Coronary sinus diameter to estimate congestion and predict survival.

Background: Congestion predicts a poor prognosis, but its assessment is challenging in clinical practice and requires a multiparametric approach. We investigated if the coronary sinus (CS) diameter can predict mortality in a human model of rapid fluid unloading. Methods: We measured by echocardiography the CS, and the inferior vena cava (IVC) for comparison, in 60 patients with end-stage chronic kidney disease (ESKD) immediately before and after hemodialysis (HD; age 76 [57-81] years, 40% female, left ventricular ejection fraction 57 [53-56]%). Patients were prospectively followed up for all-cause mortality. Results: HD-induced decongestion decreased the maximum diameters of both CS and IVC (p ≤ 0.001 for all). The maximum diameter of the CS (CSmax) was as accurate as the IVC maximum diameter and collapsibility for the identification of congestion, defined as pre-hemodialysis status (AUROC CSmax = 0.902 vs IVC = 0.895, p = n.s.). A CSmax diameter after hemodialysis > 9 mm predicted all-cause mortality at 12 months (Log-rank Chi square = 11.49, p < 0.001). Conclusions: A persistently dilated CS after hemodialysis is a marker of residual congestion and predicts death at one year in high-risk ESKD patients.

Stress echocardiography pattern: a promising noninvasive test for detection of myocardial bridging with haemodynamic relevance.

: We reported a case of a young athlete with an underlying myocardial bridging in the left anterior descending coronary artery (LAD) causing myocardial ischemia suspected by contrast exercise stress echocardiography and confirmed by computed tomography coronary angiography. Our report demonstrated that a specific stress echocardiography pattern consisting of reversible focal buckling in the end-systolic to early-diastolic motion of the septum may suggest the presence of an underlying myocardial bridging in the LAD.

Addition of Exercise to Dipyridamole Stress Echocardiography in Order to Carry on the Ischemic Cascade: Role in the Diagnosis of Coronary Artery Disease and Prognostic Value.

BACKGROUND: Sensitivity of dipyridamole stress echocardiography (SE) is often lower than required. The aim of the present work is the evaluation of the association of dipyridamole and exercise echocardiography. METHODS: From June 2007 to January 2011, 259 consecutive patients referred to Camposampiero Echocardiography Laboratory underwent SE. Stress protocol started with dipyridamole infusion of 0.84 mg/kg over 6 min. In patients without a new dyssynergy after dipyridamole, SE was carried on with supine exercise. If endocardial border detection was suboptimal, ultrasound contrast agent was used. Coronary angiography was performed in positive patients. The events recorded during the follow-up were cardiac death, nonfatal myocardial infarction (hard events), and coronary revascularization. RESULTS: Of 259 patients, 74 had a positive result: 37 were positive after infusion of dipyridamole, and 37 became positive during exercise. All 74 positive patients underwent coronary angiography: 67 had significant coronary artery disease (36 positive with dipyridamole, and 31 positive with exercise), and 7 had not significant artery disease. In positive patients, the coronary revascularizations were 40. Furthermore, 3 of the 185 negative patients underwent coronary revascularization. During follow-up of 20 ± 10 months, 6 (8.1%) hard events occurred in positive patients. No hard event was observed in negative patients. CONCLUSIONS: Dipyridamole SE with the addition of exercise can be proposed as a strategy to carry on the ischemic cascade and to identify the patients who elude the dipyridamole alone SE. A negative result is suggestive of a very good prognosis, free from hard events at 20 ± 10 months.

Low cerebrovascular event rate in subjects with patent foramen ovale and different clinical presentations: results from a prospective non randomized study on a population including patients with and without patent foramen ovale closure.

BACKGROUND: There are conflicting data on the role of a patent foramen ovale (PFO) in the pathogenesis of cryptogenic stroke. The aim of this study was to evaluate the incidence of cerebrovascular events associated with PFO in a large population of patients during mid-term follow-up. METHODS AND RESULTS: We prospectively investigated 446 consecutive patients (58% female, age 50 ± 14 years) in whom PFO was detected by contrast echocardiography following cryptogenic stroke (30.5%), transient ischemic attack (TIA, 23.7%), migraine(10.5%) or evaluation for other cardiac diseases(35%). Prevalence of other clinical conditions potentially associated with cerebral embolism, such as mitral valve disease, atrial fibrillation and aortic atherosclerosis were 31%, 12.5%, 11.2%, respectively; 99 out of 446 patients (22%, group 1) underwent PFO closure, shortly after diagnosis, while 347 (78%, group 2) received only medical therapy (antiplatelet drugs and vitamin K antagonists). During 54 months (range 12-96) of average follow-up few events had been observed: one fatal stroke (1%) in group 1 and 3 nonfatal strokes (0.86%) in group 2 (not significant); there were more TIAs in group 1 than in group 2 (5, 5% versus 3, 0.86%, p=0.02): 8/12 new cerebrovascular events occurred in patients with previous cerebral ischemia and in 7/12 there were other cardioembolic sources. Kaplan-Meier survival free from cerebrovascular events showed a slightly better prognosis in unclosed PFO patients compared to closed PFO ones, statistically significant (p=0.004). CONCLUSIONS: New cerebrovascular events are rare in unselected subjects with PFO, even in those with previous cerebral ischemia and those who have not undergone PFO closure, with an event rate similar to that observed in the general population.

Microbubbles contrast inside the cyst: a pathognomonic sign of mitral valve blood cyst.

We report a case of giant blood cyst originating from the anterior mitral valve leaflet in an 18-year-old white girl. Contrast real-time transthoracic echocardiogram showed the presence of microbubbles inside the cystic cavity during diastole, confirming the presence of blood passage between the ventricular cavity and the cyst lumen and suggesting that this is a pathognomonic sign of the presence of a blood cyst. Although, in previous cases, contrast microbubbles inside the cyst have been described during systole, we report the presence of microbubbles during diastole.

Left ventricular dyssynchrony resulting from right ventricular apical pacing: relevance of baseline assessment.

OBJECTIVES: Evaluation of left ventricular (LV) dyssynchrony in patients undergoing short-term right ventricular apical (RVA) pacing and correlation with baseline echocardiographic and clinical characteristics. BACKGROUND: RVA pacing causes abnormal ventricular depolarization that may lead to mechanical LV dyssynchrony. The relationships between pacing-induced LV dyssynchrony and baseline echocardiographic and clinical variables have not been fully clarified. METHODS: Tissue Doppler echocardiography was performed in 153 patients before and after RVA pacing. LV dyssynchrony was measured by the time between the shortest and longest electromechanical delays in the five basal LV segments (intra-LV). The prevalence and degree of LV dyssynchrony after RVA pacing was evaluated in three groups: baseline LV ejection fraction (LVEF) <35%, 35-55%, and >or=55%. The intrapatient effect of RVA pacing was determined as the percent increase in intra-LV value (Deltaintra-LV%). The pacing-induced intra-LV was correlated with baseline variables. RESULTS: The prevalence and degree of LV dyssynchrony after RVA pacing was significantly higher in patients with lower LVEF (P < 0.001). DeltaIntra-LV% was inversely correlated with baseline intra-LV and LVEF (B =-2.6, B =-4.2, P < 0.001). Baseline intra-LV and LV end-systolic volume correlated positively with intra-LV after RVA pacing (B = 0.49, B = 0.6, P < 0.001), whereas LVEF showed an inverse correlation. CONCLUSIONS: The degree of LV dyssynchrony induced by RVA is variable. Patients with higher baseline LV dyssynchrony, more dilated LV, and more depressed LVEF showed a higher degree of LV dyssynchrony during pacing. These findings may assume importance in predicting the risk of heart failure in pacemaker patients.

Sine-wave pattern on the electrocardiogram and hyperkalaemia.

Hyperkalaemia is an electrolyte disturbance that can have effects on myocardial conduction causing electrocardiographic changes. Several factors may predispose to and promote potassium serum level increase leading to typical electrocardiographic abnormalities. We describe the case of a patient who presented with hyperkalaemia and an electrocardiographic aspect consistent with a sine-wave pattern.

Transoesophageal echocardiographic evaluation of pulmonary vein anatomy in patients undergoing ostial radiofrequency catheter ablation for atrial fibrillation: a comparison with magnetic resonance angiography.

OBJECTIVE: A detailed definition of pulmonary vein (PV) anatomy is of great importance in patients undergoing radiofrequency catheter ablation for atrial fibrillation. In fact, it is known that variations in the number and anatomy of the PV ostia are more frequent than thought. The aim of this study was to assess the usefulness of transoesophageal echocardiography (TOE) in defining the exact PV anatomy by comparing it with magnetic resonance angiography (MRA), which is proven to be very accurate. METHODS: Forty-five consecutive patients (39 male, 6 female, mean age 50 + or - 6 years) affected by drug-refractory atrial fibrillation underwent radiofrequency catheter ablation. They were all studied with MRA and then with TOE in order to exclude intra-atrial thrombi and to assess PV anatomy. RESULTS: TOE visualised the superior PVs in 100% of cases and the right and left inferior PVs in 98% and 94% of cases, respectively. Only 19 patients (42%) showed typical PV anatomy, with two left and two right distinct PV ostia. In 14 patients (31%), one or two intermediate right PVs and in 12 patients (27%) a common left trunk were detected. The concordance with MRA was high (95%). CONCLUSIONS: TOE is accurate in assessing PV anatomy and in showing anatomic variations in the PV ostia compared with MRA. Anomalous pulmonary venous drainage is more frequent than expected. TOE can provide functional Doppler information, thus being particularly useful in the follow-up after radiofrequency catheter ablation.

Systolic and diastolic function in renal replacement therapy: a cross-sectional study.

BACKGROUND: Heart disease is the main cause of death among uremic patients (pts). Our study aimed to assess left ventricular (LV) systolic and diastolic function in all of our pts on renal replacement therapy (RRT), investigating any differences between hemodialysis (HD), peritoneal dialysis (PD) and transplantation (TX) pts. METHODS: All pts on RRT at our nephrology unit were enrolled in the study and evaluated once over a period of 6 months: 125 pts were studied: 61 pts on HD, 30 pts on PD and 34 TX pts. Systolic and diastolic function indexes were compared between HD, PD and TX pts. All comparisons were corrected for the effects of age, gender and time on treatment. RESULTS: HD pts suffered from worse systolic function, with a lower mean fractional shortening and ejection fraction (EF), than TX pts. Twenty percent of HD pts had an EF value <55%. PD pts showed worse diastolic function than TX pts and >80% of them suffered from pathological diastolic indexes. The proportion of hypertensive pts was TX 88.2%, PD 86.7% and HD 50.8%. The percentage of pts with LV hypertrophy (LVH) was TX 55.9%, PD 53.3% and HD 36.1%. CONCLUSIONS: TX pts had better systolic and diastolic function than HD and PD pts, despite having more hypertension and LVH.

Transesophageal echocardiographic follow-up of pulmonary veins in patients undergoing ostial radiofrequency catheter ablation for atrial fibrillation.

BACKGROUND: Ostial radiofrequency catheter ablation (RFCA) of pulmonary veins (PVs) is a promising invasive approach for the non-pharmacologic treatment of atrial fibrillation, but PV stenosis has been reported as a possible complication of this intervention. The aim of this study was to assess PV anatomy and stenosis (i.e. number and progression) by means of transesophageal echocardiography (TEE) during the follow-up of patients undergoing RFCA. METHODS: Twenty-three consecutive patients with refractory and highly symptomatic atrial fibrillation underwent ostial radiofrequency isolation of arrhythmogenic triggers/foci, localized into the PVs, by an electroanatomic approach (CARTO system) or circular mapping with a multipolar catheter (LASSO) placed under radioscopic guidance. All patients were investigated using TEE and magnetic resonance angiography before radiofrequency application to evaluate PV anatomy. TEE examination was repeated after 2 months of follow-up and, in the presence of a stenosis, 1 year later. RESULTS: TEE allowed to identify 100% of the left and right superior PVs, 96% of right inferior PVs, and 74% of the left inferior PVs. Anatomic variants were detected at TEE in 33% of patients against 37% at magnetic resonance angiography (95% of concordance). After ostial RFCA, TEE disclosed a significant reduction in the mean diameters of the left superior PV (14.1 +/- 3.2 vs 12.0 +/- 2.7 mm, p < 0.01), left inferior PV (11.2 +/- 2.3 vs 9.8 +/- 2.2 mm, p = 0.05) and right superior PV (14.2 +/- 2.6 vs 12.9 +/- 2.7 mm, p < 0.05), and an increase in the mean peak velocities of the left superior PV (69.8 +/- 14.8 vs 91 +/- 42.4 cm/s, p < 0.05) and left inferior PV (59.2 +/- 18.1 vs 79.3 +/- 40.5 cm/s, p < 0.05). From a total of 88 PVs treated, 7 (7.9%) showed a higher significant stenosis in patients treated using the LASSO than the CARTO system (31.3 vs 2.8% respectively, p < 0.01). After 1-year follow-up there was no progression of PV stenosis. CONCLUSIONS: TEE was successful to evaluate PV anatomy and stenosis of patients undergoing ostial RFCA for atrial fibrillation. This complication is not rare and seems to be strictly related to the method of ablation, in particular when circular mapping and disconnection of triggers/foci was carried out by only a circular multipolar catheter without an electroanatomic approach.

Unusual tumor-like calcification of the mitral annulus: diagnosis and tissue characterization by ultrasound, computed tomography and magnetic resonance imaging.

Calcification of the mitral annulus is a common echocardiographic finding in the elderly, particularly in females. Calcium deposits are generally located in the posterior mitral ring, sometimes extending to the whole mitral annulus and involving the mitral valve apparatus. The present report refers to 2 patients with a very atypical mass-like calcification of the mitral annulus resembling a cardiac tumor. A detailed evaluation of the mass was obtained at transthoracic and transesophageal echocardiography; the differential diagnosis with other intracardiac masses was aided by the use of computed tomography and magnetic resonance imaging. To our knowledge there has been no prior report of such a lesion evaluated at cardiac magnetic resonance imaging.

Left ventricular diastolic function in pregnancy-induced hypertension.

BACKGROUND: Hypertension occurs in some 10% of pregnancies and its effects on the left ventricular (LV) morphology and systolic function have been well elucidated. Little is known, however, about the changes in LV diastolic function in such a condition. The aim of this study was to evaluate the LV diastolic function in women with pregnancy-induced hypertension (PIH) using new Doppler echocardiographic methods. METHODS: Twenty-two women with PIH (mean age 31.0 +/- 4.1 years) were examined during the third trimester of pregnancy. Other 15 normotensive pregnant women (mean age 31.8 +/- 5.7 years, p = NS) were used as controls. Doppler parameters of diastolic function included: mitral inflow variables, pulmonary venous flow (PVF) variables, M-mode color Doppler of LV inflow and pulsed tissue Doppler of the mitral annulus. Furthermore, patients underwent an echocardiographic evaluation immediately after delivery and 1 month later. RESULTS: PIH women showed an increased E/A ratio and an increase in the diastolic forward components of PVF. The ratio of systolic to diastolic time-velocity integral and the systolic fraction of time-velocity integrals subsequently decreased. Women with PIH also presented a significantly increased velocity of reversal PVF at atrial contraction, a decrease in the ratio between mitral and PVF duration at atrial contraction and a slower flow propagation velocity with M-mode color Doppler. LV wall thickness and mass were significantly higher in hypertensive pregnant women. In women with PIH the abnormal PVF parameters became similar to those of controls immediately after delivery, while the E/A ratio, M-mode flow propagation velocity and LV mass did so after 1 month. CONCLUSIONS: Hypertension complicating pregnancy significantly affects ventricular diastolic filling. These alterations chiefly involve PVF, mitral inflow and intraventricular flow propagation velocities. The LV systolic function is preserved, in the presence of a transient LV remodeling.

Dissection of the ascending aorta mimicking an acute coronary syndrome: usefulness of transthoracic echocardiography for the differential diagnosis.

We describe the case of 2 patients presenting with chest pain and electrocardiographic signs of myocardial ischemia, in whom a transthoracic echocardiogram, performed urgently at the bedside, allowed a diagnosis of dissection of the ascending aorta. Prompt recognition of this condition avoided inappropriate aggressive medical treatments and permitted emergency surgical intervention. Aortic dissection can mimic other conditions including an acute coronary syndrome. When the diagnosis is unclear it may be useful to perform a transthoracic echocardiogram before starting any aggressive medical treatment because in such cases thrombolytic or anticoagulant therapy and antithrombotic treatment with platelet glycoprotein IIb/IIIa receptor antagonists can results in serious side effects. On the other hand, transthoracic echocardiography can confirm the suspicion of an acute coronary syndrome or suggest other diagnoses such as aortic dissection.

Dynamic Left Ventricular Outflow Tract Obstruction During Myocardial Ischemia in Mitral Valve Prolapse Syndrome.

Systolic anterior motion of the mitral valve (MV) with dynamic left ventricular (LV) outflow tract obstruction is a well known phenomenon in hypertrophic cardiomyopathy, or other forms of hyperdynamic LV function associated with hypovolemic states, or LV hypertrophy. We report three patients with MV prolapse in the absence of the above predisposing factors, who developed an LV outflow dynamic gradient during acute transient myocardial ischemia. An interaction between structural abnormalities of the mitral apparatus and ischemia-dependent LV shape deformity most likely accounted for the outflow gradient.