Left ventricular wall motion abnormalities in subarachnoid hemorrhage: an echocardiographic study.

Although electrocardiographic (ECG) abnormalities and autopsy evidence of myocardial necrosis are associated with subarachnoid hemorrhage, their relation to in vivo measures of left ventricular function in this condition has not been established. Thirteen patients with subarachnoid hemorrhage and no prior history of heart disease were studied by two-dimensional echocardiography, performed initially 10 to 48 h (mean 18) after admission and serially for less than or equal to 14 days. Serum creatine kinase (total and myocardial isoenzyme) was determined 5 times over the first 48 h; ECGs were performed daily. Neurologic state was assessed with the use of a standard grading system. Four patients (Group I) exhibited left ventricular wall motion abnormalities in one to eight segments. In two of these patients there was also left ventricular apical mural thrombus that embolized in one patient, leading to further neurologic deterioration. The initial creatine kinase myocardial isoenzyme was higher in Group I than in Group II (patients without wall motion abnormalities) (10.3 versus 2.1 U/liter, p less than 0.001), initial heart rate was higher (91 versus 61 beats/min, p less than 0.01), neurologic grade was higher (2.5 to 4.5 versus 1 to 2, p less than 0.001) and inverted T waves were more common (4 of 4 versus 1 of 9). Three of the four patients in Group I died; two of the three underwent autopsy and were found to have no significant coronary artery disease. No other patients died.(ABSTRACT TRUNCATED AT 250 WORDS)

Right atrial myxoma presenting as Budd-Chiari syndrome.

A 25-year-old man experienced rapidly progressing Budd-Chiari syndrome. Despite extensive radiological investigations, no atrial mass could be identified. At operation, a right atrial myxoma was found that originated from the eustachian valve and prolapsed into the inferior vena cava. Following successful removal of the myxoma, the ascites and peripheral edema resolved completely. Right atrial myxoma is a rare cardiac tumor that may present with embolic, obstructive, or constitutional signs and symptoms and is a potentially curable cause of Budd-Chiari syndrome.

Isolated thickening of one aortic cusp: preferential thickening of the noncoronary cusp.

Over a 2-year period we identified 197 patients with the previously undescribed finding of isolated thickening of one aortic cusp. The noncoronary cusp was involved most frequently in 56% (p less than 0.01), followed by the right coronary cusp in 35%, and the left coronary cusp in 9%. Isolated thickening of one aortic cusp occurs more commonly in male patients (64%) (p less than 0.01) and at an earlier age (65 years) than mitral annular calcification (70 years) (p less than 0.001).

Identification of Chiari's network with transesophageal echocardiography.

A prominent Chiari's network may be difficult to distinguish from pathologic right atrial masses on transthoracic echocardiography. We report a 38-year-old woman who had a cerebrovascular accident. Transthoracic echocardiogram revealed an atrial septal aneurysm and a mobile right atrial mass. This mass was correctly identified as Chiari's network on the basis of the transesophageal echocardiographic findings of a broad base of attachment in the right atrium and filamentous nature of the mass. These findings were confirmed at surgery.

Transesophageal echocardiography in the diagnosis of left atrial appendage aneurysm.

Intrapericardial left atrial appendage aneurysm is rare. We describe the transthoracic and transesophageal echocardiographic findings in a 42-year-old man with atrial arrhythmia and an abnormal left atrial appendage on chest roentgenogram. Presence of an intrapericardial left atrial appendage aneurysm was confirmed at surgery.

Anti-CD18 antibodies improve cardiac function following cardiopulmonary bypass in dogs.

PURPOSE: Cardiopulmonary bypass is associated with activation of neutrophils, which may adhere to vascular endothelium causing lung, heart, and brain injury. We tested whether blocking neutrophil adherence would improve organ function following cardiopulmonary bypass in dogs. MATERIALS AND METHODS: All dogs received a standard anesthetic, and then one group (n = 6) received 2 hours of cardiopulmonary bypass followed by 4 hours of observation. A second group (n = 6) received a monoclonal antibody (6 mg/kg) to CD18, a neutrophil adherence factor, immediately before cardiopulmonary bypass. A third group (n = 6) did not receive cardiopulmonary bypass or antibody. RESULTS: Using flow cytometry we found that the antibody bound essentially all neutrophil CD18 sites. All three groups had similar gas exchange and hemodynamics. Lung and heart histology results were similar between groups. By echocardiography, five animals receiving cardiopulmonary bypass alone showed regional wall abnormalities, whereas only one receiving antibody showed wall motion abnormality (P < .05). Following cardiopulmonary bypass, intracellular myocardial pH was higher (P < .05) in the antibody-treated group compared with the group that had cardiopulmonary bypass alone (7.23 +/- 0.05 v 7.07 +/- 0.07 respectively). CONCLUSION: Monoclonal antibodies to CD18 can prevent the deterioration in cardiac function routinely observed following cardiopulmonary bypass.

Cardiac tamponade by loculated pericardial hematoma following open heart surgery: diagnosis by transesophageal echocardiography.

Loculated pericardial hematoma following open heart surgery may cause significant hemodynamic compromise. Recognition of this entity may be delayed because of the absence of the classical signs of cardiac tamponade. A 54-year-old woman is described in whom transesophageal echocardiography allowed rapid diagnosis of right atrial compression by a pericardial hematoma, following mitral valve replacement. Transesophageal echocardiography should be considered for the detection of posterior loculated pericardial hematoma in the hypotensive cardiac surgical patient with a suboptimal transthoracic echocardiogram.

Cardiac abnormalities in patients with systemic lupus erythematosus.

OBJECTIVE: To determine the prevalence of cardiac abnormalities in patients with systemic lupus erythematosus. DESIGN: Prospective survey. SETTING: Rheumatic diseases unit of a university hospital. PATIENTS: Volunteer sample comprising 83% of patients with systemic lupus erythematosus followed annually in the rheumatic disease unit (93 patients; mean age 46 +/- 13 years; female 79, male 14). These patients were age-matched with 16 female control volunteers (mean age 43 +/- 5 years) recruited from hospital staff. INTERVENTIONS: Electrocardiograms, two-dimensional echocardiograms and radionuclide angiograms were performed in patients and controls. Anticardiolipin antibodies were measured by enzyme-linked immunosorbent assay in the systemic lupus erythematosus patients. MAIN RESULTS: At least one cardiac abnormality was detected in 44 of 93 systemic lupus erythematosus patients (47%). These abnormalities included: aortic valve thickening 12%; mitral valve thickening, prolapse, vegetations or stenosis 23%; left ventricular segmental dysfunction 4%; left ventricular global hypokinesis 4%; right ventricular hypokinesis 4%; left ventricular hypertrophy 14%; left ventricular diastolic dysfunction 16%; and pericardial effusion 2%. Three of the 16 controls (19%) had cardiac abnormalities consisting of mitral valve prolapse (one), right ventricular hypokinesis (one) and pericardial effusion (one). Cardiac abnormalities were more common in the systemic lupus erythematosus group compared with controls (47% versus 19%, P less than 0.05). Raised anticardiolipin antibodies were specific (88%) but not sensitive (33%) for the presence of cardiac abnormalities in systemic lupus erythematosus patients. Renal disease and prednisone therapy were more common in systemic lupus erythematosus patients with cardiac involvement than in such patients without evidence of cardiac disease (40% versus 16%, P = 0.03; and 81% versus 59%, P = 0.04, respectively). CONCLUSIONS: Cardiac abnormalities can be identified noninvasively in 47% of patients with systemic lupus erythematosus.

Colour flow imaging in severe mitral and aortic regurgitation.

Several criteria have been proposed for the grading of severe aortic and mitral regurgitation by colour flow imaging. To evaluate the sensitivity of these criteria, colour flow imaging was performed in 21 patients with isolated severe mitral regurgitation and 11 patients with isolated severe aortic regurgitation prior to clinically indicated valvular surgery. In the colour flow imaging assessment of mitral regurgitation the criterion of the maximum distance of mitral regurgitant jet from mitral orifice greater than 4.5 cm was 95% sensitive (range 4.4 to 8.4 cm). Maximum ratio of mitral regurgitant jet area to left atrial area greater than 40% was 86% sensitive (range 32 to 84%) and maximum mitral regurgitant jet area greater than 6 cm2 was 100% sensitive (range 8.1 to 35.7 cm2) in the detection of severe mitral regurgitation. For aortic regurgitation, the criterion of height of regurgitant jet to height of left ventricular outflow tract greater than 65% in the parasternal long axis view was 100% sensitive (range 71 to 100%), whereas the ratio of area of regurgitant jet to area of left ventricular outflow tract greater than 60% in the short axis view was only 36% sensitive (range 8 to 74%) in the detection of severe aortic regurgitation requiring surgery. It is concluded that the most sensitive colour flow imaging criteria for severe mitral regurgitation is an absolute mitral jet area greater than 8 cm2; and for severe aortic regurgitation, ratio of height of regurgitant jet to height of left ventricular outflow tract greater than 65%.

Comparison of Doppler echocardiography and cardiac catheterization in patients requiring valve surgery: search for a 'gold standard'.

OBJECTIVE: To compare the sensitivities of Doppler echocardiography and cardiac catheterization in the diagnosis of severe valvular heart disease in patients requiring valve surgery. DESIGN: Retrospective analysis of Doppler echocardiograms and cardiac catheterizations. SETTING: Tertiary referral cardiovascular centre in a university setting. PATIENTS: Sixty-nine patients undergoing valve surgery between July 1988 and July 1990. RESULTS: The sensitivities of echocardiography and cardiac catheterization were 84 and 87%, respectively (P = 1.0) in 32 patients who underwent aortic valve surgery primarily for severe aortic stenosis; 83 and 67%, respectively (P = 1.0) in six patients with severe aortic regurgitation, and 100 and 85%, respectively (P = 1.0) in seven patients with combined severe aortic stenosis and regurgitation. The sensitivities of echocardiography and cardiac catheterization in 11 patients who underwent mitral valve surgery for severe mitral stenosis were 73 and 91%, respectively (P = 0.6) and 69 and 92%, respectively (P = 0.3) in 13 patients with severe mitral regurgitation. Sensitivities of echocardiography and cardiac catheterization in the diagnosis of severe tricuspid regurgitation in five patients who had tricuspid valve repair were 100 and 80%, respectively (P = 1.0). Two patients with severe aortic stenosis by echocardiography, but not by catheterization, did not undergo aortic valve replacement during valvular surgery; both required aortic valve replacement within two years of initial surgery because of heart failure. Four patients with severe tricuspid regurgitation identified by echocardiography did not have tricuspid repair; three had pulmonary hypertension and these patients had resolution of tricuspid regurgitation on follow-up. One patient with severe tricuspid regurgitation and absence of pulmonary hypertension required reoperation for tricuspid valve repair 10 months after initial operation. CONCLUSIONS: The sensitivity of echocardiography and cardiac catheterization in the detection of severe valvular lesions requiring surgery is similar. Discordant results should be reviewed carefully with knowledge of the inherent pitfalls of both techniques in order to ensure optimal patient outcome.

Transesophageal echocardiography: experience of a Canadian centre.

Transesophageal echocardiography (TEE) is a new application of echocardiography in which an ultrasonic transducer is positioned in the esophagus and stomach to obtain images of the heart without interference from lung and bone. It is particularly useful in the assessment of left atrial masses, atrial septal defects, mitral valve disease, valvular prostheses and aortic dissection. In the operative setting, TEE is used to detect early myocardial ischemia in patients with coronary artery disease undergoing noncardiac surgery as well as in the assessment of the results of valvular surgery. This review examines the technique of TEE, its indications and the early experience with the first 100 patients examined at the Toronto Western Hospital with this technique.

Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks.

BACKGROUND: Patent foramen ovale (PFO) is found in up to 50% of patients less than 55 years of age who have had a stroke. Therapeutic options include no therapy, antiplatelet therapy, warfarin and surgical closure of the PFO. OBJECTIVES: To determine the relative and attributable risks of PFO for recurrent cerebral ischemic events in young patients with stroke or transient ischemic attacks. The predictors of recurrent cerebral ischemic events and the effects of different therapies on recurrence rates were sought. DESIGN: Follow-up of a retrospective cohort of patients with cryptogenic stroke or transient ischemic attacks identified from an echocardiography database. SETTING: University-based regional neurology referral centre. PATIENTS: Consecutive group of 90 patients less than 60 years of age who underwent transesophageal echocardiography following a cryptogenic transient ischemic attack (TIA) or stroke (cerebrovascular accident [CVA]) between 1991 and 1997. INTERVENTIONS: Structured telephone interviews and chart reviews. RESULTS: Fifty-two patients had a PFO, and 38 patients did not have a PFO. During a mean follow-up of 46 months, 19 recurrent cerebral ischemic events (12 TIA and seven CVA) occurred in 14 patients with PFO, and eight recurrent events (three TIA and five CVA) occurred in six patients without PFO. The recurrence rates were 12% and 5%/patient/year in the PFO and control groups, respectively, for a crude recurrence rate ratio of 2.39 (95% CI 1.01 to 6.32, P < 0.03). The attributable risk of PFO in recurrent neurological events was 7%/patient/year. In a Cox regression model, predictors of recurrent neurological events were presence of PFO (hazard ratio 5.27, 95% CI 1.58 to 17.6, P < 0.007), history of migraine (hazard ratio 4.54, 95% CI 1.11 to 18.52, P < 0.035), hypertension requiring therapy (hazard ratio 3.5, 95% CI 1.33 to 9.01, P < 0.01), and antiplatelet or no therapy instead of warfarin therapy (hazard ratio 2.88, 95% CI 1.11 to 8.7, P < 0.04). Fourteen patients underwent surgical closure of PFO; there were no neurological recurrences during a mean follow-up of 43 months (crude incidence rate difference 12%/patient/year, 95% CI 6.6 to 17.9, P < 0.02). CONCLUSIONS: Patients with PFO had a significantly higher rate of recurrent cerebral ischemic events than those without PFO. Surgical PFO closure prevented any recurrences during a mean follow-up of 43 months. Warfarin was better than antiplatelet therapy or no therapy in preventing recurrences.

Right ventricular nerve sheath tumour and patent foramen ovale presenting with transient ischemic attack.

A 66-year-old man presented with dyspnea and a transient ischemic attack. Echocardiography revealed a right ventricular mass and patent foramen ovale. During surgery the mass was found to be a malignant nerve sheath tumour. Several weeks later, the patient developed small bowel obstruction, and laparotomy disclosed multiple metastases involving the small and large bowel. The paper describes the clinical course and management of this patient and reviews the pertinent literature.

Inhaled nitric oxide reduction in systolic pulmonary artery pressure is less in patients with decreased left ventricular ejection fraction.

OBJECTIVE: To assess whether inhaled nitric oxide decreases pulmonary artery pressure in patients with depressed left ventricular ejection fraction. DESIGN: Randomized, blinded, crossover clinical trial. SETTING: Tertiary care university referral hospital. PATIENTS: Thirty-three patients with pulmonary hypertension and left ventricular dysfunction or valvular heart disease were recruited by convenience. INTERVENTIONS: Systolic pulmonary artery pressure was measured by Doppler echocardiography during randomized inhalation of either 20 ppm or 40 ppm nitric oxide in 30% oxygen as well as during control periods without nitric oxide. MAIN RESULTS: Systolic pulmonary artery pressure was significantly (P < 0.05) decreased with 20 ppm nitric oxide (53.4 +/- 13.9 mmHg) and 40 ppm nitric oxide (53.1 +/- 14.4 mmHg) compared with either initial control (55.8 +/- 15.3 mmHg) or terminal control (56.3 +/- 15.2 mmHg) values. The regression equation for the change in systolic pulmonary artery pressure (y) as predicted by the left ventricular ejection fraction (x) alone for 20 ppm nitric oxide was y = 13.8x-2.9; R2adj = 0.30, P < 0.0001. For 40 ppm nitric oxide alone, the regression equation was y = 16.3x-3.3; R2adj = 0.25, P < 0.0001. Left ventricular ejection fraction was the most explanatory independent variable in the multivariate equation for nitric oxide-induced change in systolic pulmonary artery pressure (R2 = 0.61, P = 0.0000). The change in systolic pulmonary artery pressure was -5.1 +/- 5.2 versus 0.8 +/- 4.9 mmHg (P < 0.0000) in patients with left ventricular ejection fractions greater than 0.25, and 0.25 or less, respectively. CONCLUSIONS: These data imply that in patients with left ventricular ejection fraction of 0.25 or less, nitric oxide may not decrease systolic pulmonary artery pressure. Nitric oxide inhalation may result in a paradoxical increase in systolic pulmonary artery pressure in patients with severely depressed left ventricular ejection fraction. This effect would significantly limit the therapeutic role of nitric oxide in patients with severe heart failure.

Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency.

A left atrial thrombus is most often associated with atrial fibrillation and/or rheumatic mitral stenosis. It is very infrequently detected in the presence of sinus rhythm. The present report describes the case of a 66-year-old woman who presented with a stroke and was subsequently found to have two potential sources of embolization, including a vegetation on the native aortic valve, with associated severe aortic insufficiency, and a left atrial appendage thrombus despite being in sinus rhythm. To the authors' knowledge, the present report is the first to describe a left atrial thrombus in sinus rhythm associated with aortic valve endocarditis.

Comparison of self, nurse, and physician assessment of residents rotating through an intensive care unit.

OBJECTIVE: Compare resident evaluations by self, nurses, and attending physicians. DESIGN: Prospective cohort. SETTING: University intensive care unit. SUBJECTS: Sixty residents. INTERVENTIONS: End-rotational evaluation using a standardized, multiple-choice examination and one of two subjective instruments, Global Rating Scale and Behaviorally Anchored Rating Scale. MEASUREMENTS AND MAIN RESULTS: Means for overall competence, using both the Behaviorally Anchored Rating Scale and the Global Rating Scale clustered between 3 to 4 on a 5-point scale. Physicians' evaluations correlated with the multiple-choice test scores (Spearman's rho 0.3082, p = .005, n = 82), whereas neither self-evaluation (Spearman's rho 0.1124, p = .65, n = 42) nor nurses' evaluations (Spearman's rho 0.2060, p = .069, n = 79) had a significant correlation with test scores. Spearman's correlations were not significant for either overall competence or specific medical knowledge by any category of evaluator using the Global Rating Scale. Spearman's rho correlations and kappa statistic between the three types of evaluators (physicians, nurses, and self) for each criterion of the Behaviorally Anchored Rating Scale demonstrated significant correlations between the ratings of physicians and nurses, except for the assessment of humanistic qualities. Pooled clinical skills-history taking (b = 0.277, p <.009), humanistic qualities (b = 0.607, p <.000), and professional attitudes and behavior (b = 0.488, p < .000) systematically differed in ratings comparing self with nurse and physician (by analysis of variance). The explanatory power of the model of ratings (independent variables of year of residency, category of evaluator, evaluation criteria, and interaction terms) was 47.3% (r2adj). CONCLUSIONS: Self-rating by residents did not correlate to multiple-choice test scores and differed in some criteria with physicians' or nurses' evaluations. We found many similarities and some differences between physicians' and nurses' evaluations of residents. We speculate that different categories of evaluators assess different aspects of performance. Assessment by a varied group of evaluators should be used when attempts to predict future practice are made.

Ataxia-hemiparesis and cardiac embolic disease.

Ataxia-hemiparesis is a clinical stroke syndrome with mild weakness and ataxia out of proportion to the weakness. Although most patients with ataxia-hemiparesis have small (lacunar) infarctions in the brainstem, internal capsule, or corona radiata, the syndrome has also been reported with infection, hemorrhage, and neoplasm in the same region. We now report a patient who presented with right ataxia-hemiparesis whose initial cranial computed tomography (CT) scan was normal and a second CT scan showed infarctions in the right cerebellum, left thalamus, and left frontal cortex. Initial echocardiogram showed segmental akinesis; a second study revealed a thrombus in the left ventricle. Ataxia-hemiparesis can sometimes be secondary to multiple infarcts resulting from cardiac emboli. In such cases, early recognition and anticoagulation could help prevent recurrences.