Balanced left ventricular myocardial SSFP-tagging at 1.5T and 3T.

The purpose of the study was to evaluate the performance of steady-state free precession (SSFP)-tagging at 1.5T and 3T and to define the ideal settings with respect to optimized tag contrast throughout the cardiac cycle for both field strengths. To identify optimal imaging parameters data acquisition was repeated for different flip angles. Left ventricular tag-tissue contrast, tag fading times, tag persistence, and myocardial signal-to-noise ratio (SNR) were quantified in basal, mid-ventricular, and apical slice locations. To assess the effect of field strength on image quality and artifact level, additional semiquantitative image grading was performed by two experienced readers. SSFP-tagging at 3T proved superior to 1.5T and provided significantly enhanced tag persistence and myocardial SNR while maintaining overall image quality and artifact level. The definition of a tag quality index demonstrated optimal SSFP-tagging performance for a flip angle of 20 degrees . Diastolic tag visibility was improved at 3T and resulted in enhanced average tag persistence of 789 +/- 128 ms compared to 523 +/- 40 ms at 1.5T. For SSFP-tagging at 3T the combination of T(1) lengthening and superior myocardial SNR is highly promising and has the potential to improve the depiction of tagged myocardial function throughout the entire cardiac cycle.

Reliability of aortic MRI at 3 Tesla in patients with acute cryptogenic stroke.

OBJECTIVES: To evaluate a new three dimensional (3D) MRI protocol for the reliable detection of aortic high risk plaques compared with transoesophageal echocardiography (TOE) and to test the reliability of additional MRI in stroke of undetermined aetiology. METHODS: 74 acute stroke patients were examined by both TOE and MRI at 3 Tesla with special regard to aortic high risk plaques (ie, > OR = 4 mm, superimposed thrombi). ECG synchronised pre- and post-contrast T1 weighted 3D imaging (spatial resolution approximately 1 mm3) covering the thoracic aorta was employed. In plaques > OR = 3 mm, additional two dimensional T2 imaging and time resolved (CINE) imaging sequences were performed. Aetiology of brain ischaemia was classified according to modified TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Aortic high risk embolic sources detected by MRI in patients with cryptogenic stroke were evaluated. RESULTS: Differences in maximum aortic wall thickness for TOE and MRI were not statistically significant for all aortic segments. The overall number of high risk plaques detected by MRI (n = 74) was substantially higher compared with TOE (n = 47). Most noticeably, MRI identified aortic high risk pathologies in 8/26 (30.8%) patients with cryptogenic stroke after standard diagnostics, including TOE (n = 2: dissection or thrombus; n = 6: plaques > OR = 4 mm). CONCLUSIONS: Our results demonstrate the feasibility of this 3D MRI protocol for the reliable detection of aortic high risk plaques in acute stroke patients. Because of improved visualisation of the aortic arch and the detection of additional embolic sources not seen by standard diagnostics, this novel technique may become a valuable tool for future patients with cryptogenic stroke.

Actual management of patients with familial ascending aortic aneurysms and type-A aortic dissections.

BACKGROUND: There are few families with the diagnosis of ascending aortic aneurysm and acute type-A aortic dissection inherited as an autosomal-dominant disorder in the absence of a known genetic syndrome. METHODS: We investigated a family with 26 members in whom ascending aortic aneurysms and acute type-A aortic dissections occurred over three generations. Examinations were performed to identify family members at specific risk. RESULTS: Six members presented with acute type-A aortic dissections and three relatives had ascending aortic aneurysms. Clinical examinations showed no characteristics of a known genetic syndrome. Molecular genetic analysis revealed no mutations known to cause a form of autosomal-dominant inherited aortic disease. CONCLUSION: Adequate diagnostic measures are mandatory in families with ascending aortic aneurysms or type-A aortic dissections to identify or exclude family members at risk for aortic diseases. Even in the absence of identifiable mutations causing isolated aortic aneurysms or aortic dissections, we recommend standardised examinations of all first-degree relatives of affected families. An indication for prophylactic aortic root replacement should be considered for patients at risk.

Do stroke patients with normal carotid arteries require TEE for exclusion of relevant aortic plaques?

OBJECTIVES: This study investigated (a) the hypothesis that stroke patients with aortic atheroma would show comparable atherosclerotic changes in the carotid arteries, which are easily accessible for ultrasound evaluation and (b) the possibility of carotid duplex sonography as a replacement for transoesophageal echocardiography (TEE) for the exclusion or prediction of relevant aortic plaques. METHODS: In 301 consecutive patients (mean age 62 years) with acute cerebral ischaemia, two dimensional ultrasound measurements were taken of common carotid artery intima media thickness (IMT) and maximal plaque area (PA) and the local degree of internal carotid artery (ICA) stenosis were determined. Maximal aortic wall thickness (AWT) was assessed by TEE. RESULTS: An IMT < or =0.9 mm yielded a negative predictive value (NPV) of 95.8% for exclusion of aortic atheromas > or =4 mm and an NPV of 100% for the exclusion of aortic thrombi. However, positive predictive value of IMT >0.9 mm was low (29.6%), increasing only slightly in the presence of carotid plaques (33%). Incidence of aortic thrombi was significantly higher with > or =50% compared with <50% ICA stenosis (11.3% v 3.9%, respectively). IMT and PA correlated moderately with AWT (r = 0.47, r = 0.53, respectively; p<0.001). Systolic blood pressure, coronary heart disease and peripheral artery disease, increased IMT, and ICA stenosis > or =50% were independently related to AWT > or =4 mm. CONCLUSIONS: A high NPV of normal carotid ultrasound does not support routine TEE for the exclusion of complex aortic plaques as a high risk source of cerebral embolism. However, in patients with carotid atherosclerosis, particularly in those with ICA stenosis > or =50%, TEE should be performed to exclude an additional high risk source for stroke.

Prognostic value of the ECG on admission in patients with acute major pulmonary embolism.

A number of ECG abnormalities can be observed in the acute phase of pulmonary embolism (PE). Their prognostic value has not yet been systematically studied in large patient populations. In 508 patients with acute major PE derived from a large prospective registry, the current authors assessed, on admission, the impact of specific pathological ECG findings on early (30-day) mortality. Atrial arrhythmias, complete right bundle branch block, peripheral low voltage, pseudoinfarction pattern (Q waves) in leads III and aVF, and ST segment changes (elevation or depression) over the left precordial leads, were all significantly more frequent in patients with a fatal outcome. Overall, 29% of the patients who exhibited at least one of these abnormalities on admission did not survive to hospital discharge, as opposed to only 11% of the patients without a pathological 12-lead ECG. Multivariate analysis revealed that the presence of at least one of the above ECG findings was, besides haemodynamic instability, syncope and pre-existing chronic pulmonary disease, a significant independent predictor of outcome. In conclusion, ECG may be a useful, simple, non-costly tool for initial risk stratification of patients with acute major pulmonary embolism.

[Cardiac arrhythmias and sudden cardiac death in women]. / Herzrhythmusstörungen und plötzlicher Herztod bei Frauen.

BACKGROUND: Gender specific cardiac arrhythmias have been recognized for more than 80 years. The impact of gonadal steroids on the autonomic system and on the cellular electrophysiology of the cardiac autonomic system are discussed as is a direct genetic disposition on a cellular, functional or metabolic level. We nevertheless have to be aware of age- and gender-specific differences of heart diseases, which have an impact on the incidence, form and severity of cardiac arrhythmias. CARDIAC ARRHYTHMIAS IN WOMEN: Gender-specific electrophysiologic differences like a higher basic heart rate and a longer QT-interval, beginning after puberty, are the main changes in ECGs in women and have a strong relationship to constitutional and hormonal influences. Supraventricular arrhythmias, i. e. in women sinus and AV-nodal-reentry tachycardias, less frequently Wolff-Parkinson-White tachycardias, may show clearly cyclical differences. Atrial fibrillation is more frequent in women, is more symptomatic, and there are more problems in therapy. Ventricular arrhythmias, occurring equally in healthy persons, show a strong relationship to coronary artery disease in men, which is less significant in women (in women more arrhythmogenic co-factors). Women suffer from acquired and congenital long-QT syndrome, and consequently more often from torsade-de-pointes tachycardias (stronger drug-induced QT-lengthening, more short-long sequences, differences in Ikr sensitivity). Sudden cardiac death is three times more often in men. Women suffer from it about ten years later; it is a more heterogenous phenomenon than in men, and the prognosis is worse. Women are underrepresented in controlled studies for primary and secondary prevention compared to men. CONCLUSIONS: As the underlying reasons of gender-specific differences in cardiac arrhythmias are not known in detail, the findings discussed imply the necessity of more basic studies to evaluate gender-specific solutions for risk stratification and therapy.

Experimental model for heart failure in rats--induction and diagnosis.

BACKGROUND: Clinical heart failure is generally preceded by hypertrophy. Many animal models (e. g. toxic heart failure models) do not consider this hypertrophy. We set out to develop a heart failure model in rats by inducing pressure-overload hypertrophy. METHODS: We induced coarctation of the aortic arch with a tantalum clip (0.35 mm internal diameter) In 3-week-old rats (n=17). Starting at seven weeks postoperatively, we measured ejection fraction (EF), fractional shortening (FS), end-systolic (LVESD) and end-diastolic (LVEDD) left ventricular dimensions by echocardiography each week. Heart, lung, and liver specimens were analyzed histopathologically at least eleven weeks after the operation. RESULTS: Contractile function was significantly decreased in hearts from animals with aortic banding (EF: 45+/-5% vs. 73+/-5%, p<0.01; FS: 20+/-3% vs. 35+/-5%, p<0.01). At the same time, left ventricles were dilated (LVEDD: 9.1+/-0.6 mm vs. 7.4+/-0.5 mm; LVESD: 7.3+/-0.6 mm vs. 4.8+/-0.4 mm, p<0.01). These observations were associated with clinical and histopathological changes characteristic for chronic left heart failure. CONCLUSION: Placing a tantalum clip around the aortic arch in 3-week-old rats consistently induces left ventricular decrease in contractile function and dilatation after eleven weeks.

Improved 3-D-echocardiographic endocardial border delineation using the contrast agent FS069 (Optison) transesophageal studies in a porcine model.

3-D echocardiography has the potential for quantitative assessment of regional wall motion. However, the 3-D procedures used to date do not provide the same spatial and temporal resolution as 2-D echocardiography, which results in problems with border delineation of the endocardium. There are, as yet, few studies testing if the use of contrast agent can improve endocardial definition in the 3-D data set. FS069 (Optison) was used for the first time for this purpose in the present study. A total of 12 mechanically-ventilated pigs were examined by transesophageal 3-D echocardiography, 1. using fundamental imaging and 2. following left-atrial injection of FS069 (Optison). The left ventricle was analyzed using an 18-segment model. Score with the value 0 (not visible), 1 (moderately visible) and 2 (well defined) were used to rate endocardial definition. All segments were assessed both end-diastolic and end-systolic. Various LV regions were examined by grouping segments (anterior/lateral/inferior and basal/mid-ventricular/apical). Using the contrast agent, the proportion of nonvisible segments fell diastolic from 40 (18.5%) to 15 (6.9%), and systolic from 26 (12.0%) to 11 (5.1%). The proportion of well defined segments increased diastolic from 62 (28.7%) to 108 (50%) and systolic from 73 (33.8%) to 123 (56.9%). The mean visibility score increased diastolic from 1.10 +/- 0.68 to 1.43 +/- 0.62 (p < 0.001), systolic from 1.22 +/- 0.64 to 1.52 +/- 0.59 (p < 0.001). The benefit was greatest in regions where the visibility score was lowest without contrast: in the area of the lateral wall and systolic near the apex. In conclusion, the use of FS069 (Optison) results in significantly better endocardial delineation in the 3-D data set. This could be important in future for the 3-D echocardiographic assessment of regional wall motion.

Dynamic changes of atrial septal defect area: new insights by three-dimensional volume-rendered echocardiography with high temporal resolution.

AIMS: The purpose of this study was: (i) to record dynamic changes in the area of atrial septal defects (ASD) during a cardiac cycle, and (ii) to investigate factors which influence ASD dynamics. Implementation of new software modifications allowed the frame rate to be doubled, as compared to usual techniques. METHODS AND RESULTS: Twenty patients were examined using transoesophageal three-dimensional (3D) echocardiography. In 10 patients the 3D dataset was recorded with a frame rate of 25Hz, in another 10 patients with a frame rate of 50Hz. The ASD area was planimetried for each picture and the changes analysed over time. The ASD area showed dynamic changes during the cardiac cycle with an end-systolic maximum and end-diastolic minimum. The influence of the various phases of the cardiac cycle on area changes could be differentiated especially at higher temporal resolution. The relative change in ASD area showed no significant relationship to Q(p)/Q(s)ratio, mean ASD size or heart rate. By contrast, there was a slight inverse correlation to age (r=-0.t45,P <0.05). CONCLUSION: Transoesophageal 3D volume-rendered echocardiography permits quantitative recording of ASD dynamics. The ASD area changes are influenced especially by the various phases of the cardiac cycle.

[Non-invasive diagnostic procedures for heart failure: echocardiography, myocardial perfusion scintigraphy and radionuclide ventriculography]. / Nicht-invasive Untersuchungen zur Diagnose der Herzinsuffizienz: Echokardiographie, Myokardszintigraphie und Radionuklidventrikulographie.

Even though the diagnosis of heart failure can often be made at bedside from the patient's history and a thorough physical examination, some mechanical examinations are needed to objectify the clinical symptoms. Due to the chronic and progressive character of heart failure with repeated periods of clinical treatment, non-invasive and reproducible methods are of great importance. Thanks to technical progress in data-acquisition and -processing, echocardiography has become one of the most important diagnostic tools in clinical cardiology. Many questions associated with the diagnosis and treatment of heart failure can be answered with the aid of the wide spectrum of echocardiography, including morphological description in conventional M- or B-Mode and functional analysis based on Dopplertechnique. On the other hand well-established nuclear techniques like myocardial perfusion scintigraphy and radionuclide ventriculography profit from recent technical development. In addition, the modification, specification and standardisation of examination protocols improve the diagnostic reliability of nuclear medical techniques. Performed by a specialist, both principles of examination--ultrasound and scintigraphy--are valid in the diagnosis of heart failure and in therapy-management.

Myxoma of the mitral valve: diagnosis by 2-dimensional and 3-dimensional echocardiography.

In this report we describe a 39-year-old patient who had left-sided hemiparesis. In search of a source of embolism, we performed transthoracic echocardiography, which did not show any abnormalities. Transesophageal echocardiography revealed a small tumor of the posterior mitral leaflet. Three-dimensional transesophageal echocardiography was subsequently performed and demonstrated more accurate information about the size, the morphology, and the attachment point of the tumor. Furthermore, the reconstruction provided excellent spatial visualization of the pathomorphology of the mitral valve and was a useful addition for optimal preoperative diagnostic management. The tumor was excised, and histologic examination confirmed the myxomatous character of the tumor. Mitral valve myxomas are rare. This is the first case reported of a mitral valve myxoma being visualized by 3D echocardiography.

[Echocardiographic evaluation in unoperated congenital heart disease in adults]. / Echokardiographische Diagnostik angeborener Herzfehler im Erwachsenenalter.

Echo and Doppler echocardiographic procedures have gained special importance in the diagnostics of congenital diseases in adults. These procedures permit detailed visualization of the pathomorphology of the heart as well as reliable evaluation of the hemodynamic changes. There are differentiated indications for the various procedures, such as transthoracic and transesophageal echocardiography, Doppler and color-Doppler echocardiography, contrast echocardiography and 3-dimensional echocardiography. This article discusses the opposition of the various echo and Doppler echocardiographic procedures with respect to the diagnostics of the most frequent non-operated congenital diseases in adults. The pathomorphology of the various congenital diseases will be summarized and then the important echocardiographic criteria presented which are decisive for the diagnostic procedure. In simple congenital malformation of cardiac valves, such as bicuspid aortic valve (Figure 1: aortic ring abscess), pulmonary valve stenosis (Figure 2), Ebstein's anomaly (Figure 3) or malformations of the mitral valve (Figure 4: cleft in the anterior mitral cusp), the diagnosis can often be made using transthoracic echo and Doppler echocardiography, and the severity of the defect determined. However, the sonographic conditions, especially in adults, are frequently too limited to permit recognition of detailed smaller changes, so that transesophageal examination is required to finally confirm the diagnosis in these patients. In the diagnostics of diseases of the left ventricular outflow tract and the thoracic aorta, such as subvalvular aortic valve stenosis (Figure 5), the sinus of Valsalva aneurysm or the coarctation of the aorta (Figure 6), the left ventricular outflow tract can be evaluated morphologically from a transthoracic procedure and the accelerations of flow can be recorded by continuous wave Doppler. If there is no sclerosis of the fibrous membrane, these can often not be depicted by transthoracic procedures, so that a supplementary transesophageal examination is meaningful. This is required in any case for diseases of the descending thoracic aorta. In the case of congenital lesions, such as atrial septal defects (Figure 7: anomalous pulmonary venous return, Figure 8: 3-dimensional visualization of an atrial septal defect, Figure 9: sinus venosus defect), ventricular septal defect or a patent ductus arteriosus Botalli (Figure 10), color-Doppler and contrast echocardiography have become especially important. Transesophageal examination is also indicated for these congenital diseases for direct depiction of the defect as well as for precise evaluation of the shunt. Moreover, in atrial septal defects, it has been shown that a 3-dimensional echocardiography provides additional advantage with respect to spatial relationship of the defect to the other cardiac structures, as well as presenting dynamic changes during a heart cycle. Extensive knowledge of complex congenital heart disease, such as tetralogy of Fallot (Figure 11), complete transposition of the great arteries, congenitally corrected transposition of the great arteries (Figure 12), the double-outlet right ventricle, truncus arteriosus communis, the cor triatriatum, tricuspid atresia (Figure 13) or the univentricular heart (Figure 14) usually requires performance of a transthoracic echo- and Doppler echocardiographic examination to assess the pathomorphological changes and to examine hemodynamics. In the majority of patients, supplementary transesophageal echocardiography and an echo contrast examination are important. Initial examinations using 3-dimensional echocardiography are very promising in this connection and with respect to the exact spatial presentation of pathoanatomical structures.

Submassive and massive pulmonary embolism: a target for thrombolytic therapy?

Thrombolytic agents have been consistently demonstrated to dissolve pulmonary thrombi much more rapidly and effectively than heparin alone. Rapid resolution of pulmonary embolism (PE) is accompanied by a significant decrease in pulmonary artery pressure and an improvement in right ventricular function. However, it is no longer than 7 days until the findings of patients treated with heparin improve to a similar extent. Previous studies were not designed to determine whether this short-lasting difference in favor of thrombolysis can indeed affect the prognosis of patients with PE and thus justify the 1% (or even higher) risk of cerebral or fatal bleeding. Recently, two large registries demonstrated the importance of right ventricular dysfunction assessed by echocardiography as an independent predictor of mortality. Thrombolytic treatment was shown in one of these registries to be associated with a 50% reduction of death risk in clinically stable patients with right ventricular enlargement. It was thus possible to identify a group of patients with massive PE who are most likely to benefit from early thrombolysis. These findings now have to be confirmed by a prospective randomized trial which will compare thrombolysis with heparin alone in this high-risk patient population, focusing on clinical end points such as overall and event-free survival in the acute phase of PE.

Comparison of alteplase versus heparin for resolution of major pulmonary embolism.

Complete resolution of major pulmonary embolism (PE) treated with heparin alone can often take > 3 weeks. Thrombolytic agents effectively resolve pulmonary artery thrombi within a few hours. However, the effect of the 2 types of treatment on recovery of right ventricular function has not yet been followed for periods of > 24 hours. We prospectively examined 40 consecutive patients with documented major PE (symptoms being present for < or = 8 weeks). After diagnosis, 27 patients (68%) were treated with alteplase plus heparin and 13 (32%) with heparin alone. There was no significant difference between the 2 groups with regard to baseline parameters. At 12 hours, systolic pulmonary artery pressure decreased from 56 +/- 20 to 37 +/- 21 mm Hg in the alteplase group, and from 50 +/- 11 to 46 +/- 12 mm Hg in the heparin group (significantly more; p = 0.016). On echocardiographic follow-up, a decrease in end-diastolic dimensions of the right ventricle and an increase in left ventricular dimensions was significantly more pronounced in the alteplase group (p <0.001 and p = 0.05, respectively). The incidence of right ventricular dilation and paradoxical septal wall motion decreased significantly only in the thrombolyis group. However, at 1-week follow-up, no difference was seen between the 2 groups regarding the overall change in right or left ventricular dimensions or the final values of other echocardiographic parameters. Thus, echocardiography is particularly useful for hemodynamic follow-up of major PE. Thrombolysis may rapidly reduce pulmonary artery pressure, but resolution of right ventricular pressure overload also occurs within 1 week in patients treated with heparin alone.

Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism.

BACKGROUND: Right-to-left shunt through a patent foramen ovale is frequently diagnosed by contrast echocardiography and can be particularly prominent in the presence of elevated pressures in the right side of the heart. Its prognostic significance in patients with pulmonary thromboembolism, however, is unknown. METHODS AND RESULTS: The present prospective study included 139 consecutive patients with major pulmonary embolism diagnosed on the basis of clinical, echocardiographic, and cardiac catheterization criteria. All patients underwent contrast echocardiography at presentation. The end points of the study were overall mortality and complicated clinical course during the hospital stay defined as death, cerebral or peripheral arterial thromboembolism, major bleeding, or need for endotracheal intubation or cardiopulmonary resuscitation. Patent foramen ovale was diagnosed in 48 patients (35%). These patients had a death rate of 33% as opposed to 14% in patients with a negative echo-contrast examination (P=.015). Logistic regression analysis demonstrated that the only independent predictors of mortality in the study population were a patent foramen ovale (odds ratio [OR], 11.4; P<.001) and arterial hypotension at presentation (OR, 26.3; P<.001). Patients with a patent foramen ovale also had a significantly higher incidence of ischemic stroke (13% versus 2.2%; P=.02) and peripheral arterial embolism (15 versus 0%; P<.001). Overall, the risk of a complicated in-hospital course was 5.2 times higher in this patient group (P<.001). CONCLUSIONS: In patients with major pulmonary embolism, echocardiographic detection of a patent foramen ovale signifies a particularly high risk of death and arterial thromboembolic complications.

Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.

OBJECTIVES: The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism. BACKGROUND: The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated. METHODS: The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies. RESULTS: Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%). CONCLUSIONS: Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.

Transcatheter closure of atrial septal defects by the "buttoned" device: complications and need for surgical revision.

Immediate and medium-term experience with transcatheter closure of a secundum atrial septal defect by the "buttoned" device in seven patients is reported. Complications occurred in two patients during the procedure. In one patient with complications, the occluder was partly released in the right atrium. All efforts to correct its position were unsuccessful and caused considerable deformation of the device, which had to be removed surgically. In the other patient with complications, disconnection of the occluder and counteroccluder occurred immediately after removal of the loading wire. Both parts were retrieved by catheter. Five patients had uneventful closure of the atrial septal defect. On follow-up, however, displacement of the device towards the mitral valve was observed in two patients, which caused mitral regurgitation. Surgical removal of the device and repair of the mitral valve was necessary in both patients. Two years after the procedure, the atrial septal defect was closed completely in two of the remaining three patients and a small residual defect persisted in one patient.

Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry.

BACKGROUND: Thrombolytic treatment has been shown to accelerate resolution of major pulmonary embolism and lead to a rapid improvement of right-side hemodynamics. However, the association between these favorable effects and the clinical outcome of patients who have no severe hemodynamic compromise at presentation remains unknown. METHODS AND RESULTS: The present multicenter registry included 719 consecutive patients with major pulmonary embolism according to clinical, echocardiographic, scintigraphic, and cardiac catheterization criteria. Symptom onset was acute (<48 hours) in 63% of patients. All patients were hemodynamically stable (ie, without evidence of cardiogenic shock) at presentation. Primary thrombolytic treatment (within 24 hours of diagnosis) was given to 169 patients (23.5%), whereas the remaining 550 patients were initially treated with heparin alone. Overall 30-day mortality was significantly lower in the patients who received thrombolytic agents (4.7 versus 11.1%, P=.016). Clinical factors associated with a higher death rate were syncope (P=.012), arterial hypotension (P=.021), history of congestive heart failure (P=.013), and chronic pulmonary disease (P=.032). However, only primary thrombolysis was found by multivariate analysis to be an independent predictor of survival (odds ratio for in-hospital death, 0.46; 95% confidence interval, 0.21 to 1.00). Patients who underwent early thrombolytic treatment had a reduced rate of recurrent pulmonary embolism (7.7 versus 18.7%, P<.001) but also a higher frequency of major bleeding episodes (21.9% versus 7.8%, P<.001). Cerebral bleeding occurred in 2 patients in each treatment group, and 1 patient in each group died of a bleeding complication. CONCLUSIONS: The results of our study suggest that thrombolysis may favorably affect the clinical outcome of hemodynamically stable patients with major pulmonary embolism.

Noninvasive estimation of right ventricular systolic pressure in postinfarction ventricular septal rupture: an assessment of two Doppler echocardiographic methods.

OBJECTIVE: To evaluate the diagnostic accuracy of Doppler echocardiography in the assessment of right heart hemodynamics and the diagnosis of pulmonary hypertension in patients with ventricular septal rupture due to acute myocardial infarction. DESIGN: A prospective, echocardiographic and right-heart catheterization study. SETTING: Medical intensive care unit (ICU) of a university hospital. PATIENTS: Twelve consecutive patients admitted to the ICU with the diagnosis of ventricular septal rupture in the setting of acute myocardial infarction. Confirmation of diagnosis was made during surgery (11 patients) or by autopsy (one patient). INTERVENTIONS: All patients were examined by two-dimensional and Doppler echocardiography on admission and subsequently underwent bedside right-heart catheterization. MEASUREMENTS AND MAIN RESULTS: After identification and localization of the rupture site by two-dimensional echocardiography and/or color flow Doppler mapping, the maximal flow velocity of the transseptal jet was measured by continuous-wave Doppler and was used to calculate the peak interventricular pressure gradient by the modified Bernoulli equation. This value was subtracted from the systolic arterial blood pressure value to estimate right ventricular systolic pressure. The values obtained correlated well with catheter-derived measurements (r2 = .71; p = .001). Furthermore, in eight (67%) patients, right ventricular systolic pressure could also be determined by Doppler interrogation of the tricuspid regurgitant jet. Direct comparison of the results of the two echocardiographic methods yielded a good correlation (r2 = .66; p = .016). CONCLUSION: Doppler examination of the transseptal and tricuspid regurgitant jets is applicable to patients with ventricular septal rupture for rapid, noninvasive prediction of right ventricular hemodynamics.