Echocardiographic long-term follow-up of adult survivors of pediatric cancer treated with Dexrazoxane-Anthracyclines association.

AIMS: Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer treated with anthracyclines. Co-administration of Dexrazoxane has been shown to significantly reduce short-term and mid-term cardiotoxicity. Aim of this study was to assess cardiac function in long-term (>10 years) survivors of childhood tumors treated with dexrazoxane/anthracycline association. METHODS AND RESULTS: Twenty cancer survivors previously treated with co-administration of anthracyclines-dexrazoxane for childhood renal tumors or sarcoma and a control group of 20 healthy subjects were enrolled in the study. Echocardiographic measurements included 3D left ventricular (LV) ejection fraction (LVEF) and LV and right ventricular (RV) global longitudinal strain (GLS). Among cancer survivors group the median age at diagnosis was 5 years (1-17) and they were evaluated at median follow-up time of 21.5 years (10-26). No evidence of cardiac toxicity, as defined by current guidelines, was reported in all survivors. No significant differences in standard and deformation imaging parameters were observed between survivors and controls (3D LVEF 58 ±â€¯3% vs 60 ±â€¯5% p = NS; LV GLS -21 ±â€¯1% vs -21 ±â€¯2% p = NS; RV GLS -23 ±â€¯2% vs -23 ±â€¯5% p = NS). No second tumor was registered in dexrazoxane-treated survivors. CONCLUSIONS: Our findings may support the role of dexrazoxane as a useful strategy for cardio-protection in children undergoing anthracycline based treatment. However, large randomized trials are needed to confirm the cardio-protective role of dexrazoxane in pediatric setting at long-term follow-up.

Counseling intervention to improve quality of life in patients with pre-existing acute myocardial infarction (AMI) or chronic obstructive pulmonary disease (COPD): a pilot study.

BACKGROUND: In the light of diagnostic and therapeutic advances, patients with a previous myocardial infarction or with a diagnosis of chronic obstructive pulmonary disease are vulnerable and need continuous monitoring over time. These pathological frameworks have a strong impact on the economy and on the status of the population and require effective and low-cost solutions. AIMS: The objective of this clinical trial is to evaluate the efficacy in the short term of a telephone counseling intervention to modify the lifestyles of these two patient populations. METHODS: In May 2015, all the patients included in the study underwent a questionnaire to evaluate their eating and smoking habits and their quality of life. After randomization in two groups, the intervention group received telephone counseling related to the correct lifestyles. The control group did not undergo any intervention. In September-October 2015, the same initial questionnaire was administered to evaluate changes in patients' behavior. RESULTS: 64 patients were included in the study: 34 were assigned to the intervention group and 30 to the control group. The outcomes evaluated were: quality of life, assessment of eating habits and smoking status. After the telephone counseling, the intervention group (34 persons) showed a significant improvement in the score of adherence to the Mediterranean diet (p = 0.01) and a significant reduction in the percentage of smokers (p = 0.01) compared to the population that did not receive any intervention (30 persons). On the other hand, the changes related to the quality of life questionnaire were not significant. CONCLUSIONS: A single telephone counseling intervention is effective in modifying the lifestyles of patients with a previous myocardial infarction or diagnosed with chronic obstructive pulmonary disease in the short term, reducing their risk profile.

Chronic cerebrospinal venous insufficiency in patients with Ménière's disease.

To analyze the presence of chronic cerebrospinal venous insufficiency parameter and vascular abnormalities, in the internal jugular veins (IJVs) and/or vertebral veins in sitting and supine posture, in patients with Meniere's disease compared to healthy general population. A prospective study on 32 patients affected by definite Ménière was performed from February 2012 to January 2013. All subjects underwent an echo-color Doppler examination of the cerebrospinal venous flow. 21 of the 32 Menieric patients showed a statistically significant reflux in the intracranial veins versus healthy (65.6 vs 25%; P < 0.001). A high prevalence of IJVs stenosis with hemodynamic changes (increased velocity or absence of flow) was observed (66.7 vs 33.3%; P < 0.05). The other parameters considered did not show statistically significant differences among the two groups. The results obtained showed a vascular pattern of cerebrospinal venous system present in patients affected by definite Meniere. This vascular impairment significantly affects the vascular areas more directly involved in the venous drainage of the inner ear. Thus venous stasis may be considered a further pathogenetic mechanism for development of Meniere's disease.

Quantitative analysis of intraventricular blood flow dynamics by echocardiographic particle image velocimetry in patients with acute myocardial infarction at different stages of left ventricular dysfunction.

AIMS: Left ventricular (LV) diastolic filling is characterized by the formation of a vortex that supports an efficient transit into systolic ejection. Aim of this study was to assess the intraventricular (IV) blood flow dynamics among patients with ST elevated myocardial infarction (STEMI) at different degrees of LV dysfunction, in the attempt to find novel indicators of LV pump efficiency. METHODS AND RESULTS: Sixty-four subjects, 34 consecutive STEMI patients and 30 healthy controls, underwent before hospital discharge 2D speckle tracking echocardiography to assess global longitudinal strain (GLS), and echo-particle image velocimetry analysis to assess flow energetic parameters. Left ventricular volumes ejection fraction (LVEF) and global wall motion score index (GWMSI) were evaluated by 3D echocardiography. ST elevated myocardial infarction patients were subdivided into three groups according to LVEF. Energy dissipation, vorticity fluctuation, and kinetic energy fluctuation indexes, which characterize the degree of disturbance in the flow, exhibit a biphasic behaviour in STEMI patients when compared with controls, with the highest values in patients with still preserved LV function and progressive lower values with LV function worsening. Significant linear correlations were found between energy dissipation index and both LVEF and GLS (r = 0.57, P < 0.001 and r = -0.61, P = 0.001, respectively). Kinetic energy fluctuation index significantly correlates with both LVEF (r = 0.75, P < 0.001) and GLS (-0.58, P = 0.002). Finally, a significant correlation was observed between GWMSI and energy dissipation index (-0.56, P = 0.008). CONCLUSIONS: The present study describes, for the first time, the progression of IV flow energetic properties in patients with acute myocardial infarction at different stages of LV dysfunction when compared with healthy controls. Further data are needed to assess the role of these parameters in the development and maintenance of LV dysfunction.

Effect of therapeutic inhibition of TNF on circulating endothelial progenitor cells in patients with rheumatoid arthritis.

Endothelial dysfunction has been detected in RA patients and seems to be reversed by control of inflammation. Low circulating endothelial progenitor cells (EPCs) have been described in many conditions associated with increased cardiovascular risk, including RA. The aim of this study was to investigate the effect of inhibition of TNF on EPCs in RA patients. Seventeen patients with moderate-severe RA and 12 sex and age-matched controls were evaluated. Endothelial biomarkers were tested at baseline and after 3 months. EPCs were identified from peripheral blood mononuclear cells by cytofluorimetry using anti-CD34 and anti-vascular endothelial growth factor-receptor 2. Asymmetric dimethylarginine (ADMA) was tested by ELISA and flow-mediated dilatation (FMD) by ultrasonography. Circulating EPCs were significantly lower in RA patients than in controls (P = 0.001). After 3 months EPCs increased significantly (P = 0.0006) while ADMA levels significantly decreased (P = 0.001). An inverse correlation between mean increase in EPCs number and mean decrease of DAS28 after treatment was observed (r = -0.56, P = 0.04). EPCs inversely correlated with ADMA (r = -0.41, P = 0.022). No improvement of FMD was detected. Short-term treatment with anti-TNF was able to increase circulating EPCs concurrently with a proportional decrease of disease activity suggesting that therapeutic intervention aimed at suppressing the inflammatory process might positively affect the endothelial function.

Global and regional longitudinal strain assessed by two-dimensional speckle tracking echocardiography identifies early myocardial dysfunction and transmural extent of myocardial scar in patients with acute ST elevation myocardial infarction and relatively preserved LV function.

AIMS: Global and regional longitudinal strain (GLS-RLS) assessed by two-dimensional speckle tracking echocardiography (2D-STE) are considered reliable indexes of left-ventricular (LV) function and myocardial viability in chronic ischaemic patients when compared with delayed-enhanced cardiac magnetic resonance (DE-CMR). In the present study, we tested whether GLS and RLS could also identify early myocardial dysfunction and transmural extent of myocardial scar in patients with acute ST elevation myocardial infarction (STEMI) and relatively preserved LV function. METHODS AND RESULTS: Twenty STEMI patients with LVEF ≥40%, treated with PPCI within 6 h from symptoms onset, underwent DE-CMR and 2D-echocardiography for 2D-STE analysis 6 ± 2 days after STEMI. Wall motion score index (WMSI) and LV ejection fraction (LVEF) were calculated by both methods. Infarct size and transmural extent of necrosis were assessed by CMR. GLS and RLS were obtained by 2D-STE. Mean GLS of the study population was -14 ± 3.3, showing a significant correlation with both LVEF and WMSI, by CMR (r = -0.86, P = 0.001, and r = 0.80, P = 0.001, respectively) and time-to-PCI (r = 0.66, P = 0.038). A weaker correlation was found between GLS and LVEF and WMSI assessed by 2D-echo (r = -0.65, P = 0.001, and r = 0.53, P = 0.013, respectively). RLS was significantly lower in DE-segments when compared with normal myocardium (P < 0.0001). A cut-off value of RLS of -12.3% by receiver-operating characteristic (ROC) curves identified DE-segments (sensitivity 82%, specificity 78%), whereas a cut-off value of -11.5% identified transmural extent of DE (sensitivity 75%, specificity 78%). CONCLUSION: Our findings indicate that RLS and GLS evaluation provides an accurate assessment of global myocardial function and of the presence of segments with transmural extent of necrosis, with several potential clinical implications.

Cardiovascular adverse reactions after the administration of recombinant human erythropoietin: light and shade.

From the trials published till now, it is clear that the most important and frequent adverse reactions related to the treatment with recombinant human erythropoietin (rHuEpo) are thrombovascular accidents and systemic hypertension. Only on very rare occasions cephalea and epileptic fits may occur. Even if these adverse reactions are so precisely defined, there is no evident interpretation of the biological and pathophysiological mechanisms that sustain these events. This work intends to describe the state of the art in the international literature in order to enable the reader to understand the real risks of rHuEpo administration.

Utility of T2-weighted short-tau inversion recovery (STIR) sequences in cardiac MRI: an overview of clinical applications in ischaemic and non-ischaemic heart disease.

T2-weighted short-tau inversion recovery (T2w-STIR) imaging is the best approach for oedema-weighted cardiac magnetic resonance imaging (MRI), as it suppresses the signal from flowing blood and from fat and enhances sensitivity to tissue fluid. The purpose of this pictorial review is to illustrate the clinical use and application of this technique in various ischaemic and non-ischaemic conditions. In ischaemic heart disease, T2w-STIR represents the technique of choice for detecting oedema in patients with acute myocardial infarction (MI), allowing discrimination of acute and chronic injuries. Myocardial haemorrhage may also be depicted as a region of signal abnormality characterised by a central hypointense core with a peripheral hyperintense rim, presumably reflecting the presence of intracellular methaemoglobin within the necrotic area. In the acute setting, elevated T2 relaxation times in association with regional contractile dysfunction but no signs of delayed enhancement may also signify a reversible ischaemic injury without necrosis. In acute myocarditis, the distribution pattern of T2w hyperintensity may be focal in approximately 30% of patients or diffuse in the remaining 70%, and myocardial oedema may be the only marker of disease. Tissue oedema may also be observed in various other conditions, such as primary cardiomyopathies (CMP), storage disease, pulmonary hypertension and cardiac transplant rejection. T2w-STIR represents an appealing and versatile technique that can be applied in a wide variety of ischaemic and non-ischaemic conditions, allowing detection of segmental or global increase of myocardial free water content, reflecting an acute myocardial injury.

Anti-endothelial cell antibodies in rheumatic heart disease.

To evaluate the anti-endothelial cell antibodies (AECA), anti-cardiolipin antibodies (aCL) and serum mannose-binding lectin (MBL) profiles of a large cohort of Yemeni patients with rheumatic heart disease (RHD) and to correlate these findings with clinical features of the disease. Patients (n = 140) were recruited from Al-Thawra Hospital in Sana'a, Yemen. All had RHD diagnosed according to modified Jones' criteria. We also studied 140 sex- and age-matched healthy blood donors from the same area. Echocardiography was performed according to the recommendations of the American Society of Echocardiography. Solid phase enzyme-linked immunosorbent assays (ELISAs) were used to measure AECA and aCL titres and serum MBL levels. Forty per cent of the patients were AECA-positive, but only 7·8% were positive for aCL antibodies. Serum MBL levels were significantly lower in the RHD group (median 4221 ng/ml versus 5166 ng/ml in healthy controls). AECA titres were correlated positively with patient age, duration of RHD and the severity of aortic stenosis, as determined by echocardiographic findings. In several autoimmune rheumatic diseases, such as systemic lupus erythematosus, vasculitis and scleroderma, AECA have been shown to play pathogenic roles by producing proinflammatory and procoagulant effects (increased expression of adhesion molecules and tissue factors, increased cytokine release) in endothelial cells. In RHD, these autoantibodies might represent a pathological link between activation of the valvular endothelium and valvular damage.

Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST elevation myocardial infarction.

OBJECTIVE: To evaluate prospectively the impact on left ventricular (LV) remodelling of an intracoronary aspiration thrombectomy device as adjunctive therapy in primary percutaneous coronary intervention (PCI) in patients with anterior ST elevation myocardial infarction (STEMI). METHODS: 76 consecutive patients with anterior STEMI (65.3 (11.2) years, 48 men) were randomly assigned to intracoronary thrombectomy and stent placement (n = 38) or to conventional stenting (n = 38) of the infarct related artery. Each patient underwent transthoracic echocardiography immediately after PCI and at six months. At the time of echocardiographic control, major adverse cardiovascular events (MACE) in terms of death, new onset of myocardial infarction, and hospitalisation for heart failure were also evaluated. RESULTS: After a successful primary PCI, patients in the thrombectomy group achieved a higher rate of post-procedure myocardial blush grade 3 (36.8% v 13.1%, p = 0.03) and effective ST segment resolution at 90 minutes (81.6% v 55.3%, p = 0.02). Six months after the index intervention, 19 patients (26.8%) developed LV dilatation, defined as an increase in end diastolic volume (EDV) >or= 20%: 15 in the conventional group and four in the thrombectomy group (p = 0.006). Accordingly, at six months patients treated conventionally had significantly higher end systolic volumes (82 (7.7) ml v 75.3 (4.9) ml, p < 0.0001) and EDV (152.5 (18.1) ml v 138.1 (10.7) ml, p < 0.0001) than patients treated with thrombectomy. No differences in cumulative MACE were observed (10.5% in the conventional group v 8.6% in the thrombectomy group, not significant). CONCLUSION: Compared with conventional stenting, adjunctive aspiration thrombectomy in successful primary PCI seems to be associated with a significantly lower incidence of LV remodelling at six months in patients with anterior STEMI.

Quantification methods in contrast echocardiography.

New technologies and the availability of new echo-contrast agents have resulted in advances of diagnostic and prognostic indications of left ventricular opacification (LVO) and myocardial perfusion. The clinical diagnostic value of ultrasound contrast media for LVO and its impact on the clinical decision-making process has been demonstrated in several studies. Recent research aims at developing new quantitative software to improve the delineation of the endocardial border, to assess 3D myocardial perfusion for more accurate regional/global LV function measurements, and to evaluate 4D intra-cardiac flow dynamics. Furthermore, a general consensus has been reached on the incremental value of myocardial contrast echocardiography (MCE) for obtaining additional information in both chronic and acute coronary artery disease (CAD) patients and on the possibility to make quantitative measurements of microvascular damage. Q-contrast is a new software system which provides quantitative measurements to generate parametric images of microcirculatory flow. In a research project including 120 patients, Q-contrast software has been tested to assess the role of contrast in AMI (Acute Myocardial Infarction Contrast Imaging (A.M.I.C.I. Study); good agreement between parametric MCE and SPECT has been found. Preliminary results further confirm that quantitative MCE may provide additional clinical value over qualitative information for the assessment of LV function and of the effects of coronary artery disease on the myocardial microcirculation (viability, ischemia or infarct).

[Myocardial contrast echography. History, methodology and clinical applications]. / Ecocontrastografia miocardica. Cenni storici, aspetti metodologici e applicazioni cliniche.

Recent studies have demonstrated the usefulness of myocardial contrast echocardiography (MCE) in studying myocardial perfusion. Several first and second generation contrast agent such as Levovist, Sonovue, Optison, Definity and Imagent are commercially available or close to be introduced into the market. Use of MCE allowed the clinical demonstration of no-reflow phenomenon in patients with acute myocardial infarction (AMI) after recanalization of the infarct related artery (IRA). Coronary angiography is unable to assess the microvascular damage as showed by the poor correlation between TIMI grading and perfusion score evaluated by MCE. Furthermore, the use of MCE is important to determine coronary stenosis, to identify microvascular damage during ischaemia-reperfusion and to evaluate the presence of collateral circulation in the area at risk. MCE seems to be the most effective technique for assessing microvascular integrity after reperfusion as compared to TIMI myocardial perfusion grade, nuclear myocardial perfusion imaging and magnetic resonance imaging. These techniques are expensive, invasive and not available in most of the hospitals. Furthermore, as compared to nuclear medicine and echo-dobutamine, MCE has greater specificity and higher accuracy in detecting coronary artery disease. Recent studies showed that not only primary percutaneous coronary intervention (PCI) but also rescue and delayed PCI reduced microvascular damage and that MCE play a key role in assessing myocardial salvage after reperfusion. The most exciting aspect of MCE is the independent role in predicting left ventricular (LV) remodelling and functional recovery. The extent on no-reflow is an important predictor of LV dysfunction and remodelling at follow-up. Several studies have demonstrated that the extent of infarct-zone viability is a powerful independent predictor of LV dilation. There is a close relationship between the extent of microvascular damage, the extension of necrosis, the site of AMI and LV remodelling. We demonstrated that MCE performed 24 hours after reperfusion, at 1 week and 6 months appears to provide important prognostic information. These data support the daily use of MCE in coronary care unit and could establish a strategy for clinical decision making in patients with AMI.

Assessment of no-reflow phenomenon after acute myocardial infarction with harmonic angiography and intravenous pump infusion with Levovist: comparison with intracoronary contrast injection.

Myocardial contrast echocardiography (intracoronary application) has emerged as an accurate method to detect the "no-reflow phenomenon." To investigate the diagnostic value of harmonic angiography after intravenous infusion of Levovist in assessing "no-reflow," both intracoronary and intravenous contrast injections were performed in a group of patients with acute myocardial infarction. Seventeen consecutive patients with a successfully reperfused acute myocardial infarction within 6 hours of symptom onset were selected for this study. All patients underwent contrast echocardiography with harmonic angiography with Levovist (400 mg/mL, intravenous pump infusion, trigger intervals 1:4 to 1:8) and sonicated albumin (0.5 to 1 mL, intracoronary bolus) on day 1 after the achievement of a sustained coronary reflow. Myocardial perfusion was qualitatively assessed with a 12-segment model. The endocardial length of the residual contrast defect after reflow was also calculated. Forty-four of 204 segments were not analyzed after intravenous contrast echocardiography and 37 after intracoronary contrast echocardiography because of artifacts. Intracoronary and intravenous injections showed a perfusion defect in 31 (19%) segments, with a concordance of 89% (kappa coefficient, 0.72). Concordance in anteroseptal, anterolateral, and inferolateral segments was 95% (kappa = 0.92), 88% (kappa = 0.66), and 83% (kappa = 0.57), respectively. With intracoronary injection used as the reference method, intravenous injection had a sensitivity of 74% and a specificity of 93% for diagnosing contrast defects. The endocardial extent of no-reflow was 18 +/- 19 after intravenous and 21 +/- 17 after intracoronary contrast echocardiography (P = not significant). Intravenous contrast echocardiography with Levovist reliably identifies the no-reflow phenomenon after successful reperfusion, especially in acute anteroseptal myocardial infarction.

Non-invasive assessment of myocardial perfusion by intravenous contrast echocardiography: state of the art.

Many technical problems, related to both imaging instrumentation and contrast agents, have to be taken into account before attempting non-invasive evaluation of myocardial perfusion by intravenous contrast media injection. Potentials and pitfalls of first generation contrast agents (i.e. Levovist, Schering AG, Berlin, Germany) using intermittent harmonic angio imaging and of second generation contrast media (i.e. SonoVue, Bracco SpA, Milan, Italy) using real-time perfusion imaging in the non-invasive assessment of myocardial perfusion were described and discussed. We still need more solid data before introducing intravenous myocardial echocardiography into the clinical arena. However, convincing data from several research laboratories are paving the way for the widespread use of this new method in clinical practice.

Role of echocardiography in acute chest pain syndrome.

Fewer than one third of patients presenting to the emergency department with complaints of chest pain have an acute coronary syndrome. The electrocardiogram provides a specific diagnosis only in 40% of patients with acute myocardial infarction. The presence of regional wall-motion abnormalities at echocardiography in patients without known coronary artery disease is a moderate indicator of an increased likelihood of acute myocardial ischemia or myocardial infarction with a positive predictive accuracy of about 50%. More important, the absence of regional wall-motion abnormalities identifies a subset of patients unlikely to have a myocardial infarction with a negative predictive accuracy of about 95%. Echocardiography can provide incremental prognostic information to identify patients at risk of early or late cardiac events, even after consideration of clinical, historical, and electrocardiographic variables. The application of new contrast agents to echocardiography will probably allow an early and more accurate evaluation of patients with chest pain of uncertain significance.

Detection of residual tissue viability within the infarct zone in patients with acute myocardial infarction: ultrasonic integrated backscatter analysis versus dobutamine stress echocardiography.

OBJECTIVES: The goals of this study were to analyze temporal changes in cardiac cyclic variation of integrated backscatter (CVIB) in acute myocardial infarction (AMI) and to investigate the predictive value of CVIB normalization compared with that of dobutamine stress echocardiography (DSE) in the assessment of functional recovery after revascularization. BACKGROUND: The normal CVIB is blunted by ischemia and recovers early after reperfusion, faster than wall motion improvement. Analysis of CVIB has been widely investigated for its potential to detect viable myocardium in the early stage of infarction. No studies have compared CVIB analysis with other techniques for viability assessment in patients with acute ischemic. METHODS AND RESULTS: Integrated backscatter images were obtained in 12 patients with AMI on days 1, 3, and 7 after admission and 1 month after revascularization. On day 7, DSE was performed in all patients. On admission, 22 of 144 segments were dyssynergic. On day 1, CVIB was abnormal in all 22 infarcted segments, on day 3, in 16, and on day 7, in only 10 infarcted segments. Eight of 10 segments nonviable by CVIB (CVIB-nonviable) were also nonrespondent by DSE; whereas 12 of 14 segments viable by DSE (DSE-viable) were also CVIB-viable. At follow-up, 10 CVIB-viable segments and 1 CVIB-nonviable segment showed functional recovery; whereas 10 of 14 DSE-viable segments showed functional recovery. Thus the positive predictive value of CVIB and DSE was 83% and 72%, respectively, with a diagnostic agreement between techniques in 77% of segments. CONCLUSIONS: Our data suggest that the normalization in CVIB in the first week after AMI accurately predicts residual tissue viability within the infarct zone. We also observed that the initial pattern of cyclic variation may be predictive of functional recovery. Finally, we found a good correlation between the recovery of a normal CVIB in segments that were still dysfunctional and a more validated method to assess tissue viability, such as the dobutamine test.

Harmonic imaging with Levovist for transthoracic echocardiographic reconstruction of left ventricle in patients with post-ischemic left ventricular dysfunction and suboptimal acoustic windows.

BACKGROUND: Attempts to perform transthoracic 3-dimensional echocardiography (3DE) are often encumbered by poor definition of chamber borders in adult patients who have technically suboptimal acoustic windows. METHODS: To assess whether harmonic imaging (HI) and contrast agents can facilitate transthoracic 3DE assessment of the left ventricle, we used fundamental imaging (FI), HI alone, and HI coupled with the echo-enhancing contrast agent Levovist in 15 consecutive patients with post-ischemic left ventricular (LV) dysfunction and technically difficult windows. Dynamic 3DE image data sets were obtained at 5-degree angles (36 slices) from a transthoracic apical view. From these data a total of 240 myocardial segments were analyzed with the use of dynamic short-axis paraplane slices at basal, middle, and apical LV levels (standard 16 segment model). For border definition, each segment was scored in random sequence on the following scale by 2 independent investigators: 0 = not seen, 1 = suboptimal visualization, and 2 = well defined. RESULTS: Our results showed a significant increase in the number of well-visualized segments when harmonic mode combined with Levovist injection was compared with FI and HI alone. CONCLUSION: Harmonic imaging alone improves LV assessment by 3DE when compared with FI. Contrast imaging in which Levovist is added to HI further improves the capability of transthoracic tomographic 3DE in the visualization of LV myocardial segments. This could allow 3DE by transthoracic windows to be used more widely in adults for the evaluation of LV volume and function.

Enhanced left ventricular endocardial border delineation with an intravenous injection of SonoVue, a new echocardiographic contrast agent: A European multicenter study.

The safety and efficacy of SonoVue (also referred to as BR1), a new contrast agent for delineating endocardial border of the left ventricle after intravenous administration, was assessed. Two hundred and eighteen patients with suspected coronary artery disease undergoing fundamental echocardiography for the assessment of left ventricle were enrolled in a prospective multicenter, single blind, cross-over study with random sequence allocation of four different doses of SonoVue. Endocardial border definition in the apical and parasternal views was scored as 0 = not visible, 1 = barely visible, and 2 = well visualized before and after contrast enhancement. Analysis was performed by two pairs of off-site observers. Safety of SonoVue was also assessed. Results of our study indicated that the mean improvements in the endocardial border visualization score were as follows: 3.1 +/- 7.8 (95% CI, 2.5 and 3.7) for 0.5 ml, 3.4 +/- 8.0 (95% CI, 2.8 and 4.0) for 1 ml, 3.4 +/- 7.9 (95% CI, 2.8 and 4.0) for 2 ml, and 3.7 +/- 8.0 (95% CI, 3.1 and 4.3) for 4 ml (P < 0.05 for all doses from baseline). Changes from baseline in endocardial visualization scores were also seen in the apical views (P < 0.05) and they were dose-dependent (P < 0.001). Similar enhancements of endocardial visualization scores were observed in the apical views in patients with suboptimal baseline echocardiographic images. Diagnostic confidence for assigning a score and image quality also were significantly better following contrast enhancement. No significant changes in the laboratory parameters and vital signs were noted following contrast enhancement, and the side effects were minimal. It was concluded that SonoVue is safe and effective in delineating endocardial border, including in patients with suboptimal baseline images.

Microvascular integrity after reperfusion therapy.

Several perfusion techniques have definitively shown that microvascular dysfunction plays a crucial role in patients with acute myocardial infarction. In those patients, despite a rapid and sustained restoration of flow throughout a previously occluded epicardial coronary artery, microvascular damage still may be observed. Duration of ischemia and/or time to recanalization are the most powerful determinants of microvascular dysfunction. However, the amount of tissue perfusion in infarcted patients is dependent on many other complex interrelated factors including extent of collateral circulation before recanalization, residual stenosis severity of the culprit artery, vasodilator reserve in the infarct territory, extent of reperfusion injury, and loading conditions. Because microvascular dysfunction is associated with progressive left ventricular dilation and a high frequency of postinfarction complications, all of the efforts to improve the relation between coronary reflow and microvascular perfusion are justified.