Real-time three-dimensional dobutamine stress echocardiography in assessment stress echocardiography in assessment of ischemia: comparison with two-dimensional dobutamine stress echocardiography.

OBJECTIVES: This study was designed to test the feasibility and efficacy of using real-time three-dimensional echocardiography (RT-3D) to detect ischemia during dobutamine-induced stress (DSE) and compares the results with conventional two-dimensional echocardiography (2D). BACKGROUND: Real-time three-dimensional echocardiography, a novel imaging technique, offers rapid acquisition with multiple simultaneous views of the left ventricle (LV). These features make it attractive for application during stress. METHODS: Of 279 consecutive patients screened for image quality by 2D, 253 patients with adequate images underwent RT-3D and 2D within 30 s of each other at baseline and at peak DSE. RESULTS: Real-time three-dimensional echocardiography and 2D showed good concordance in detection of abnormal LV wall motion at baseline (84%: Kappa = 0.59) and at peak DSE (88.9%: Kappa = 0.72). Left ventricular wall motion scores were similar at baseline and peak DSE using both techniques. Interobserver agreements for detection of ischemia at peak DSE were superior for RT-3D, 92.7% compared with 84.6% for 2D (p < 0.05). Mean scanning time at peak stress by RT-3D in 50 randomly selected patients was shorter, 27.4 +/- 10.7 s compared with 62.4 +/- 20.1 s by 2D (p < 0.0001). In 90 patients with coronary angiograms, RT-3D had a sensitivity of 87.9% in the detection of coronary artery disease (CAD) compared with 79.3% by 2D. CONCLUSIONS: Real-time three-dimensional dobutamine stress echocardiography is feasible and sensitive in the detection of CAD. The procedure offers shorter scanning time, superior interobserver agreements and unique new views of the LV.

Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes.

OBJECTIVES: We prospectively evaluated the relation between cardiac troponin T (cTnT) level, the presence and severity of coronary artery disease (CAD) and long-term prognosis in patients with chest pain but no ischemic electrocardiographic (ECG) changes who had short-term observation. BACKGROUND: Cardiac TnT is a powerful predictor of future myocardial infarction (MI) and death in patients with ECG evidence of an acute coronary syndrome. However, for patients with chest pain with normal ECGs, it has not been determined whether cTnT elevation is predictive of CAD and a poor long-term prognosis. METHODS: In 414 consecutive patients with no ischemic ECG changes who were triaged to a chest pain unit, cTnT and creatine kinase, MB fraction (CK-MB) were evaluated > or = 10 h after symptom onset. Patients with adverse cardiac events, including death, MI, unstable angina and heart failure were followed for as long as one year. RESULTS: A positive (>0.1 ng/ml) cTnT test was detected in 37 patients (8.9%). Coronary artery disease was found in 90% of 30 cTnT-positive patients versus 23% of 144 cTnT-negative patients who underwent angiography (p < 0.001), with multivessel disease in 63% versus 13% (p < 0.001). The cTnT-positive patients had a significantly (p < 0.05) higher percent diameter stenosis and a greater frequency of calcified, complex and occlusive lesions. Follow-up was available in 405 patients (98%). By one year, 59 patients (14.6%) had adverse cardiac events. The cumulative adverse event rate was 32.4% in cTnT-positive patients versus 12.8% in cTnT-negative patients (p = 0.001). After adjustment for baseline clinical characteristics, positive cTnT was a stronger predictor of events (chi-square = 23.56, p = 0.0003) than positive CK-MB (>5 ng/ml) (chi-square = 21.08, p = 0.0008). In a model including both biochemical markers, CK-MB added no predictive information as compared with cTnT alone (chi-square = 23.57, p = 0.0006). CONCLUSIONS: In a group of patients with chest pain anticipated to have a low prevalence of CAD and a good prognosis, cTnT identifies a subgroup with a high prevalence of extensive and complex CAD and increased risk for long-term adverse outcomes.

High-output heart failure resulting from a remote traumatic aorto-caval fistula: diagnosis by echocardiography.

Congestive heart failure (CHF) due to high output states is known to occur in a variety of systemic illnesses and in patients with arterial-venous fistulas. This paper reports the case of a 45-year-old man admitted to the emergency room with a diagnosis of new onset atrial fibrillation and CHF, whose past medical history was not significant except for a gunshot wound to his abdomen 22 years previously. The etiology of his CHF together with the cardiomegaly and hyperdynamic left ventricular systolic function was unknown. A subcostal view routinely done during transthoracic echocardiography revealed a severely dilated inferior vena cava and the presence of an aorto-caval fistula by color doppler. The patient underwent successful corrective repair with dramatic improvement in symptoms and resolution of the atrial fibrillation, and cardiac size returned to normal. This rare case emphasizes that patients with refractory CHF must be closely examined with particular attention to palpation and auscultation over all scars, irrespective of the duration since any traumatic or surgical event.

Results of surgical treatment for infective endocarditis in intravenous drug users.

OBJECTIVE: To determine the early and late results of surgical treatment for infective endocarditis (IE) in intravenous drug users (IVDU). DESIGN: Cohort study of consecutive IVDUs undergoing surgical treatment for IE. SETTING: Large public hospital serving the urban population of Chicago, Ill. PATIENTS: Consecutive IVDUs operated on between July 1982 and June 1991 for IE. MAIN OUTCOME MEASURES: Death, stroke, noncerebral systemic embolization, major bleeding, recurrent endocarditis, and repeated valve replacement. RESULTS: There were 80 patients, 58 men and 22 women, with a mean age of 37.5 +/- 10 (SD) years. The hospital course in all patients and follow-up data on 75 (94%) patients were complete. The primary indication for surgery was acute congestive heart failure in 44 (56%), persistent sepsis in 21 (26%), and multiple systemic embolization in 15 (19%) patients. Six patients (7.5%) died within 30 days of surgery. An additional 13 of 69 patients (17.6%) died during the follow-up, 8 from cardiovascular causes. The probability of survival at 36 months and at 60 months was 0.74 +/- 0.05 (SE) and 0.70 +/- 0.05, respectively. Seventeen (30%) of the survivors had at least one major cardiovascular event; 6 (8.8%) had recurrent endocarditis, 4 (5.8%) had stroke, 3 (4.4%) had extracerebral bleeding, 1 had extracerebral systemic embolism, and 3 (4.4%) required repeated valve replacement. Probability of event-free survival at 36 months and 60 months was 0.65 +/- 0.06 and 0.52 +/- 0.08, respectively. The median duration of event-free survival was 65 months. CONCLUSION: Since the expected mortality without surgery in patients with IE in whom medical treatment fails is almost 100%, it is concluded that surgical treatment is indicated for, and substantially improves the outlook for early and late survival of, IVDUs with IE who fail to respond to medical management.