriculaire droite au cours de l'infarctus du ventricule droit?

The aim of this study was to test the hypothesis that Doppler study of hepatic venous flow, reflecting right atrial pressures and right ventricular dysfunction, allows prediction of increased right atrial pressure and right ventricular dysfunction in patients with right ventricular infarction. The authors studied 30 patients (27 men, mean age 54 +/- 12 years) in sinus rhythm with acute inferior myocardial infarction who underwent right heart catheterisation and Doppler echocardiography including recording of regurgitant and hepatic vein flow within 48 hours of hospital admission. Hepatic venous flow was used to measure peak velocity and velocity time integrals (VTI) of the systolic (S), diastolic (D) and atrial (a) contraction waves. The fraction of systolic filling was calculated: VTI S/VTI S + VTI D. The pressure half-time of pulmonary regurgitant flow (PHT IP) was also measured. Using haemodynamic criteria (non-compliant right atrial pressure wave form or right ventricular end diastolic pressure/pulmonary capillary pressure > or = 0.8), patients were divided into two groups: Group 1: right ventricular infarction (VD+, N = 22). Group 2: no right ventricular infarction (VD-, N = 8). No correlation was observed between Doppler parameters of hepatic venous flow and haemodynamic data, in particular right atrial pressure and pressure wave form. Moreover, no statistically significant difference was observed between the two groups with respect to the Doppler parameters derived from hepatic venous flow. On the other hand, the results confirmed good diagnostic performance of Doppler analysis of pulmonary regurgitant flow: sensitivity 80%, specificity 83%, positive predictive value 94%, negative predictive value 55%. The authors conclude that, in patients with acute inferior wall infarction, Doppler analysis of hepatic venous flow does not allow assessment of right atrial pressure or of ischaemic right ventricular dysfunction.

[Dobutamine stress echocardiography; a monocentric experience on 600 consecutive patients. Effect of age]. / Echocardiographie sous dobutamine; expérience monocentrique portant sur 600 patients consécutifs. Influence de l'âge.

The increasing indications of dobutamine stress echo in the investigation of myocardial ischaemia, viability and evaluation of the prognosis of coronary artery disease has made this technique a tool of everyday clinical practice. The authors reviewed the results of 600 investigations in consecutive unselected including patients aged over 75. No significant difference was observed with respect to the causes of interruption of the test between patients aged less than 75 (521 patients) and those older than 75 (79 patients). Attaining the target theoretical maximal heart rate was the commonest reason for stopping the test (47 and 48% respectively). Ventricular arrhythmias were not more common (12 and 10% respectively). Twelve cases of ventricular tachycardia were observed, 8 of which were non-sustained; 9 led to interruption of the test. No cases of ventricular fibrillation were observed. A previous history of cardiac arrhythmias was not associated with a higher frequency of arrhythmia during the test (8% in those with a previous history, 4% in those patients without). Supraventricular arrhythmias were significantly more common in patients over 75 years of age (15 versus 8%, p = 0.046). Dobutamine stress echocardiography' is feasible in a population of unselected patients, including those over 75. Therefore, age does not represent a limitation to the extension of this investigation.

Aortic root dilatation in patients with spontaneous cervical artery dissection.

BACKGROUND: Spontaneous cervical artery dissections are a relatively common cause of ischemic stroke in young adults. Their mechanism is unknown, though it is generally assumed that an underlying minor form of extracellular matrix defect could exist. The present study tested the hypothesis that aortic and cardiac morphological abnormalities usually seen in patients with heritable connective diseases are more frequent in patients with spontaneous cervical artery dissections than in patients without such dissections. METHODS AND RESULTS: We performed a case-control study of 28 case patients with spontaneous cervical artery dissection and 84 control subjects with an ischemic stroke not due to cervical artery dissection. Control subjects were matched to case patients for age (+/-5 years), sex, and year of hospitalization. The aortic root was more frequently enlarged (ie, diameter > 34 mm) in case patients (56%) than in control subjects (15%). Mitral valve prolapse, mitral valve dystrophy, and aortic valve dystrophy were more frequent in case patients than in control subjects. In multivariate analyses, aortic diameter > 34 mm was the only variable associated with an increased risk of spontaneous cervical artery dissection (odds ratio, 14.2; 95% CI, 3.2 to 63.6; P < .001). CONCLUSIONS: These results suggest that aortic root diameter enlargement is associated with an increased risk of spontaneous cervical artery dissection. This finding is consistent with the idea that a generalized defect of the extracellular matrix is present in patients with spontaneous cervical artery dissection.

Comparison of echocardiographic markers of embolism in atrial flutter and fibrillation: frequency of protruding atherosclerotic plaques in the thoracic aorta.

The potential additional embolic risk of protruding aortic plaques > or = 4 mm and left atrial abnormalities such as thrombus, spontaneous echocardiographic contrast (SEC), low left atrial appendage velocity, recently has been shown in patients with atrial fibrillation (AF). However, the presence and potential role of transesophageal echocardiographic (TEE)-detected protruding aortic plaques > or = 4 mm have not been systematically evaluated in patients with atrial flutter. Among 2493 patients evaluated by TEE, 271 consecutive patients with atrial flutter (n = 41) and AF (n = 230) > or = 2 days duration were included in the study. Clinical and echocardiographic characteristics in consecutive patients with atrial flutter were compared to those in patients with AF, especially atrial morphology and function and atherosclerotic disease of the thoracic aorta. Clinical characteristics of patients with atrial flutter and AF were similar with regard to age (68 +/- 13 and 67 +/- 12, P = 0.628), sex ratio (men, 66% and 54%, P = 0.212), and previous embolic events (5% and 15%, P = 0.126), respectively. The frequency of protruding atherosclerotic plaques > or = 4 mm (12% and 11%, P = 0.919) and SEC (15% and 14%, P = 0.847) in the thoracic aorta was similar in patients with atrial flutter and AF. Left atrial appendage area was smaller (3.1 +/- 0.7 and 6.0 +/- 3.0 cm(2), P = 0.001), left atrial appendage SEC was less frequent (17% and 37%, P = 0.024), and left atrial appendage emptying velocity was higher (47 +/- 10 and 30 +/- 10 cm/s, P = 0.030) in patients with atrial flutter as compared to those with AF. There was no difference between the two groups regarding left ventricular fractional shortening (30 +/- 10% and 33 +/- 13%, P = 0.630), rheumatic valvular disease (5% and 12%, P = 0. 301), left atrial diameter (43 +/- 7 and 45 +/- 8 mm, P = 0.134), right atrial area (16 +/- 4 and 17 +/- 6 cm(2), P = 0.384), left atrial SEC (39% and 53%, P = 0.124), or atrial thrombus ( 2% and 3%, P = 0.888) respectively. Our results point to the high prevalence of protruding atherosclerotic plaques in the thoracic aorta in patients with atrial flutter.