Relation of arterial properties to left ventricular hypertrophy in hypertensive adults: focus on gender-related differences.

BACKGROUND: Although gender-related differences in ventricular remodeling and arterial stiffness have been described, the impact of gender on the association between vascular compliance and left ventricular hypertrophy (LVH) has not been investigated. The current study was designed to determine the gender-related differences in the association between echographically determined LVH measures and arterial stiffness in hypertensive men and women. METHODS: In the current study, 104 hypertensive participants (61 men and 43 women) were enrolled. Large artery elasticity index (LAEI) and small artery elasticity index (SAEI) were determined using pulse wave contour analysis (HDI CR 2000, Eagan, Minnesota). Left ventricular hypertrophy parameters including intraventricular septum thickness (IVST), posterior wall thickness (PWT), and left ventricular mass index (LVMI) were assessed echographically. RESULTS: Hypertensive male versus female were similar in terms of age, body mass index (BMI), blood pressure, concomitant medications, and cardiovascular risk factors. Left ventricular mass index was significantly, inversely associated with IVST (r = -.32, P = .01), PWT (r = -.32, P = .01), and LVMI (r = -.28, P = .03) in men and significantly, inversely associated with IVST (r = -39, P = .01), PWT (r = -.42, P = .005), LVMI (r = -.54, P < .0001) in women. Small artery elasticity index was significantly, inversely associated with LVMI (r = -0.36, P = .02) in women only. In regression analysis, LAEI explained more variability than SAEI and was an independent predictor of LVH parameters in hypertensive men and women. CONCLUSIONS: Compliance of large arteries is potentially an independent predictor of LVH in hypertensive men and women. Therefore, arterial compliance is being considered an important tool in predicting LVH in hypertensive participants.

Long-term thyrotropin-suppressive therapy with levothyroxine impairs small and large artery elasticity and increases left ventricular mass in patients with thyroid carcinoma.

BACKGROUND: Exogenous subclinical hyperthyroidism, caused by long-term thyrotropin (TSH)-suppressive treatment with levothyroxine (LT(4)), is associated with several cardiovascular abnormalities. In order to assess the effect of long-term thyroid hormone-suppressive therapy on the blood vessels and myocardium, we determined the arterial elasticity, using the pulse wave contour analysis. METHODS AND RESULTS: Twenty-six athyreotic patients receiving TSH-suppressive LT(4) therapy for periods ranging from 3 to 21 years at a mean daily dose of 2.25 +/- 0.5 microg/kg per day were included in the study. Twenty six age- and gender-matched healthy subjects served as controls. Arterial elasticity of large and small arteries was evaluated using pulse wave contour analysis method (HDI CR 200, Eagen, MN). Cardiac structure was assessed by two-dimensional echocardiography. We found decreased large artery elasticity in subclinical hyperthyroidism (sHT) patients compared to controls (14.14 +/- 3.38 versus 10.53 +/- 2.43 L/mm Hg x 100, p < 0.000). Small artery elasticity was also lower in patients than in controls (5.42 +/- 1.82 versus 4.30 +/- 1.75 mL/mm Hg x 100, p < 0.056). The echocardiographic data showed significantly increased left ventricular (LV) mass index (101.90 +/- 18.61 versus 88.03 +/- 22.01 g/m(2), p < 0.049) and interventricular septum thickness (10.61 +/- 1.46 versus 9.11 +/- 1.13 mm, p < 0.002) in LT(4)-treated patients compared to controls. CONCLUSIONS: We found impaired vascular elasticity of large and small arteries and increased LV mass in patients receiving long-term TSH-suppressive therapy with LT(4).

Caseous calcification of the mitral annulus: a neglected, unrecognized diagnosis.

BACKGROUND: Mitral annular calcification is a common echocardiographic finding. Caseous calcification is a rare variant seen as a large mass with echolucencies that resembles a tumor, occasionally resulting in exploratory cardiotomy. The aim of this study was to assess the prevalence of caseous calcification of the mitral annulus, to evaluate patient characteristics and the echocardiographic variables for diagnosing this entity, and to describe the clinical outcome on follow-up of such patients. METHODS: Caseous calcification was defined as a large, round, echo-dense mass with smooth borders situated in the periannular region, with no acoustic shadowing artifacts and containing central areas of echolucencies resembling liquefaction. Eighteen patients were diagnosed by 2-dimensional echocardiography as having caseous calcification of the mitral annulus. One had calcification of the tricuspid annulus. Nine patients underwent transesophageal echocardiographic studies. RESULTS: A typical finding of a round, sometimes semilunar, large, echo-dense, soft mass with central echolucencies seen on both transthoracic and in particular transesophageal echocardiography, resembling a periannular mass, was demonstrated. The mass was posteriorly located in all mitral patients. Transesophageal echocardiography added limited information. Three patients underwent mitral valve replacement. The operative findings were a solid mass adherent to the posterior portion of the mitral valve. Sectioning revealed a toothpaste-like, white, caseous material. Sixteen (84%) patients were treated conservatively. On follow-up of 3.8 +/- 2.4 years, 4 patients died of unrelated causes. CONCLUSION: The characteristic appearance of a large, soft, echo-dense mass containing central areas of echolucencies resembling liquefaction at the posterior periannular region of the mitral valve on 2D echocardiography is compatible with the diagnosis of caseous abscess. Such a finding should not be confused with a tumor. Transesophageal echocardiography does not appear to contribute to the diagnosis. This rather impressive lesion appears to carry a benign prognosis.

Acute myocardial infarction caused by coronary embolism complicated by left ventricular free wall rupture.

Acute myocardial infarction with normal coronary arteries is a relatively infrequent finding. This report describes a rare combination of an embolic event to a normal coronary artery, presumably originating from a left atrial thrombus. An anomalous origin of the infarct-related coronary artery presumably enabled preferential penetration of the clot into the artery. The infarction was further complicated by rupture of the left ventricular free wall.

Unusual form of cardiac rupture: sealed subacute left ventricular free wall rupture, evolving to intramyocardial dissecting hematoma and to pseudoaneurysm formation--a case report and review of the literature.

This report describes an unusual course of rupture of the left ventricular free wall, complicating acute myocardial infarction. Spontaneous sealing of the rupture site enabled close echocardiographic follow-up, during which we monitored the development of intramyocardial dissecting hematoma and, finally, development of a full tear in the left ventricular free wall, leading to the formation of a pseudoaneurysm. The pathophysiology, management, and diagnostic criteria of these processes are being revised.

Sex differences in management and outcome after acute myocardial infarction in the 1990s: A prospective observational community-based study. Israeli Thrombolytic Survey Group.

BACKGROUND: Previous studies have suggested that women with acute myocardial infarction (AMI) are less aggressively managed than are men. The aim of this study was to assess sex differences in medical and invasive coronary procedures (angiography, PTCA, and CABG) in AMI patients admitted to cardiac care units (CCUs) in Israel in the mid 1990s and their association with early and 1-year prognosis. METHODS AND RESULTS: We studied 2867 consecutive AMI patients (2125 men, 74%) hospitalized in all 25 CCUs in Israel from 3 prospective nationwide surveys conducted in 1992, 1994, and 1996. Women were, on average, older than men (69 versus 61 years, P:<0.0001) and had a higher prevalence of hypertension, diabetes, Killip class >/=II on admission, and in-hospital complications. Women received aspirin and beta-blockers less often than did men, but these differences were not significant after age adjustment. The unadjusted rates of thrombolysis, angiography, and PTCA/CABG use were lower in women than in men but not after covariate adjustment: 42% versus 48% (adjusted odds ratio [OR] 0.92, 95% CI 0.77 to 1.11), 23% versus 31% (OR 0.88, 95% CI 0.70 to 1.09), and 15% versus 19% (OR 0.93, 95% CI 0.72 to 1.19), respectively. The 30-day mortality was higher in women than in men (17.6% versus 9.6%, respectively; OR 1.39, 95% CI 1.06 to 1.82), but the 30-day to 1-year mortality rate was not (9.1% versus 5.6%, respectively; hazard ratio 1.18, 95% CI 0.84 to 1.66). CONCLUSIONS: This prospective nationwide observational community-based study of consecutive AMI patients hospitalized in the CCUs in the mid 1990s indicates that women fare significantly worse than do men at 30 days but not thereafter at 1-year. The difference in 30-day outcome was not influenced by the use of different therapeutic modalities, including thrombolysis and invasive coronary procedures, but was rather due to the older age and greater comorbidity of women; these findings seem also to explain the less frequent use of invasive procedures in women.

Mortality trends in men and women with acute myocardial infarction in coronary care units in Israel. A comparison between 1981-1983 and 1992-1994. For the SPRINT and the Israeli Thrombolytic Survey Groups.

AIMS: To assess trends in the management and subsequent outcome in men and women in two cohorts of consecutive patients with acute myocardial infarction hospitalized in coronary care units in Israel, in the pre-reperfusion and the reperfusion eras. METHODS AND RESULTS: We compared trends in the in-hospital management, and 30-day and 1-year mortality in men and women in two cohorts of patients hospitalized with acute myocardial infarction in coronary care units in Israel, in the pre-reperfusion and the reperfusion eras. The first cohort of 5839 consecutive patients (4315 men, 74%) was from the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) registry of 1981-1983; the second cohort of 1940 patients (1429 males, 74%) derived from two prospective nationwide surveys conducted in all coronary care units in Israel in January/February 1992 and 1994. The demographic and clinical characteristics of patients with acute myocardial infarction in both periods were comparable. Patients in 1992-94 received aspirin, angiotensin-converting enzyme inhibitors, beta-blockers and nitrates more frequently than in 1981-83. Thrombolysis, coronary angiography, angioplasty and bypass grafting were not used in 1981-83, whereas in 1992-94 these procedures were used in 45%, 28%, 11% and 4% of men, respectively, and in 39%, 20%, 9% and 3% of women, respectively. The 30-day age-adjusted mortality declined, in men, from 17.0% in 1981-83 to 10.8% in 1992-94 (multivariate-adjusted odds ratio [OR]=0. 69; 95% confidence interval [CI] 0.55 to 0.87), and the cumulative 1-year age-adjusted mortality declined from 24.6% to 16.9% (adjusted hazard ratio [HR]=0.70%; 95% CI 0.60 to 0.81). In women, the decline in mortality rates were of similar magnitude, from 24.0% to 15.1% (OR=0.70; 95% CI 0.52 to 0.94), and from 33.6% to 21.0% (HR=0.67; 95% CI 0.55 to 0.81), respectively. In both sexes, the decline in mortality was more marked in patients reperfused by thrombolysis and/or mechanical revascularization, but was also evident in non-reperfused patients. CONCLUSIONS: Despite higher mortality in both periods in women compared to men, the prognosis of men and women with acute myocardial infarction improved considerably during the last decade, with a similar decline in 1-year mortality of approximately 30%. The implementation in daily practice of new therapeutic modalities proven to be effective in clinical trials after acute myocardial infarction, probably played a major role in this favourable outcome in both sexes.

Ventricular aneurysm repair: a new approach.

Repair of chronic left ventricular aneurysm or acute rupture of the heart after myocardial infarction is associated with technical difficulties and major morbidity and mortality. We describe a new endoventricular repair for both conditions. The repair consists of externally covering a Duran ring with Dacron and internally lining it with autologous pericardium. The modified ring is then sewn into the neck of the lesion. The technique is rapid, simple, and hemostatic. After repair of the chronic aneurysm, ventricular hemodynamics are improved during both diastole and systole. We have performed this technique in two patients with chronic aneurysm and one with subacute rupture.

Complete atrioventricular block complicating acute myocardial infarction in the thrombolytic era. SPRINT Study Group and the Israeli Thrombolytic Survey Group. Secondary Prevention Reinfarction Israeli Nifedipine Trial.

OBJECTIVES: We assessed the incidence, associated clinical parameters and prognostic significance of complete atrioventricular block (CAVB) complicating acute myocardial infarction (AMI) in the thrombolytic era and compared them to data from the prethrombolytic era. BACKGROUND: The introduction of new therapeutic modalities to treat AMI, aimed to enhance coronary reperfusion and to limit myocardial necrosis, was expected to decrease the incidence of CAVB and to improve prognosis. However, there are only limited data regarding the incidence and the prognosis of AMI patients with CAVB in the thrombolytic era. METHODS: Data from 3,300 patients from the Israeli Thrombolytic Surveys (prospective, nationwide surveys of consecutive patients with AMI in all 25 coronary-care units in Israel in 1992 and 1996) were analyzed and compared with data from 5,788 patients included in the SPRINT (Secondary Prevention Reinfarction Israeli Nifedipine Trial) Registry (1981 to 1983). RESULTS: During the 1990s, the incidence of CAVB was 3.7% compared with 5.3% in the 1980s, p = 0.0007. In the 1990s, mortality of patients with CAVB was significantly higher than in those without CAVB at 7 days (odds ratio [OR] = 4.05 95% CI [confidence interval] 2.34 to 6.82, 30 days OR = 3.98 [95% CI 2.44 to 6.43] and one-year hazard ratio [HR] = 2.36, [95% CI 1.68 to 3.30]) and similar in thrombolysis-treated and not-treated patients. Mortality of patients with CAVB has not changed significantly between the two periods; seven-day OR = 0.82 (95% CI 0.46 to 1.43); 30-day OR = 0.78 (95% CI 0.45 to 1.33) and one-year HR = 0.79 (95% CI 0.54 to 1.56), respectively, in the 1990s as compared to a decade earlier. CONCLUSIONS: The incidence of CAVB complicating AMI is lower in the thrombolytic era than in the prethrombolytic era. Mortality among patients with CAVB is still high and has not declined within the last decade. The AMI patients who develop CAVB in the thrombolytic era have significantly worse prognosis than do patients without CAVB.

Long-term (three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction. Israeli Thrombolytic Survey Group.

OBJECTIVES: This survey sought to assess the frequency of the use of thrombolytic therapy, invasive coronary procedures (ICP) (angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting [CABG]), variables associated with their use, and their impact on early (30-day) and long-term (3-year) mortality after acute myocardial infarction (AMI). BACKGROUND: Few data are available regarding the implementation in daily practice of the results of clinical trials of treatments for AMI and their impact on early and long-term prognosis in unselected patients after AMI. METHODS: A prospective community-based national survey was conducted during January-February 1994 in all 25 coronary care units operating in Israel. RESULTS: Among 999 consecutive patients with an AMI (72% men; mean age 63+/-12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardial infarction (MI) and prior angioplasty or CABG were independently associated with its lower use. The three-year mortality of patients treated with ART was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mainly as the result of 30-day to 3-year outcome (12.4% vs. 21.1%; hazard ratio = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predictors of long-term mortality were: age, heart failure on admission or during the hospitalization, ventricular tachycardia or fibrillation and diabetes. The outcome of patients not treated with ART differed according to the reason for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, angioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patients, respectively. Their use was independently associated with recurrent infarction or ischemia, on-site catheterization or CABG facilities, non-Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non-Q-wave AMI, performance of ICP was associated with lower 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0.21, 0.03 to 0.84, respectively), but not thereafter. CONCLUSIONS: This survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis in an unselected population after AMI.

Effects of aspirin treatment on survival in non-insulin-dependent diabetic patients with coronary artery disease. Israeli Bezafibrate Infarction Prevention Study Group.

PURPOSE: The benefit of aspirin treatment among diabetic patients with chronic coronary artery disease is not well established. The purpose of this study was to assess the effect of aspirin on cardiac and total mortality in a large cohort of diabetic patients with established coronary artery disease and to compare it with the effect of aspirin in nondiabetic counterparts. PATIENTS AND METHODS: In this observational study among patients screened for participation in the Bezafibrate Infarction Prevention Study, the effects of aspirin treatment in 2,368 non-insulin-dependent diabetic patients with coronary artery disease were compared to those in 8,586 nondiabetic patients. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated with proportional hazards models. RESULTS: Fifty-two percent of diabetic patients and 56% of nondiabetic patients reported aspirin therapy. After 5.1 +/- 1.3 (mean +/- SD) years of follow-up, the absolute benefit per 100 patients treated with aspirin was greater in diabetic patients than in nondiabetic patients (cardiac mortality benefit: 5.0 versus 2.1, and all-cause mortality benefit: 7.8 versus 4.1). Overall cardiac mortality among diabetic patients treated with aspirin was 10.9% versus 15.9% in the nonaspirin group (P < 0.001), and all-cause mortality was 18.4% and 26.2% (P < 0.001). After adjustment for possible confounders, treatment with aspirin was an independent predictor of reduced overall cardiac (HR = 0.8; 95% CI: 0.6-1.0) and all-cause mortality (HR = 0.8; 95% CI: 0.7-0.9) among diabetic patients, similar to those in nondiabetic patients. CONCLUSION: Treatment with aspirin was associated with a significant reduction in cardiac and total mortality among non-insulin-dependent diabetic patients with coronary artery disease. The absolute benefit of aspirin was greater in diabetic patients than in those without diabetes.

Unilateral pulmonary edema during transesophageal echocardiography.

Transesophageal echocardiography is considered to be a relatively safe procedure, the complications of which are well known and include probe-related and procedure-related complications. Congestive heart failure rarely occurs. Unilateral pulmonary edema is relatively uncommon and to the best of our knowledge has never been reported in association with transesophageal echocardiography. Herein we describe an unusual case of unilateral pulmonary edema that developed during the course of transesophageal echocardiography.

Hemodynamic performance of four mechanical bileaflet prosthetic valves in the mitral position: an echocardiographic study.

OBJECTIVES: The CarboMedics, Duromedics, Sorin Bicarbon and the St. Jude Medical valves are bileaflet mechanical prostheses of modern but different design. Choosing a valve with the best hemodynamic profile is of clinical importance in patients with small ventricles and a small mitral annulus. METHODS: The hemodynamic performance of these valves in the mitral position was compared in 76 asymptomatic, ambulatory patients with normally functioning prosthesis and left ventricle, using Doppler echocardiography. Of the 76 patients studied, 22 had the CarboMedics, 16 had the Duromedics, 17 had the Sorin Bicarbon and 21 had the St. Jude prosthesis. The patients ages ranged from 18 to 81 years. There were 44 women and 32 men. The time from implantation to echocardiographic study ranged from 1 to 55 months. RESULTS: The echocardiographic study was performed earlier after surgery in the Sorin Bicarbon group. There was no significant difference in women/man ratio, incidence of atrial fibrillation, left ventricular or left atrial diameters between the four groups. The mean prosthesis size was significantly smaller for Sorin Bicarbon and Duromedics valves compared to the CarboMedics and the St. Jude valves (mean+/-SD, 27.2+/-1.3, 27.1+/-1.1 and 30.0+/-1.9 and 30.0+/-2.7 mm, respectively, P<0.001). Despite its smaller size the Sorin Bicarbon valve had significantly larger effective valve area by Doppler compared to the CarboMedics valve (290+/-40 vs 250+/-60 mm2, respectively, P=0.014). The ratio of effective valve area to prosthesis size was significantly larger for the Sorin Bicarbon valve when compared with any other type of prosthesis. CONCLUSIONS: (1) The Sorin Bicarbon bileaflet valve offered the best hemodynamic results that may be explained by the valve's large leaflet opening angle and small thickness of the leaflets. (2) Since the Sorin Bicarbon is the newest bileaflet valve, durability of this valve remains uncertain.

Ethnic differences in mortality of male and female patients surviving acute myocardial infarction: long-term follow-up of 5,700 patients. The Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group.

In migrant countries, ethnic origin may represent a complex of cultural, behavioral and possibly genetic differences. These have been shown to influence acute myocardial infarction (AMI) incidence. How ethnic origin may affect survival after AMI is unknown. Data from 5,692 patients included in the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) registry were analyzed. Patients were divided into eight different ethnic groups, according to birthplaces from five continents, representing major socio-economic and possibly some genetic variation. Mortality was analyzed after adjustment for baseline characteristics known to predict death from coronary artery disease (CAD) using Jews born in Israel as a reference. The odds ratio for in-hospital mortality was higher in women than in men, but unrelated to ethnic origin. The odds ratio for men ranged between 1.08 (95% confidence interval (CI): 0.67-1.73) for Jews born in Eastern Europe and 1.84 (95% CI: 1.07-3.15) for counterparts born in the Middle East. The odds ratio for women ranged between 0.73 in Jews born in Central Europe (95% CI: 0.35-1.50) and 1.45 (95% CI: 0.76-3.15) for Jewish women born in the Balkan countries. Among 4,686 patients surviving the hospital phase, long-term mortality rates (mean follow-up 7.1 +/- 3.5 years) were 43.3% in men and 57.6% in women. Among 3,586 surviving men, the adjusted risk ratios for 10-year mortality varied between 0.92 (95% CI: 0.72-1.18) for men born in Romania and 1.49 (95% CI: 1.07-2.09) for Israeli born Arabs. The variation among men is within the limits of statistical error. However, among 1,100 surviving women, the risk ratio for 10-year mortality differed significantly, from as low as 1.43 (95% CI: 0.84-2.41) in Jewish women born in Central Europe to as high as 2.83 (95% CI: 1.67-4.79) in counterparts born in the Middle East. The latter observations were consistent with the mortality after 3 years. Thus, ethnic origin of Israelis marginally influenced the in-hospital mortality. The long-term prognosis varied significantly among women from different origins but not among men.

Effect of aspirin on mortality in women with symptomatic or silent myocardial ischemia. Israeli BIP Study Group.

The benefit of aspirin therapy among women with coronary artery disease (CAD) is not well established. Previous studies have shown conflicting results among women. Data from 2,418 women with CAD screened for participation in the ongoing Bezafibrate Infarction Prevention (BIP) study were analyzed: 45% reported aspirin therapy. Baseline characteristics were similar in both groups. Cardiovascular mortality at 3.1 +/- 0.9 years of follow-up was 2.7% in the aspirin treated group versus 5.1% in the non-aspirin-treated women (p = 0.002). All cause mortality was 5.1% and 9.1%, respectively (p = 0.0001). Treatment with aspirin emerged as an independent predictor of reduced cardiovascular (RR = 0.61, 95% confidence interval [CI] 0.38 to 0.97) and all cause (RR = 0.66, 95% CI 0.47 to 0.93) mortality after multiple adjustment for possible confounders such as age, history of myocardial infarction, systemic hypertension, diabetes mellitus, peripheral vascular disease, current smoking, New York Heart Association classification, and concomitant treatment with digitalis. Women who benefited the most from aspirin therapy were older, diabetic, symptomatic, or had a previous myocardial infarction. Thus, treatment with aspirin was associated with reduced mortality among women with CAD. This study suggests that women with CAD should be treated with aspirin, unless specific contraindications exist.

Isolated splenic infarction following left cardiac catheterization: case report and a review of the literature.

A cardiac catheterization was performed in a 57-year-old man for post-infarction angina. A severe left flank pain developed following the angiography. Ultrasonography, computed tomography, and radionuclear scanning of the abdomen showed splenic infarction. An isolated cholesterol atheroembolism of spleen from disrupted atheromatous plaques so far has not been reported.

Effects of high gravity on cardiac dimensions in trained air crew.

We conclude that there is no difference in LV wall thickness, dimensions, or functional parameters between air crew members who fly high + Gz aircraft and those who fly other types of aircraft. No differences were detected between high +Gz air crew personnel and others in development of structural and functional changes over the short-term course of a flying career.

Ultrasound accelerates urokinase-induced thrombolysis and reperfusion.

We have shown that ultrasound accelerates TPA-induced thrombolysis in vitro as assessed by release of labeled fibrinogen from radioactive labeled clots. Others have shown that ultrasound shortens the time to recanalization of TPA treated thrombi in animal models. The aim of this study was to test the hypothesis that ultrasound enhances thrombolysis and reperfusion by using urokinase in an in vitro flow system. An in vitro flow system of a branching tubing circuit was developed. Flow in one branch was obstructed by a thrombus. Five control clots were exposed to continuous wave ultrasound at a frequency of 1 MHz and intensity of 2.5 W/cm2 only without any thrombolytic agent (group 1). Twenty clots were exposed to a bolus of 80,000 U of urokinase and randomized to either ultrasound exposure (group 2) or to urokinase only without ultrasound (group 3). Flow distal to the clot and the rate of release of radiolabeled fibrin were used as indexes of reperfusion and thrombolysis, respectively. Exposure to ultrasound significantly accelerated urokinase-mediated reperfusion, with 40.6% +/- 11.8% of maximal flow in group 2 versus 1.3% +/- 0.7% in group 3, p < 0.0015 after 25 min. The maximal difference in flow between groups 2 and 3 was achieved at 40 minutes (67.4% +/- 11.1% vs 13.1% +/- 5.6%, p < 0.0009). Thrombolysis was significantly higher after 25 minutes of ultrasound exposure (24.1% +/- 4.6% in the ultrasound-treated group vs 9.7% +/- 3.5% in group 3, p < 0.013). The maximal difference in thrombolysis between groups 2 and 3 was 60 minutes. (52.5% +/- 5.1% vs 18.7% +/- 6.2%, p < 0.00015).(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal echocardiographic recognition of an unusual complication of aortic valve endocarditis.

Aortic valve endocarditis can cause complications due to involvement of the subaortic structures. These complications include satellite vegetations on the aortic regurgitant jet lesion sites, involvement of the anterior or posterior mitral valve leaflets in the form of aneurysms, perforation, and involvement of the mitral-aortic intervalvular fibrosa, namely abscess, aneurysm, and perforation into the left atrium or the pericardial sac. These complications can be identified accurately by echocardiography. We report an unusual case which demonstrates (1) coexistence of both mitral-aortic intervalvular fibrosa and mitral valve aneurysms, and (2) echocardiographic follow-up of a mitral valve aneurysm to perforation. These complications were recognized by transesophageal echocardiography and verified at surgery.