The role of carotid atherosclerosis in the distinction between ischaemic and non-ischaemic cardiomyopathy.

AIM: Sometimes ischaemic cardiomyopathy is a result of severe coronary artery disease of an occult course, without typical symptoms or evidence of myocardial infarction. This form of presentation is usually indistinguishable from non-ischaemic dilated cardiomyopathy. Carotid bifurcation atherosclerosis and coronary artery disease have been shown to be strongly associated. We prospectively examined the value of extracranial carotid atherosclerosis in the distinction between ischaemic and non-ischaemic aetiology in patients with clinically unexplained cardiomyopathy. METHODS AND RESULTS: Seventy-eight patients with undetermined dilatation and diffuse impairment of the left ventricular contraction were studied within 28 months. They underwent carotid scan and coronary arteriography. Carotid atherosclerosis was found to be very common in ischaemic and rare in non-ischaemic cardiomyopathy. The presence of at least one abnormal carotid finding (intima-media thickness >1 mm, plaques, severe carotid stenosis) was 96% sensitive and 89% specific for ischaemic cardiomyopathy. CONCLUSION: Carotid scanning may be a useful screening and decision making tool in patients with cardiomyopathy of indecisive cause. Patients with carotid atherosclerosis are likely to suffer from severe coronary artery disease. Coronary angiography and subsequent myocardial viability studies, when indicated, could be considered early during their evaluation. In contrast, a negative carotid scan predicts non-ischaemic cardiomyopathy.

Reliability of M-mode, two-dimensional and Doppler echocardiography in diagnosing a flail mitral valve leaflet.

The purpose of this study was to evaluate the M-mode, two-dimensional, and Doppler echocardiographic signs for a flail mitral valve leaflet. This was a retrospective evaluation of 54 patients who had (1) significant mitral regurgitation, (2) a technically adequate echocardiographic study, and (3) description of valve anatomy done at surgery or necropsy. The following M-mode signs were examined for their ability to detect a flail valve: (1) systolic flutter of the mitral valve closure line, sensitivity 29%, specificity 76%; (2) abnormal diastolic posterior leaflet motion, sensitivity 73%, specificity 71%; (3) abnormal diastolic anterior leaflet motion, sensitivity 67%, specificity 86%; (4) systolic atrial echoes, sensitivity 28%, specificity 68%; (5) multiple independent systolic closure lines, sensitivity 71%, specificity 52%. The two-dimensional echocardiographic signs evaluated were (1) diastolic inversion of the anterior leaflet toward the left atrium, sensitivity 29%, specificity 96%; (2) diastolic inversion of the posterior leaflet toward the left atrium, sensitivity 54%, specificity 93%, (3) systolic inversion of the anterior leaflet into the left atrium, sensitivity 57%, specificity 93%; (4) systolic inversion of the posterior leaflet into the left atrium, sensitivity 79%, specificity 86%; (5) systolic whipping of the mitral leaflets, sensitivity 73%, specificity 74%; (6) presence of floating apical chordae, sensitivity 30%, specificity 91%. Doppler echocardiographic signs evaluated were (1) presence of left atrial systolic antegrade flow, sensitivity 30%, specificity 91%; (2) vertical striations superimposed on the typical regurgitant flow pattern, sensitivity 75%, specificity 69%. When all the two-dimensional signs except systolic whipping and the M-mode signs for abnormal diastolic leaflet motion were combined, the sensitivity for detecting a flail mitral valve was maximized at 97%, but specificity was reduced to 64%. In conclusion, two-dimensional echocardiographic signs are more sensitive and specific than either M-mode or Doppler signs for detecting a flail mitral valve. The various M-mode, two-dimensional, and Doppler echocardiographic signs, however, are complementary to each other, and sensitivity is maximized when they are combined.