Dual source multidetector CT-angiography before Transcatheter Aortic Valve Implantation (TAVI) using a high-pitch spiral acquisition mode.

OBJECTIVES: Transcatheter Aortic Valve Implantation (TAVI) is an alternative to surgical valve replacement in high risk patients. Angiography of the aortic root, aorta and iliac arteries is required to select suitable candidates, but contrast agents can be harmful due to impaired renal function. We evaluated ECG-triggered high-pitch spiral dual source Computed Tomography (CT) with minimized volume of contrast agent to assess aortic root anatomy and vascular access. METHODS: 42 patients (82 ± 6 years) scheduled for TAVI underwent dual source (DS) CT angiography (CTA) of the aorta using a prospectively ECG-triggered high-pitch spiral mode (pitch = 3.4) with 40 mL iodinated contrast agent. We analyzed aortic root/iliac dimensions, attenuation, contrast to noise ratio (CNR), image noise and radiation exposure. RESULTS: Aortic root/iliac dimensions and distance of coronary ostia from the annulus could be determined in all cases. Mean aortic and iliac artery attenuation was 320 ± 70 HU and 340 ± 77 HU. Aortic/iliac CNR was 21.7 ± 6.8 HU and 14.5 ± 5.4 HU using 100 kV (18.8 ± 4.1 HU and 8.7 ± 2.6 HU using 120 kV). Mean effective dose was 4.5 ± 1.2 mSv. CONCLUSIONS: High-pitch spiral DSCTA can be used to assess the entire aorta and iliac arteries in TAVI candidates with a low volume of contrast agent while preserving diagnostic image quality.

[Coronary intervention. 2012 update]. / Koronarintervention. Update 2012.

In-stent restenosis and stent thrombosis are still the main topics of any update on coronary intervention. One of the challenging issues in the past year lay in answering the question of whether the data on first-generation drug-eluting stents are still relevant in the light of newer stent designs and drugs. Other issues include new strategies in antiplatelet therapy, treatment of in-stent restenosis, particularly drug-eluting stent restenosis, treatment of multivessel and left-main disease, as well as the latest developments in bioresorbable polymers and "scaffolds". In the light of demographic changes, the main challenge for the interventional community is to build an evidence base for the adequate treatment of elderly patients in order to resolve uncertainties in the treatment of this challenging patient group.

[Diabetes and dementia]. / Diabetes und Demenz.

Diabetes mellitus is a known risk factor for cognitive dysfunction and dementia. Chronic hyperglycemia, genetic predisposition, arterial hypertension, hyperlipoproteinemia, micro- and macrovascular diseases, and depression play a major role in the development of cognitive dysfunction. Both pathophysiology of diabetes and dementia and the specifics of diabetes therapy in patients with dementia are presented in this review.

The transradial approach. An increasingly used standard for coronary diagnosis and interventions.

In the 20 years since its introduction, radial access for diagnostic and interventional coronary procedures has been well validated in countless scientific studies. Nevertheless, the use of this access route varies greatly among--and even within--countries. Fear of the unknown may make some experienced interventionalists hesitant to adopt the transradial approach in spite of its proven advantages. In our review, we describe practical aspects of the transradial access, such as the role of Allen's test in patient selection and considerations on the optimal puncture technique of the radial artery. Catheter selection, anatomic variations which may complicate access, as well as strategies to avoid and/or manage possible complications are outlined. Finally, we review the literature on the reduction of access site complications by adopting the transradial approach. Even in interventions for acute myocardial infarction, transradial access can be used safely and effectively. In addition to a reduced rate of access site complications, a reduction in overall in-hospital major adverse cardiac events has been demonstrated. The advantage regarding access site complications could be seen even when closure devices were utilized for transfemoral procedures.

African and Asian leopards are highly differentiated at the genomic level.

Leopards are the only big cats still widely distributed across the continents of Africa and Asia. They occur in a wide range of habitats and are often found in close proximity to humans. But despite their ubiquity, leopard phylogeography and population history have not yet been studied with genomic tools. Here, we present population-genomic data from 26 modern and historical samples encompassing the vast geographical distribution of this species. We find that Asian leopards are broadly monophyletic with respect to African leopards across almost their entire nuclear genomes. This profound genetic pattern persists despite the animals' high potential mobility, and despite evidence of transfer of African alleles into Middle Eastern and Central Asian leopard populations within the last 100,000 years. Our results further suggest that Asian leopards originated from a single out-of-Africa dispersal event 500-600 thousand years ago and are characterized by higher population structuring, stronger isolation by distance, and lower heterozygosity than African leopards. Taxonomic categories do not take into account the variability in depth of divergence among subspecies. The deep divergence between the African subspecies and Asian populations contrasts with the much shallower divergence among putative Asian subspecies. Reconciling genomic variation and taxonomy is likely to be a growing challenge in the genomics era.

Sequential changes in myocardial function after valve replacement for aortic stenosis by speckle tracking echocardiography.

AIMS: Regional myocardial function may change differently in different pathology. Speckle tracking echocardiography (STE) was applied to evaluate longitudinal, radial, and circumferential function in patients with aortic stenosis (AS) before, within 1 week, and 6 months after aortic valve replacement (AVR). METHODS AND RESULTS: In 40 consecutive patients with severe AS, we acquired apical four-, three-, and two-chamber views and standard short-axis view pre- and post-AVR and after 6 months. Longitudinal, radial, and circumferential (LS, RS, and CS) were calculated by commercial STE software. Further, we analysed diastolic myocardial function by measuring E/e' ratio. With AVR, valve area increased and remained stable at 6 months follow-up. Left ventricular mass was unchanged 1 week after AVR (270 +/- 58 g vs. 267 +/- 58 g, n.s.) but decreased significantly during the next 6 months (219 +/- 50 g, P < 0.05). Left ventricular ejection fraction remained unchanged. Strain values did not change significantly within 1 week after AVR but increased significantly after 6 months (LS by 16%, RS by 21%, and CS by 28% of baseline values). E/e' ratio was highly augmented before AVR (26.1 +/- 12.5) and decreased significantly 6 months after AVR (15.9 +/- 5.9). CONCLUSION: Myocardial function significantly recovers after replacing the stenosed aortic valve. However, there is a considerable difference between the response of longitudinal, radial, and circumferential function. Our data suggest that echocardiographic assessment of regional function is feasible and of potential clinical importance.

Recommendations for transoesophageal echocardiography: update 2010.

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Ancestral mitogenome capture of the Southeast Asian banded linsang.

Utilising a reconstructed ancestral mitochondrial genome of a clade to design hybridisation capture baits can provide the opportunity for recovering mitochondrial sequences from all its descendent and even sister lineages. This approach is useful for taxa with no extant close relatives, as is often the case for rare or extinct species, and is a viable approach for the analysis of historical museum specimens. Asiatic linsangs (genus Prionodon) exemplify this situation, being rare Southeast Asian carnivores for which little molecular data is available. Using ancestral capture we recover partial mitochondrial genome sequences for seven banded linsangs (P. linsang) from historical specimens, representing the first intraspecific genetic dataset for this species. We additionally assemble a high quality mitogenome for the banded linsang using shotgun sequencing for time-calibrated phylogenetic analysis. This reveals a deep divergence between the two Asiatic linsang species (P. linsang, P. pardicolor), with an estimated divergence of ~12 million years (Ma). Although our sample size precludes any robust interpretation of the population structure of the banded linsang, we recover two distinct matrilines with an estimated tMRCA of ~1 Ma. Our results can be used as a basis for further investigation of the Asiatic linsangs, and further demonstrate the utility of ancestral capture for studying divergent taxa without close relatives.

Elevated VEGF-plasma levels in young patients with mild essential hypertension.

BACKGROUND: Growing evidence shows that inflammation plays a pivotal role in the pathophysiology of essential hypertension (EH). Vascular endothelial cell growth factor (VEGF) is currently discussed as a possible mediator of inflammation. To investigate the hypothesis that VEGF plays a role as an inflammatory mediator in EH we performed the present pilot study of young patients in a very early stage of EH. MATERIALS AND METHODS: 15 young patients with mild EH [33.8 +/- 7.3 years, systolic blood pressure (SBP): 143.8 +/- 10.5 mmHg, diastolic blood pressure (DBP): 88.2 +/- 11.1 mmHg, mean arterial pressure (MAP) 106.6 +/- 10.4 mmHg] and 15 healthy controls (31.7 +/- 10.6 years) were examined. Blood was drawn from a peripheral vein and serum levels of VEGF, monocyte-chemoattractant-protein (MCP)-1, high-sensitivity C-reactive protein (hsCRP), interleukin (IL)-6, and tumour-necrosis-factor (TNF)-alpha were measured via commercially available enzyme-linked immunoassays. RESULTS: Hypertensives showed increased plasma levels of VEGF (P < 0.05) and MCP-1 (P < 0.05). VEGF positively correlated with MAP (r = 0.46, P < 0.05) and MCP-1 (r = 0.63, P < 0.01). Multivariate analysis demonstrated VEGF to be an independent predictor of MCP-1 levels. Furthermore, hypertensives had higher levels of hsCRP (P < 0.01), IL-6 (P < 0.001) and TNF-alpha (P < 0.05). IL-6 levels correlated with SBP (r = 0.59, P < 0.001), DBP (r = 0.67, P < 0.001) and MAP (r = 0.46, P < 0.001). A significant positive correlation was also found between hsCRP levels and SBP (r = 0.39, P < 0.05). CONCLUSIONS: This pilot study demonstrates that in an early state of EH, inflammatory pathways have already been activated. Besides classical pro-inflammatory cytokines, VEGF serum levels are significantly elevated. The positive correlation of VEGF with MCP-1 is suggestive for the already described induction of MCP-1 via VEGF.

CD40/CD154 system and pro-inflammatory cytokines in young healthy male smokers without additional risk factors for atherosclerosis.

OBJECTIVE AND DESIGN: Atherosclerosis, as an inflammatory disease, is characterized by pathologically altered levels of cytokines. We investigated whether smoking affects the CD40/CD154 system and pro-inflammatory cytokines in young males without other risk factors for atherosclerosis. SUBJECTS: Young male smokers (n=13) and 14 non-smoking controls were investigated. METHODS: The differences in CD40/CD154 system and serum cytokines between the groups were measured using flow cytometry and ELISA. RESULTS: In smokers, there was a strong trend (P<0.06) for increased CD40 expression on platelets as compared with non-smokers. However, there were no significant differences in CD40 expression on monocytes or in CD154 expression on platelets and T-cells between smokers and non-smokers. There was a strong trend for increased platelet-monocyte aggregates in smokers (P<0.06). Also, smokers had slightly but not significantly elevated hsCRP and IL-6 levels, and slightly decreased TNF-alpha and MCP-1. Interestingly, IL-18, a cytokine which has the ability to promote both Th1 and Th2 responses, was significantly decreased in smokers group (P=0.03 vs controls). CONCLUSIONS: In young healthy males, smoking is not associated with dramatic changes in CD40/CD154 system. However, cigarette smoke alters the secreted cytokine profile, leading to significant decrease in systemic IL-18 levels.

Differentiation of total occlusion and high-grade stenosis in coronary CT angiography.

In coronary CT angiography (CTA), both high-grade stenoses and total occlusions of a coronary artery may appear as a complete interruption of the contrast-enhanced lumen. Parameters to differentiate between occlusions and stenoses have not been systematically assessed. We evaluated 40 consecutive patients with a lesion demonstrating complete interruption of the contrast-enhanced lumen in coronary CTA and in whom invasive coronary angiography was available. Length of the vessel segment without luminal contrast enhancement; luminal enhancement proximal, in and distal to the lesion; degree of coronary remodelling; and the degree of lesion calcification were assessed by a blinded observer unaware of the invasive angiogram. Mean length of complete occlusions (n = 20; range 4-54 mm; mean 16.6 +/- 3.5 mm) was significantly longer than for high-grade stenoses (n = 20; 2-8 mm; mean 4.6 +/- 1.7 mm, p < 0.001). A lesion length > or = 9 mm was 100% specific and 70% sensitive for an occlusion. No significant differences were found for vessel enhancement in or distal to the lesion, remodelling index or degree of calcification. Lesion length is the only parameter that may differentiate complete occlusions and high-grade stenoses in coronary CTA. For lesions > or = 9 mm, an occlusion is very likely.

Interobserver variability of 64-slice computed tomography for the quantification of non-calcified coronary atherosclerotic plaque.

PURPOSE: Multidetector CT (MDCT) is a reliable tool to assess and quantify calcified plaque in coronary arteries. Only very limited information is available concerning the accuracy of MDCT for evaluating non-calcified plaque. We determined the interobserver variability for measuring non-calcified plaque volumes in the three main coronary arteries using 64-slice computed tomography. MATERIALS AND METHODS: We retrospectively evaluated data sets of 41 patients who received a 64-slice CT scan (Sensation 64, Siemens Forchheim, Germany, 330 msec rotation, 0.6 mm collimation, 60 ml contrast agent i. v. at 5 ml/sec) due to suspected stable coronary artery disease. The patients showed presence of non-calcified plaque in the proximal part of at least one main coronary artery. The image quality was defined on the basis of a 4-point rating scale. Two independent and blinded investigators measured the plaque volume of the non-calcified plaque by manually tracing plaque areas in contiguous cross-sectional reconstructions rendered along the vessel centerline using a slice thickness of 1 mm and an increment of 0.5 mm. The interobserver variability was evaluated and the influence of plaque volume and image quality on interobserver variability was determined. RESULTS: The mean volume of non-calcified plaque was 157 +/- 85 mm (3), 76 +/- 43 mm (3) and 133 +/- 80 mm (3) for the LAD, LCX and RCA, respectively (LAD vs. LCX: p < 0.01; LAD vs. RCA: p = 0.33; LCX vs. RCA: p < 0.01). There was a mean absolute difference in plaque volume between the two observers of 23 +/- 15 mm (3), of 20 +/- 9 mm (3) and of 38 +/- 21 mm (3), which corresponds to a mean interobserver variability of 17 +/- 10 %, 29 +/- 13 % and 32 +/- 13 % for the LAD, LCX and RCA, respectively (LAD vs. LCX: p < 0.01; LAD vs. RCA: p < 0.01; LCX vs. RCA: p = 0.87). A significant inverse correlation between interobserver variability and the extent of the plaque volume (r = - 0.48; p = 0.01) was found. Interobserver variability was dependent on image quality: The highest image quality was observed in the LAD (2.4 +/- 0.5), while the image quality in the LCX (2.1 +/- 0.7) and the RCA (2.0 +/- 0.6) was lower. CONCLUSION: Interobserver variability for the quantification of non-calcified plaque volumes in 64-slice MDCT is substantial. Interobserver variability in the LAD was significantly lower than in the LCX and the RCA. This might be due to a larger mean plaque volume and better image quality in the LAD than in other coronary arteries.

Progression of aortic valve calcification: association with coronary atherosclerosis and cardiovascular risk factors.

BACKGROUND: Recent studies demonstrated an influence of atherosclerotic risk factors on the progression of aortic valve stenosis. The extent of aortic valve calcification (AVC) was also found to be a strong predictor of stenosis progression. We investigated the influence of the LDL cholesterol level (LDL), other standard cardiovascular risk factors, and the extent of coronary calcification (CC) on the progression of AVC quantified by electron beam tomography (EBT). METHODS AND RESULTS: In 104 patients (64.7+/-8 years, 89 male) with an EBT scan positive for AVC, CC and AVC were quantified using a volumetric score. EBT was repeated at a mean interval of 15 months (10 to 36 months), and the progression of AVC and CC was determined. Patients were divided into 2 groups according to LDL: group 1, LDL3.36 mmol/L (130 mg/dL), 47 patients. Mean values for CC were 546+/-932 mm(3) in scan 1 and 665+/-1085 mm(3) in scan 2 for AVC 324+/-796 mm(3) and 404+/-1076 mm(3), respectively. The mean progression of CC was 27+/-37% (group 1, 16+/-22%; group 2, 39+/-46%, P

Noninvasive coronary angiography by retrospectively ECG-gated multislice spiral CT.

BACKGROUND: We investigated the applicability and image quality of contrast-enhanced coronary artery visualization by multislice spiral CT using retrospective ECG gating. METHODS AND RESULTS: Twenty-five patients in sinus rhythm (significant coronary artery stenoses ruled out by invasive angiography) were studied with a multislice spiral CT (Siemens SOMATOM Volume Zoom). In inspiration (mean breath-hold, 37 seconds), a volume data set of the heart was acquired (intravenous contrast agent; 4 x 1-mm slice thickness; 500-ms rotation; table feed, 1.5 mm/360 degrees ). Simultaneous recording of the ECG permitted retrospective reconstruction of contiguous cross sections in intervals of 1 mm at any desired interval of the cardiac cycle. The mean duration of the image reconstruction window was 185 ms. Next to 3-dimensional reconstructions of the heart and coronary arteries, multiplanar reconstructions were rendered to determine the visualized length of the coronary arteries, the contrast-to-noise ratio, and the correlation of coronary artery diameters to quantitative coronary angiography. CONCLUSIONS: The coronary arteries could be visualized over long segments (left main, 9+/-4 mm; left anterior descending, 112+/-34 mm; left circumflex, 80+/-29 mm; right coronary artery, 116+/-33 mm). On average, 78+/-16% of these distances were visualized free of motion artifacts. The mean contrast-to-noise ratio was 9.3+/-3.3. Coronary artery diameters in multislice spiral CT showed close correlation to quantitative coronary angiography (CT, 3.3+/-1.0 mm; angiography, 3. 2+/-0.9 mm; mean difference, 0.38 mm; r=0.86). Contrast-enhanced multislice spiral CT permits visualization of the coronary artery lumen. Further studies are necessary to determine whether image quality is sufficient to reliably detect coronary artery stenoses.

Detection of coronary artery stenoses by contrast-enhanced, retrospectively electrocardiographically-gated, multislice spiral computed tomography.

BACKGROUND: Multislice spiral computed tomography (MSCT) with retrospectively ECG-gated image reconstruction permits coronary artery visualization. We investigated the method's ability to identify high-grade coronary artery stenoses and occlusions. METHODS AND RESULTS: A total of 64 consecutive patients were studied by MSCT (4x1 mm cross-sections, 500-ms rotation, table feed 1.5 mm/rotation, intravenous contrast agent, retrospectively ECG-gated image reconstruction). All coronary arteries and side branches with a luminal diameter >/=2.0 mm were assessed concerning evaluability and the presence of high-grade stenoses (>70% diameter stenosis) or occlusions. Results were compared with quantitative coronary angiography. Of 256 coronary arteries (left main, left anterior descending, left circumflex and right coronary artery, including their respective side branches), 174 could be evaluated (68%). In 19 patients (30%), all arteries were evaluable. Artifacts caused by coronary motion were the most frequent reason for unevaluable arteries. Overall, 32 of 58 high-grade stenoses and occlusions were detected by MSCT (58%). In evaluable arteries, 32 of 35 lesions were detected, and the absence of stenosis was correctly identified in 117 of 139 arteries (sensitivity, 91%; specificity, 84%). If analysis was extended to all stenoses with >50% diameter reduction, sensitivity was 85% (40 of 47) and specificity was 76% (96 of 127). CONCLUSIONS: MSCT with retrospective ECG gating permits the detection of coronary artery stenoses with high accuracy if image quality is sufficient, but its clinical use may presently be limited due to degraded image quality in a substantial number of cases, mainly due to rapid coronary motion.

Upregulation of CD40 and CD40 ligand (CD154) in patients with moderate hypercholesterolemia.

BACKGROUND: Hypercholesterolemia, a risk factor for cardiovascular disease, is associated with inflammation and hypercoagulability. Both can be mediated by the CD40 system. This study investigated whether the CD40 system is upregulated in patients with moderate hypercholesterolemia and whether it is influenced by therapy with a hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor. METHODS AND RESULTS: Fifteen patients with moderate hypercholesterolemia and 15 healthy control subjects were investigated. CD154 and P-selectin were analyzed on platelets and CD40 was analyzed on monocytes before and under therapy with the statin cerivastatin by double-label flow cytometry. Blood concentrations of soluble CD154 and monocyte chemoattractant protein-1 (MCP-1) were evaluated. Our main findings were as follows. Patients with moderate hypercholesterolemia showed a significant increase of CD154 and P-selectin on platelets and CD40 on monocytes compared with healthy subjects. Soluble CD154 showed a nonsignificant trend for higher plasma levels in patients. A positive correlation was found for total or LDL cholesterol and CD154, but not for CD40 on monocytes. The latter was upregulated in vitro by C-reactive protein, which was found to be significantly elevated in patients with moderate hypercholesterolemia. CD154 on platelets proved to be biologically active because it enhanced the release of MCP-1, which was markedly elevated in an in vitro platelet-endothelial cell coculture model and in the serum of patients. Short-term therapy with a HMG-CoA reductase inhibitor significantly downregulated CD40 on monocytes and serum levels of MCP-1. CONCLUSION: Patients with moderate hypercholesterolemia show upregulation of the CD40 system, which may contribute to the known proinflammatory, proatherogenic, and prothrombotic milieu found in these patients.

High-dose intravascular beta-radiation after de novo stent implantation induces coronary artery spasm.

BACKGROUND: Intracoronary brachytherapy is effective in preventing restenosis after coronary interventions. However, in vitro and animal studies have shown that irradiation produces immediate and sustained endothelial dysfunction. This study assesses the clinical relevance of impaired vasomotoric function induced by brachytherapy. METHODS AND RESULTS: We analyzed the occurrence of postradiation coronary artery spasms in 1 animal study and 2 clinical trials investigating the effects of high-dose intracoronary beta-radiation after de novo coronary artery stenting. Irradiated segments (IRSs) proximal and distal to the stent were studied by quantitative coronary angiography after stenting, after radiation, and at the end of the procedure. There was an 67% overall incidence of coronary artery spasm in the IRSs immediately after beta-radiation compared with 9% after sham treatment (P<0.001). Whereas in most cases this phenomenon was only minor or moderate, in 12 cases, 4 (22%) animals and 8 (28%) patients, severe coronary spasm (>90% diameter stenosis) with significant ECG-changes or hemodynamic instability was observed. Relief of spasms was protracted (mean time until complete relief of spasm 423+/-122 seconds) and required repetitive intracoronary administration of nitroglycerin (mean dose: 1.2+/-0.6 mg). CONCLUSIONS: Vasoconstriction is a frequent reaction of coronary arteries after high-dose intracoronary beta-radiation, necessitating repetitive administration of vasodilators.

Identification of patent foramen ovale permitting paradoxic embolism.

OBJECTIVES: We sought to analyze the morphologic and functional characteristics of the patent foramen ovale in patients with different clinical likelihoods for paradoxic embolism. BACKGROUND: The incidence of patent foramen ovale is increased in patients with otherwise unexplained arterial ischemic events. Because signs of venous thrombosis are absent in most patients, the diagnosis of paradoxic embolism is often questioned, even when patent foramen ovale is the only potential explanation for the ischemic event. METHODS: Seventy-eight patients with a patent foramen ovale detected by contrast transesophageal echocardiography were studied: 21 patients with an otherwise unexplained arterial ischemic event and clinical evidence implying paradoxic embolism (group I), 30 patients with an unexplained ischemic event but no clinical evidence for paradoxic embolism (group II) and 27 patients without an ischemic event (group III). RESULTS: During transesophageal contrast echocardiography, patients in group I had more severe right to left shunting (mean +/- SD 52 +/- 16% of the left atrial area filled with contrast medium) and a wider opening of the patent foramen ovale (7.1 +/- 3.6-mm separation between the septum primum and the septum secundum) than did patients in group II (35 +/- 15% and 4.4 +/- 3.2 mm, respectively, p < 0.001) or group III (23 +/- 12% and 3.0 +/- 2.0 mm, respectively, p < 0.001). The incidence of atrial septal aneurysm was similar in the three groups. Severe contrast shunting (> or = 50% of the left atrial area filled with contrast medium) and wide opening of the patent foramen ovale (> or = 5-mm separation) revealed a high sensitivity (71% and 86%, respectively) and high specificity (86% and 96%, respectively) for identification of group I patients. CONCLUSIONS: Right to left contrast shunting is more severe and opening of the patent foramen ovale is larger in patients with ischemic arterial events considered to be due to paradoxic embolism. In patients with a patent foramen ovale as the only potential cause for ischemic events and no signs of venous thrombosis, morphologic and functional variables assessed by transesophageal echocardiography may be helpful in estimating the likelihood of paradoxic embolism.

Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach.

In 105 patients with active infective endocarditis, disease-associated complications defined as severe heart failure (New York Heart Association class IV), embolic events and in-hospital death were correlated to the vegetation size determined by both transthoracic and transesophageal echocardiography. A detailed comparison between anatomic and echocardiographic findings, performed in a subgroup of 80 patients undergoing surgery or necropsy, revealed that true valvular vegetations can be reliably identified by echocardiography in the vast majority of patients; the detection rate was significantly higher for the transesophageal (90%) than for the transthoracic (58%) approach, particularly when infected prosthetic valves were evaluated. However, an accurate echocardiographic differentiation between true vegetations and other endocarditis-induced valve destruction (ruptured leaflets or chordae) is impossible. The correlation of vegetation size with endocarditis-associated complications showed that patients with a vegetation diameter greater than 10 mm had a significantly higher incidence of embolic events than did those with a vegetation diameter less than or equal to 10 mm (22 of 47 versus 11 of 58; p less than 0.01). Particularly for patients with mitral valve endocarditis, a vegetation diameter greater than 10 mm was highly sensitive in identifying patients at risk for embolic events. Vegetation size, however, was not significantly different in patients with and without severe heart failure or in patients surviving or dying during acute endocarditis. In addition, no significant correlation was found between vegetation size and location of endocarditis or type of infective organism.(ABSTRACT TRUNCATED AT 250 WORDS)

Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk.

The incidence of left atrial spontaneous echo contrast was evaluated in 52 patients with isolated or predominant mitral valve stenosis (Group 1) and 70 other patients who had undergone mitral valve replacement (Group 2). All patients were studied by conventional transthoracic and transesophageal two-dimensional echocardiography. Spontaneous echo contrast could be visualized within the left atrium in 35 Group 1 patients (67.3%) (including 7 patients with sinus rhythm) and 26 Group 2 patients (37.1%) (all with atrial fibrillation). Patients with spontaneous echo contrast had a significantly larger left atrial diameter and a greater incidence of both left atrial thrombi and a history of arterial embolic episodes than did patients without spontaneous echo contrast. Association between spontaneous echo contrast and left atrial thrombi and a history of arterial embolization (considered individually or in combination) showed a high sensitivity and negative predictive value. It is concluded that spontaneous echo contrast is a helpful finding for identification of an increased thromboembolic risk in patients with mitral stenosis and after mitral valve replacement.