Impact of aortic plaque morphology on survival rate and incidence of a subsequent embolic event ­ long-term follow-up data ­.

BACKGROUND: There are no reports about the long-term follow-up data of patients with aortic plaques among the Japanese population. The purpose of this study was to clarify the frequency of patients with severe aortic plaques and the impact of aortic plaque morphology on the prognosis. METHODS AND RESULTS: We retrospectively investigated 1,570 consecutive patients who underwent transesophageal echocardiography. Survival rate and subsequent embolic event rate were compared between patients with severe aortic plaque (>5 mm in thickness) and control patients. The relationship between aortic plaque morphology and prognosis was also estimated according to the presence of ulceration, calcification, hypoechoic plaques, and mobile plaques. The mean follow-up period was 8.7 years. Among 1,570 patients, severe aortic plaque was detected in 92 patients (5.9%). These 92 patients showed a significantly low survival rate and high subsequent embolic event rate compared to control patients (5-year survival rate: 69% vs 94%; 5-year embolic event free rate: 52% vs 95%). Among patients with severe aortic plaque, only ulceration was associated with a low survival rate (hazards ratio: 2.4, 95% confidence interval (CI): 1.1-5.2) and only mobile plaque was associated with a high embolic event rate (hazards ratio: 2.2; 95%CI: 1.1-5.1). CONCLUSIONS: Aortic plaque >5 mm in thickness was a predictor of poor prognosis. In the presence of aortic plaque >5 mm, ulceration was a predictor of a low survival rate and mobile plaque was a predictor of a high embolic event rate.

Usefulness of contrast echocardiography for detecting right-to-left cardiac shunts during the diagnosis of hypoxemia: 2 case reports.

We report two cases in which contrast echocardiography was useful for detecting right-to-left shunt. In case 1, a 53-year-old man was admitted to our hospital after being diagnosed with acute heart failure. Even after improvement of the heart failure, hypoxemia remained. Contrast echocardiography was performed. When contrast medium was injected into the left antecubital vein, it directly drained into the left atrium. When contrast medium was injected into the right antecubital vein, it drained into the right atrium not the left atrium. These findings proved the existence of a right-to-left shunt. In case 2, a 68-year-old man felt dyspnea on mild effort, especially when sitting in an anteflexing posture. In room air, his SpO2 was 95% when sitting in a resting posture and 79% when in an anteflexing sitting posture. Contrast echocardiography was performed. A patent foramen ovale (PFO) was proved using the Valsalva maneuver, and the contrast medium drained from right atrium into the left atrium via the PFO. He underwent patch closure of the PFO, and his symptoms disappeared. Contrast echocardiography should be performed for the diagnosis of chronic hypoxemia for which causes are not detected with routine clinical examinations, in order to confirm right-to-left shunt.

Late regression of left internal thoracic artery graft stenosis at the anastomotic site without intervention therapy.

OBJECTIVE: Intervention therapy has been recently performed on the left internal thoracic artery graft stenosis. The purpose of this study was to evaluate the natural course of the left internal thoracic artery graft stenosis at the anastomotic site and clarify whether intervention therapy should be performed early after surgery. METHODS: We investigated early angiographic results of the left internal thoracic artery graft in 343 consecutive patients who underwent coronary bypass surgery. In 100 of 343 patients who underwent follow-up angiography, the graft diameter and percentage diameter stenosis at the anastomotic site were compared between early postoperative and follow-up angiography. None of these patients underwent intervention therapy on the left internal thoracic artery graft. RESULTS: Of 343 patients, 46 showed 50% or greater diameter stenosis, and 20 showed 70% or greater diameter stenosis at the anastomotic site. In the 100 patients with follow-up angiography, the graft diameter significantly increased (1.8 +/- 0.4 vs 2.1 +/- 0.5 mm, P < .0001) at follow-up angiography. The percentage diameter stenosis significantly decreased (69% +/- 13% vs 35% +/- 20%, P < .0001) at follow-up angiography in the patients with 50% or greater diameter stenosis at early postoperative angiography. Regression of left internal thoracic artery graft stenosis was detected in most patients with 70% or greater diameter stenosis. CONCLUSIONS: Our study demonstrated that left internal thoracic artery graft stenosis at the anastomotic site at early postoperative angiography might improve without intervention therapy. We should consider the natural course of the left internal thoracic artery graft stenosis in determining the indication of intervention therapy early after surgery.

Infective endocarditis developing as uremia.

A 49-year-old man presented with fever and uremic symptoms such as general malaise, leg edema and decreased urine output. He was diagnosed as having infective endocarditis (IE) accompanied by renal failure. Although he had been receiving hemodialysis for a long time, renal function dramatically improved after heart valve replacement. This case suggests that uremia can develop as an initial manifestation of IE and removal of an infected heart valve can improve renal function despite persistent renal failure. From the perspective of recovery of renal function, early surgery should be considered in patients with renal failure following IE.

[Efficacy of transesophageal echocardiography in patients with cardiac arrest or shock].

OBJECTIVES: Only a few examinations are available to critically ill patients. We assessed the efficacy of transesophageal echocardiography (TEE) in the management of patients with cardiac arrest or shock. METHODS: Among a total of 2,021 patients who underwent TEE over the past 13 years at our institution, we reviewed 18 patients who underwent TEE during cardiac arrest or shock. RESULTS: TEE was performed in four patients with cardiac arrest and in 14 patients with shock. In 12 (67%) of 18 patients, TEE identified the following abnormalities: aortic dissection in four, ruptured thoracic aortic aneurysm in two, papillary muscle rupture in two, left ventricular free wall rupture in two, postoperative cardiac tamponade in one and ruptured chordae tendineae in one. TEE excluded suspected cardiac abnormality in two other patients. Transthoracic echocardiography could not be performed in 8 of 18 patients, and showed poor quality of images in the remaining 10 patients. Of the 12 patients with a diagnosis based on TEE, three patients died during cardiopulmonary resuscitation, whereas nine patients were treated with emergent surgery and six of these survived to hospital discharge. CONCLUSIONS: TEE is feasible even in patients with cardiac arrest or shock, and can play an important role in establishing the diagnosis and determining the treatment of such patients.

Usefulness of high-frequency transthoracic Doppler echocardiography in noninvasive diagnosis of the left internal thoracic artery graft stenosis at the anastomosis.

BACKGROUND: Stenosis of the left internal thoracic artery (LITA) graft, which usually occurs at the site of the anastomosis, can be noninvasively evaluated by the flow pattern in the proximal graft, but the flow pattern is influenced by several other factors. METHODS AND RESULTS: In the present study, LITA graft flow was investigated by high-frequency transthoracic Doppler echocardiography in 75 consecutive patients who underwent postoperative angiography of the LITA graft. The flow velocity was measured at both the anastomosis and proximal to it, and compared with the quantitative angiographic results. Flow at both sites was detected in 61 (81%) of the 75 patients. The diastolic velocity ratio of the anastomosis to the proximal site correlated with the percent diameter stenosis at the anastomosis. A diastolic velocity ratio >2.0 had a high sensitivity, specificity, positive predictive value and negative predictive value for the presence of significant stenosis at the anastomosis of a LITA graft. CONCLUSIONS: High-frequency transthoracic Doppler echocardiography can be used for the noninvasive diagnosis of LITA graft stenosis.