Diffuse Elevated Abdominal Activity on 99mTc-Labeled Red Blood Cell Imaging in a Pediatric Patient With Klippel Trenaunay Syndrome.

Klippel Trenaunay syndrome commonly manifests as lower limb hypertrophy where vascular malformation occurs. However, up to 20% of patients with Klippel Trenaunay syndrome can have gastrointestinal involvement. An 18-year-old man with known Klippel Trenaunay syndrome in the left lower extremity underwent Tc-labeled red blood cell imaging to determine the site of gastrointestinal bleeding. The images did not reveal the site of active bleeding. However, diffuse non-moving activity in the left abdomen and pelvis was noted, which corresponded to hypertrophied colon and related blood vessels, consistent with intestinal involvement of Klippel Trenaunay syndrome.

Dobutamine-stress echocardiography in asymptomatic patients with aortic regurgitation.

BACKGROUND: Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE: To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS: Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS: Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION: Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.

Ecocardiograma sob estresse com dobutamina em pacientes assintomáticos com regurgitação aórtica / Ecocardiografía bajo estrés con dobutamina en pacientes asintomáticos con regurgitación aórtica / Dobutamine-stress echocardiography in asymptomatic patients with aortic regurgitation

FUNDAMENTO: A reserva contrátil diminuída pode já estar presente em pacientes portadores de regurgitação aórtica, assintomáticos com fração de ejeção (FE) normal, indicando a necessidade de avaliações frequentes e acuradas da função ventricular esquerda para detectar disfunção sistólica incipiente. OBJETIVO: Analisar se incrementos na FE em doses baixas de dobutamina podem predizer cirugia e/ou morte em pacientes com regurgitação aórtica. MÉTODOS: Eco de estresse com dobutamina foi realizado em 24 pacientes portadores de regurgitação aórtica para verificar se incrementos da FE em doses baixas de dobutamina seriam capazes de predizer a necessidade de cirurgia e/ou morte nesse grupo de pacientes. RESULTADOS: A idade média foi de 37,8±16,8 anos, e 16 (66 por cento) eram homens. A FE aumentou de um valor basal médio de 62,3±7,9 por cento para 71,5±10,5 por cento, na dose de 20 µg/kg/min de dobutamina (p < 0,001). Os pacientes foram acompanhados por 36,6±20,1 meses: dois pacientes morreram (um de morte cardiovascular) e cinco foram submetidos à cirurgia cardíaca. A FE basal se correlacionou com cirurgia e morte no seguimento de pacientes. CONCLUSÃO: A FE basal se correlacionou com cirurgia ou morte no seguimento de pacientes jovens com regurgitação aórtica. Porém, o incremento percentual na FE com dose baixa de dobutamina não foi capaz de predizer eventos nesses pacientes.

BACKGROUND: Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE: To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHDOS: Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS: Mean age was 37.8±16.8 years and 16 patients (66 percent) were male. EF increased from a mean baseline value of 62.3±7.9 percent to 71.5±10.5 percent at a dobutamine dose of 20 µg/kg/min (p<0.001). The patients were followed-up for 36.6±20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION: Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.

FUNDAMENTO: La reserva contráctil disminuida puede ya estar presente en pacientes portadores de regurgitación aórtica, asintomáticos con fracción de eyección (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la función ventricular izquierda para detectar disfunción sistólica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugía y/o muerte en pacientes con regurgitación aórtica. MÉTODOS: Eco de estrés con dobutamina se realizó en 24 pacientes portadores de regurgitación aórtica para verificar se incrementos de la FE en dosis bajas de dobutamina serían capaces de predecir la necesidad de cirugía y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66 por ciento) eran varones. La FE aumentó de un valor basal promedio de 62,3±7,9 por ciento para 71,5±10,5 por ciento, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugía cardiaca. La FE basal se correlacionó con cirugía y muerte en el seguimiento de pacientes. CONCLUSIÓN: La fe basal se correlacionó con cirugía o muerte en el seguimiento de pacientes jóvenes con regurgitación aórtica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.

[Cost-effectiveness analysis of nuclear cardiology and its impact on total expense for diagnosis of coronary artery disease]. / Costo-efectividad de los estudios de gamagrafía miocárdica e impacto al gasto total por diagnóstico de cardiopatía isquémica.

BACKGROUND: Medical care in a hospital under a socialized medicine system should be highly effective at the lowest expense possible. When myocardial perfusion studies are performed in well-selected patients, the costs decrease because of the need for fewer invasive studies. When patients are not selected properly, there is an increase-wasted resource, making it necessary to perform cost-effective studies. The goal of this study is to evaluate the economical impact of the diagnostic process in patients suspected of having coronary artery disease, referred to our service (Nuclear Medicine, Hospital de Cardiología CMN, IMSS) in 2002. METHODS: We analyzed 1966 reports of myocardial gammagrams. Patient reports were stratified according to their referring unit. The sum of the unitary fixed cost was converted to the unitary cost for each reason for referral. Kappa was used to evaluate concordance. RESULTS: Patients were 62 +/- 11.39 years old, 52% male. Concordance between the referring diagnosis and the myocardial gammagram was <1% (p <0.001). The cost of cardiac gammagrams varied between $2,613.11 and $3,306.77 (Mexican pesos). Waste was calculated at 30%, which represented $1.8 million (Mexican pesos). CONCLUSIONS: Cost-effective studies are important tools in the administration of resources. In this particular case the results indicate the necessity for systematic registration of financial information, periodic review of operation costs by service, and criteria for use of high-cost services.

Angina estável: como escolher entre as diferentes formas de investigação? / Stable angina: how to choose between the different diagnosis methods?

A manifestação mais comum da doença isquêmica do coração é a angina estável, que apresenta amplo espectro clínico, de acordo com a idade, a gravidade dos sintomas e a função ventricular esquerda. Atualmente grande variedade de métodos diagnósticos está disponível para avaliação desses pacientes. Os objetivos do presente capítulo são: discutir como optar entre os diferentes recursos disponíveis na prática diária, quais são os critérios utilizados para a escolha entre os diferentes métodos e qual é a seqüência que se deve obedecer buscando racionalizar o atendimento desses pacientes com suspeita de doença arterial coronária.

Assessment of right ventricular function with Doppler echocardiographic indices derived from tricuspid annular motion: comparison with radionuclide angiography.

OBJECTIVE: To assess right ventricular systolic function using indices derived from tricuspid annular motion, and to compare the results with right ventricular ejection fraction (RVEF) calculated from radionuclide angiography. DESIGN: Pulsed Doppler echocardiography indices were obtained from 10 patients with a normal RVEF (group 1) and from 20 patients whose RVEF was less than 45% (group 2). RESULTS: The patients in the two groups were similar in age, systolic blood pressure, and heart rate. There was a close correlation between the tricuspid annular motion derived indices (D wave integral (DWI), peak velocity of D wave (PVDW), and tricuspid plane systolic excursion (TPSE)) and RVEF (r = 0.72, 0.82, and 0.79, respectively). DWI was significantly higher in group 1 than in group 2. PVDW discriminated adequately between individuals with abnormal and normal right ventricular ejection fraction. The sensitivity and specificity of tricuspid annular motion derived indices were very good. CONCLUSIONS: Indices derived from tricuspid annular motion appear to be important tools for assessing right ventricular systolic function.

Noninvasive diagnosis of allograft vascular disease after heart transplantation.

OBJECTIVE: To determine the predictive values of noninvasive tests for the detection of allograft vascular disease. METHODS: We studied 39 patients with mean ages of 48+/-13 years and a follow-up period of 86+/-13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or =50% obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results. RESULTS: Allograft vascular disease was found in 15 (38%) patients. The Holter test showed 15.4% sensitivity, 95.5% specificity. For the treadmill stress test, sensitivity was 10%, specificity was 100%. When thallium scintigraphy was used, sensitivity was 40%, specificity 95.8%. On echocardiography with dobutamine, we found a 63.6% sensitivity, 91.3% specificity. When the dobutamine echocardiogram was associated with scintigraphy, sensitivity was 71.4%, specificity was 87%. CONCLUSION: In this group of patients, the combination of two noninvasive methods (dobutamine echocardiography and thallium scintigraphy) may be a good alternative for the detection of allograft vascular disease in asymptomatic patients with normal ventricular function.

Estimation of the ejection fraction in patients with myocardial infarction obtained from the combined index of systolic and diastolic left ventricular function: a new method.

UNLABELLED: The index of myocardial performance combining systolic and diastolic time intervals (Index) is a useful method, already explained in past studies, that offers new values that have not been widely known among clinical cardiologists. The aim of this study is to obtain from this Index a measurement of the ejection fraction (EF), which is a very well-known value. The study involved 97 patients with myocardial infarction, 55 of whom were studied retrospectively (group A, aged 46-62 years, 50 men) to obtain and test the formula EF = 60 - (34 x Index). The second group (group B, aged 47-63 years, 40 men) included 42 patients who were evaluated prospectively. The EF obtained was compared with that reached through the use of radionuclide angiography (EF-RNA). The Index was obtained through the use of the formula (a - b)/b, where a is the interval between cessation and onset of the mitral inflow, and b is the ejection time. In group A the EF obtained by the Index (EF-Index) was 37.5% +/-.8%, and the EF-RNA was 37.7% +/- 11% (r = 0.76). In group B the EF-Index was 41.6% +/- 7%, and the EF-RNA was 41.2% +/- 10% (r = 0. 75). CONCLUSION: Through the new formula described here it is possible to obtain a reliable measurement of the EF in patients with myocardial infarction, a well-known and extremely useful value, especially for those patients with poor acoustic windows.

Brain death in children: clinical, neurophysiological and radioisotopic angiography findings in 125 patients.

The objective of this study was to determine the main clinical, neurophysiological and angiographic findings in brain death (BD) in children seen at the Instituto Nacional de Pediatría, a third-level facility in Mexico City, between 1991 and 1996. The following variables were retrospectively analyzed: sex, age, etiology, associated morbidity, duration of stay in hospital, and the results of two of three confirmatory studies (electroencephalogram, evoked potentials, radioisotopic angiography). In all, 125 patients were studied 78 male, median age 2 years (range: 18 days to 17 years)[. The most frequent etiology was infection (34%); 57% of the children developed associated morbidity. In 111 of 122 patients electrocerebral silence was observed; 100 of 107 had brain stem and somatosensory evoked potentials affording conclusive evidence of BD; and 83 of 90 patients had a positive radioisotopic angiography indicating BD. In 76 patients all three confirmatory studies were performed: for 15 there was at least one false-negative test result. Our age cohort showed a predominance of children less than 2 years old. BD etiologies in developing countries differ from those reported in developed countries.

Malformaçöes arteriovenosas pulmonares - aspectos radiológicos / Pulmonary arteriovenous malformations - radiological aspects

Resumo: neste trabalho os autores apresentam os aspectos radiológicos de tórax, tomografias lineares e computadorizadas e arteriografias de cinco casos de malformaçöes arteriovenosas, assim como discutem a importância de cada método de imagem no diagnóstico dessas lesöes . Dos cinco pacientes estudados, quatro eram adultos e um criança; três eram do sexo feminino e 2 do sexo masculino, com idade variando entra 7 e 53 anos. Em todos os casos eles foram realizadas radiografias de tórax e tomografias lineares. A investigaçäo diagnóstica foi complementada pela realizaçäo de tomografia computadorizada em dois casos e de angiografia em quatro casos. As tomografias lineares foram diagnósticas em todos os casos, sendo ressaltada a importância da sua realizaçäo em centros de recursos mais avançados.

Enhanced detection of reversible myocardial hypoperfusion by technetium 99m-tetrofosmin imaging and first-pass radionuclide angiography after nitroglycerin administration.

BACKGROUND: Reversal of ischemia after myocardial infarction by revascularization is worthwhile only if viability exists in a sufficiently large portion of the left ventricle. METHODS AND RESULTS: To determine myocardial hypoperfusion reversibility and its influence on segmental and global function, we studied 50 patients after myocardial infarction. Three technetium 99m-tetrofosmin scintigraphies were performed: 1 at rest, 1 after 0.6 mg sublingual nitroglycerin (NTG), and 1 after injection at peak stress. First-pass multigated radionuclide angiography was obtained at rest and after NTG. Each patient also underwent a stress redistribution-reinjection thallium-201 scintigraphy. During stress 99mTc-tetrofosmin, 104 segments had normal uptake, 51 showed moderately reduced uptake, and 186 had severely reduced uptake. Of these 186 segments, 33 (18%) improved at rest, and 41 (22%) improved only after NTG. Fifty-nine (79%) of these segments with improved uptake were also found to have reversible defects on 201TI imaging. In the 26 patients with ventricular dysfunction, a 73% agreement was found between the functional and 99mTc-tetrofosmin uptake post-NTG improvement, whereas a 69% agreement was found with thallium reinjection. No significant differences were seen between 99mTc-tetrofosmin and 201T1 imaging. CONCLUSION: Nitroglycerin administration during 99mTc-tetrofosmin scintigraphy improves the detection of myocardium with reversible hypoperfusion in patients with a previous myocardial infarction.

Cardiac autonomic impairment and early myocardial damage involving the right ventricle are independent phenomena in Chagas' disease.

Cardiac autonomic impairment and right side heart failure are prominent features in patients with Chagas' disease, but no causal relationship between these phenomena has been disclosed and the pathophysiology of such manifestations is unclear. Aim of study was to assess the cardiac autonomic control and biventricular function in chagasic patients in early stages of the disease, using radionuclide angiography, Valsalva manoeuvre, head-up tilt and baroreflex sensitivity evaluation. Thirty-one chagasic patients with no clinical signs of Chagas' heart disease-16 in the indeterminate phase and 15 with sole organic digestive involvement-were studied, and results compared with those obtained in 14 normal volunteers. No significant differences were observed among the three groups, in regard to any systolic or diastolic parameter of LV function, including ejection fraction, peak ejection and filling rates and correspondent times, time to end-systole, and the standard deviation of phase values. The indeterminate and digestive groups of chagasics had significantly lower right ventricular ejection fraction (45.7 +/- 6.3 and 46.2 +/- 10.1 respectively) and peak ejection rate (respectively 2.8 +/- 0.6 and 2.9 +/- 0.6) and higher right ventricular phase standard deviation (22.4 +/- 5.9 and 20.1 +/- 5.6 degrees, respectively), as compared with the control group (53.6 +/- 4.3, 3.5 +/- 0.5, and 15.8 +/- 3.8 respectively for right ventricular ejection fraction, peak ejection rate and phase standard deviation). No significant differences were found between the results of autonomic evaluation in the control and indeterminate groups of chagasic patients. The group of digestive disease patients showed abnormally lower Valsalva ratio (1.5 +/- 0.15), baroreflex sensitivity (8.85 +/- 2.05 ms/mmHg) and parasympathetically-dependent heart rate response to tilt (8.85 +/- 8.42 beats/mm) and higher Valsalva delay (15.67 +/- 1.35 s) values, compared with the control group (respectively 1.85 +/- 0.49, 20.23 +/- 12.66 ms/mmHg, 21.61 +/- 5.77 beats/mm and 10.1 +/- 2.5 s). Thus, cardiac autonomic impairment is a prominent feature in chagasic patients with the digestive but not the indeterminate form of Chagas' disease. It bears no causative relationship to the early myocardial damage that is apparent only regarding right ventricular function, in both groups of patients. Early right ventricular dysfunction is a likely mechanism for the marked predominance of systemic over pulmonary congestion when heart failure supervenes in patients with Chagas' disease.

Assessment of myocardial perfusion and function in childhood systemic lupus erythematosus.

OBJECTIVES: To determine the prevalence of abnormalities in myocardial perfusion or function in children with systemic lupus erythematosus (SLE), and describe potential factors that may predict their development. STUDY DESIGN: Patients (n = 40; 30 female) were enrolled through the Lupus Clinic at The Hospital for Sick Children between 1990 and 1992. Resting and exercise thallium myocardial perfusion scans, radionuclide angiography with multiple gated acquisition (MUGA), and resting M-mode and two-dimensional echocardiography were performed. RESULTS: All patients were free of symptoms, and none had a history of ischemic heart disease. Their median age was 15.9 years (range 10.5 to 19.8 years) at enrollment. Abnormalities of coronary perfusion were found in 5 (16%) of 31 patients (95% confidence interval: 3%, 29%) and included a large fixed perfusion defect in 1; 5 of 27 MUGA scans showed marginally low left ventricular ejection fractions at rest, whereas all had normal exercise responses. In the group with abnormal thallium scans, three of five patients had antiphospholipid antibodies detected, and two of four had an abnormal plasma lipid profile. This group tended to have a shorter disease duration and had received a lower cumulative dose of corticosteroids; these differences were not statistically significant compared with the group with normal scans. CONCLUSION: Asymptomatic abnormalities of myocardial perfusion occur in children with SLE and are more common than previously suspected. Patients with these abnormalities of myocardial perfusion may be predisposed to the previously recognized early-onset ischemic heart disease seen in adults with SLE.

Cambios hemodinámicos en la función sistólica, diastólica y la circulación periférica inducidas por amlodipina en pacientes con hipertensión arterial esencial asociada con disfunción ventricular izquierda / Hemodynamic changes in systolic and diastolic function and in the peripheral circulation induced by amlodipine in patients with essencial hypertension with left ventricular dysfunction

La hipertensión arterial afecta la función y la estructura cardiovascular, con hipertrofia y disfunción ventricular frecuentes, en especial en pacientes con cardiopatía isquémica asociada. Evaluamos 20 pacientes entre 40 y 70 años de edad, con diagnóstico de hipertensión esencial (presión arterial diastólica entre 95 y 115 mmHg) asociada a disfunción ventricular (fracción de eyección ó 45 por ciento). Se estudiaron por angiografía radioisotópica la función sistólica, la función diastólica y la circulación periférica en las siguientes etapas: A) al final del período lavado-placebo (pretratamiento); B) en fase aguda, a las 6 horas de amlodipina (10 mg) por vía oral; C) en fase crónica, al final de 8 semanas de igual tratamiento con monodosis. El tratamiento en fase aguda y crónica mostró una disminución significativa de la presión arterial sistólica, diastólica y de la resistencia periférica total (en un 15 por ciento, 14 por ciento y 20 por ciento respectivamente). El pico de llenado del ventrículo izquierdo basal fue 1,9 ñ 0,4 (VFD/S), mejorando un 21 por ciento en el tratamiento crónico en reposo y 17 por ciento durante el ejercicio ergométrico, lo que evidenció una mejoría de la función diastólica del ventrículo izquierdo (p<0,01). El volumen de fin de sístole o residual, aumentado como expresión de la falla de bomba, disminuyó en 15 y 19 por ciento en reposo y esfuerzo. En el pretratamiento los parámetros hemodinámicos muestran disfunción ventricular sistólica y diastólica del ventrículo izquierdo con compromiso del ventrículo derecho, tanto en reposo como en esfuerzo, con disminución de la reserva cardíaca. El efecto vasodilatador de la amlodipina, con disminución de la poscarga, produjo efectos hemodinámicos favorables, tanto en el control de la hipertensión arterial como en la mejoría de la disfunción biventricular asociada

Cambios hemodinámicos en la función sistólica, diastólica y la circulación periférica inducidas por amlodipina en pacientes con hipertensión arterial esencial asociada con disfunción ventricular izquierda / Hemodynamic changes in systolic and diastolic function and in the peripheral circulation induced by amlodipine in patients with essencial hypertension with left ventricular dysfunction

La hipertensión arterial afecta la función y la estructura cardiovascular, con hipertrofia y disfunción ventricular frecuentes, en especial en pacientes con cardiopatía isquémica asociada. Evaluamos 20 pacientes entre 40 y 70 años de edad, con diagnóstico de hipertensión esencial (presión arterial diastólica entre 95 y 115 mmHg) asociada a disfunción ventricular (fracción de eyección ó 45 por ciento). Se estudiaron por angiografía radioisotópica la función sistólica, la función diastólica y la circulación periférica en las siguientes etapas: A) al final del período lavado-placebo (pretratamiento); B) en fase aguda, a las 6 horas de amlodipina (10 mg) por vía oral; C) en fase crónica, al final de 8 semanas de igual tratamiento con monodosis. El tratamiento en fase aguda y crónica mostró una disminución significativa de la presión arterial sistólica, diastólica y de la resistencia periférica total (en un 15 por ciento, 14 por ciento y 20 por ciento respectivamente). El pico de llenado del ventrículo izquierdo basal fue 1,9 ñ 0,4 (VFD/S), mejorando un 21 por ciento en el tratamiento crónico en reposo y 17 por ciento durante el ejercicio ergométrico, lo que evidenció una mejoría de la función diastólica del ventrículo izquierdo (p<0,01). El volumen de fin de sístole o residual, aumentado como expresión de la falla de bomba, disminuyó en 15 y 19 por ciento en reposo y esfuerzo. En el pretratamiento los parámetros hemodinámicos muestran disfunción ventricular sistólica y diastólica del ventrículo izquierdo con compromiso del ventrículo derecho, tanto en reposo como en esfuerzo, con disminución de la reserva cardíaca. El efecto vasodilatador de la amlodipina, con disminución de la poscarga, produjo efectos hemodinámicos favorables, tanto en el control de la hipertensión arterial como en la mejoría de la disfunción biventricular asociada (AU)