Incorrect echocardiographic diagnosis in patients with mechanical prosthetic valve dysfunction: correlation with surgical findings.

PURPOSE: To identify the rate of occurrence and type of incorrect echocardiographic diagnoses in patients with mechanical valve prostheses. PATIENTS AND METHODS: We studied 170 consecutive patients (73 women and 97 men) with a total of 208 prostheses who underwent surgery for mitral (n = 136) or aortic (n = 72) valve dysfunction between January 1991 and December 1997. Preoperative echocardiographic data were compared with surgical findings. Any major discrepancy between the echocardiographic reports and surgery was judged to be unconfirmed when the preoperative echocardiographic diagnosis was not confirmed at surgery, but the prosthesis was found to be dysfunctioning; and was judged to be erroneous when the preoperative echocardiographic diagnosis was not confirmed, and surgical inspection failed to reveal any other prosthetic abnormality. RESULTS: There were 25 (12%) diagnostic errors. Of the 136 mitral prostheses, there were 9 unconfirmed diagnoses of paravalvular regurgitation (6 had a fibrous tissue overgrowth, 1 had a thrombus with fibrous tissue overgrowth, 1 had endocarditis vegetations, and 1 had a ball variance) and 5 erroneous diagnoses. Eleven diagnostic errors were made in the 72 aortic prostheses: there were 9 unconfirmed diagnoses (paravalvular regurgitation was diagnosed as transvalvular in 7, and transvalvular regurgitation as paravalvular in 2 cases), and 2 erroneous diagnoses. CONCLUSIONS: Although echocardiography has gained great credibility among clinicians, special care should be taken when assessing patients in whom prosthetic valve dysfunction is suspected.

Outpatient intermittent dobutamine therapy in congestive heart failure.

BACKGROUND: Patients with severe heart failure often progress to the condition where oral agents alone are inadequate to maintain a clinically compensated state. The use of outpatient intravenous inotropic therapy is contentious because it may hasten the progression of the underlying disease or aggravate existing ventricular dysrhythmia. We describe the clinical outcome of 40 pts with severe congestive heart failure (CHF) treated with outpatient dobutamine (D) Therapy. METHODS: Outpatient inotropic therapy with D was started in 40 pts (36 males, 4 females, mean age 56.3±9 years) with chronic CHF and persistence of severe symptoms despite maximal oral therapy. All the pts had required hospitalization with need for i.v. inotropic therapy during the previous 6 months (mean hospital stay 41±28 days).At baseline 35 pts were in NYHA class IV, 5 in class III, mean echo LVEF was 23±5%, cardiac index 1.8±0.4l/min/m(2), pulmonary capillary wedge pressure 22±9.4 mmHg. 18 pts were listed for heart transplantation (HTx). D was infused with portable pumps via permanent i.v. catheters and the mean dose was 3.0±0.83µg/kg/min (range 2-5). The duration of home infusion period was 60±30h/week (range 24-168). RESULTS: During follow-up (mean 393±482 days, range 10-2182) NYHA class improved (III=32-=8). There were 19 hospitalizations in 14 pts (mean hospital stay 12.7±4 days). All the listed pts underwent HTx with 1 intrahospital death, 1 late death (1591 days for lung cancer) and 16 long-term survivors (mean post-operation follow-up 936±215 days). Fourteen not listed pts died after prolonged support (580±252 days - 13 for irreversible HF, accounting for the majority of rehospitalizations and 1 suddenly while not on D infusion). One pt developed non-fatal SVT during D infusion. There were no mechanical or infectious complications related to the device. CONCLUSIONS: Low-dose outpatient D therapy improved NYHA class and decreased hospitalization in pts with refractory CHF without major deleterious effects that may impact adversely on survival on the waiting list.

A semiquantitative approach to the evaluation of acute cardiac allograft rejection at endomyocardial biopsy.

BACKGROUND: Histopathologic criteria for grading of acute cardiac allograft rejection are focused on the most severe lesion that is recognized among the myocardial fragments provided by each endomyocardial biopsy specimen. Considering the distribution of rejection lesions among all the fragments improved the accuracy in characterizing the severity of rejection in pathologic studies. This study was undertaken to verify the usefulness of a semiquantitative evaluation of endomyocardial biopsy specimens, consisting of the calculation of the proportion of fragments showing rejection in the clinical setting. METHODS: Of the 2386 biopsy specimens obtained during the first posttransplantation year in 168 consecutive cardiac allograft recipients, 290 biopsy specimens constituted by > or = 3 adequate fragments and showing rejection not followed by treatment (n = 159) or being the first biopsy specimen prompting treatment with augmented immunosuppression for that rejection episode (n = 131) were selected. These biopsy specimens (index biopsy specimens) were grouped according to whether rejection was present in < or = 33%, > 33% to < or = 67%, and > 67% of the fragments. The rejection grade (according to the standardized grading system) and the proportion of fragments positive for rejection were correlated with the occurrence of clinical symptoms and signs of rejection at index biopsy and with the results of the next biopsy. RESULTS: Rejections graded > or = 3A were more frequently symptomatic (36% vs 9% for those graded < 3, p < 0.0001), as were those involving increasing proportions of fragments (< or = 33%: 5 of 124, 4%; > 33 to < or = 67%: 13 of 99, 13%; > 67%: 19 of 67, 28% [p < 0.0001]). Spontaneous resolution after untreated biopsies was more frequent in focal (grade 1A and 2) than in diffuse mild (1B) rejections (68% vs 38% [p < 0.04]), whereas progression to grade 3A or greater was less frequent (4% vs 27% [p < 0.01]). Increasing proportions of positive fragments were associated with lower frequencies of spontaneous resolution (p < 0.05) and higher frequencies of worsening (9%, 22%, 43% [p < 0.009]) or progression to grade 3A or greater (2%, 6%, 28% [p < 0.005]). Complete resolution after treatment was less frequent for increasing proportions of positive fragments at index biopsy (80%, 66%, 49% [p < 0.05]). CONCLUSIONS: Diffuse versus focal rejection pattern and the proportion of positive fragments seem to be clinically relevant in terms of occurrence of symptoms, spontaneous evolution, and response to treatment.

[Possible influence of hemodynamic and neurohormonal factors on the heart's response to arterial hypertension]. / Possibile influenza di fattori emodinamici e neurormonali sulla risposta del cuore all'ipertensione arteriosa.

Hypertrophy represents a frequent but inconstant response of the heart to hypertension and probably other nonhemodynamic factors are involved. We have performed 2D and Doppler echocardiography and assessed of neurohumoral pattern in 85 untreated patients with hypertension (diastolic blood pressure: 101 +/- 12.8 mmHg). Left ventricular hypertrophy was defined as a mass index greater than 134 g/m2 in males and 110 g/m2 in females. Doppler evaluation of left ventricular filling pattern was performed to detect the possible association of hypertrophy and diastolic dysfunction. In all patients the following neurohumoral substances were sampled and tested: plasmatic renin activity (PRA), aldosterone and norepinephrine. At Doppler echocardiography, 27 patients had hypertrophy and diastolic dysfunction, 15 only hypertrophy and 43 only diastolic dysfunction. The presence or absence of morpho-functional anomalies were independent of age, duration of hypertension and blood pressure levels. The mean value of neurohumoral substances were: norepinephrine 323.3 +/- 245 pg/ml, PRA 2.5 +/- 4 ng/ml/h, aldosterone 153.58 +/- 102 pg/ml. A significant correlation was found between PRA and blood pressure, and between aldosterone and all the Doppler-derived parameters of diastolic dysfunction. In conclusion, left ventricular hypertrophy seems to be related to alteration in ventricular geometry rather than to hemodynamic factors. Among nonhemodynamic factors, aldosterone may be the most responsible for abnormal filling, presumably through the activation of collagen matrix growth.

Evaluation of the effectiveness of isradipine SRO in the treatment of hypertensive patients with left ventricular hypertrophy.

Myocardial hypertrophy is a response to many diseases, above all hypertension, that involves morphological and functional damage and may be the basis for the development of myocardial dysfunction. We attempted to verify the effectiveness of a new calcium antagonist, isradipine 5 mg SRO, on the reversal of left ventricular hypertrophy. For this purpose 13 hypertensive patients (pts) were treated for 12 weeks, which is the minimum period described in the literature for the regression of hypertrophy. At the end of the study, blood pressure in all patients returned to normal levels (mean blood pressure from 120.15 +/- 4.4 to 108 +/- 6.4 mmHg, p < 0.001); end-systolic stress (from 128 +/- 30 to 65 +/- 14 g/cm2, p < 0.001), and left ventricular mass index (from 142 +/- 31 to 97 +/- 23 g/m2, p < 0.001) showed significant reduction. Moreover, Doppler-derived indexes of left ventricular filling improved, particularly early to late peak velocity of the mitral valve (E/A ratio) and deceleration time (from 235 +/- 37 to 198 +/- 17 msec, p < 0.001), which were normalized after 12 weeks. In conclusion isradipine shows rapid effects in the reversal of morphofunctional damage in hypertension. For this reason it also appears to be useful for the treatment of myocardial hypertrophy in the absence of chronic hypertension.

[Pulmonary venous flow in atrial fibrillation evaluated by transesophageal Doppler echocardiography]. / Il flusso venoso polmonare nella fibrillazione atriale valutato mediante ecocardiografia Doppler transesofagea.

Pulmonary venous flow (PVF) can be recorded by transesophageal echocardiography. In normal subjects the PVF is triphasic with 2 peaks in systole and 1 peak in diastole. At atrial contraction it is possible to record a reversal flow (A wave). The evaluation of PVF pattern in patients in atrial fibrillation can better explain the role of atrial contraction. We considered 18 patients with chronic atrial fibrillation with transesophageal Doppler echocardiography. Then we compared the pattern obtained from patients with atrial fibrillation with the normal pattern. During atrial fibrillation we observed a flow reversal during early systolic period. The diastolic wave was increased and prolonged. We also observed that the A wave seems to disappear. The loss of atrial contraction deeply modifies the Doppler PVF.

[Transesophageal Doppler study of pulmonary venous flow: the role of atrial contraction]. / Doppler transesofageo del flusso venoso polmonare: ruolo della contrazione atriale.

Pulmonary venous flow (PVF) pattern can be easily recorded by using transesophageal Doppler echocardiography. Recent reports suggest that the analysis of PVF pattern could be useful to better understand the role of atrial contraction on left ventricular filling. In order to evaluate the effect of loss of atrial contraction, we studied 50 consecutive patients with atrial fibrillation. We then compared the PVF pattern of atrial fibrillation with the normal pattern obtained from 20 healthy subjects. The reversal flow (A wave) resulting from atrial contraction was lost in patients with atrial fibrillation. The systolic flow was composed by 1 wave in almost all the patients and the peak velocity was reduced compared to normal sinus rhythm. On the contrary, the diastolic flow was increased comparing to normal subjects. In atrial fibrillation the flow shifted from systolic to diastolic filling. The restore of sinus rhythm induced a normalization of PVF pattern.

[Diagnosis and assessment of thrombolytic efficacy in left atrial thrombosis using transesophageal echocardiography]. / Diagnosi e valutazione dell'efficacia trombolitica nella trombosi atriale sinistra mediante ecocardiografia transesofagea.

In order to evaluate the incidence of atrial thrombosis 17 patients underwent transesophageal echocardiography (TEE). They were referred to our department because of a recent systemic embolic event and we found thrombi located in the left atrial appendage in 14 patients, in 5 cases in the left atrium and in 4 cases in the right atrium. Transthoracic echocardiography showed left atrial masses in 5 patients. Transesophageal echocardiography was more sensitive than transthoracic echocardiography in detecting atrial thrombi. Fifteen patients were treated with thrombolytic therapy using urokinase or rt-PA. To evaluate the efficacy of thrombolysis, we repeated TEE immediately after the infusion and 24 hours later. We observed a reduction of the mass of thrombi in all patients; the effect of therapy was not different 24 hours later. Our study underlines the diagnostic power of TEE in detecting atrial thrombosis and also suggests the use of TEE in the evaluation of the efficacy of thrombolytic therapy.