Evaluation of left ventricular diastolic function using color kinesis.

PURPOSE: Color kinesis (CK) is a real-time echocardiographic technique based on acoustic quantification that yields regional and global information by tracking and color-encoding endocardial motion. The aim of this study was to determine the feasibility and usefulness of diastolic CK images with ICK software to objectively assess global and regional left ventricular (LV) diastolic function. Accordingly, diastolic properties obtained from CK images were compared with conventional Doppler echocardiographic indices. METHODS: We studied 56 subjects who underwent echocardiographic evaluation in our laboratory for assessment of cardiac structure and function. Criteria for inclusion included the presence of normal sinus rhythm and adequate two-dimensional echocardiographic imaging. Exclusion criteria were (1) all types of arrhythmias, (2) pericardial effusion, (3) heart rates <55 or >90 beats/min, (4) abnormal interventricular septal motion caused by right ventricular pressure or volume overload, (5) moderate to severe mitral or aortic regurgitation, and (6) mitral valve stenosis. Using pulsed Doppler echocardiography, peak velocities during rapid filling (E) and atrial contraction (A) were measured, and the E/A ratio and deceleration time of the E wave velocity (DT) were calculated. The time-velocity integral (TVI) of the E wave (TVI-R), A wave (TVI-A), and rapid-filling fraction (TVI-R/TVI-R+TVI-A) was measured. The early diastolic mitral annular velocity (Ea) was measured by tissue Doppler. The 56 subjects were divided into the following three groups: (1) an impaired relaxation group consisting of 30 patients with normal ejection fraction and a mitral inflow pattern with a reduced E/A ratio (E/A < 1.0); (2) a pseudonormal group consisting of 18 patients with a mitral inflow pattern with an increased E/A ratio (E/A > 1.0), an increased E/Ea ratio (E/Ea 10), and no shortened DT (≧140 ms) [patients with hypertrophic cardiomyopathy (HCM, n = 8), dilated cardiomyopathy (DCM, n = 8), and aortic valve stenosis (n = 2) were included in this group); and (3) a restrictive group consisting of eight patients with a mitral inflow pattern with an increased E/A ratio (E/A >1.5), an increased E/Ea ratio (E/Ea ≧10), and a shortened DT (<140 ms) [patients with DCM (n = 5) and HCM (n = 3) were included in this group]. As a control group, 20 normal subjects (30 ± 18 years) were selected on the basis of having high-quality echocardiographic images. Diastolic CK images were obtained from the LV midpapillary short-axis view. The analysis of CK diastolic images was performed by using ICK software. The CK-diastolic index (CK-DI) was defined as the degree of LV segmental expansion during the first 30% of diastole, expressed as a percentage. The mean CK-DI was calculated from the average CK-DI of six LV segments. RESULTS: No relationship was observed between mean CK-DI and rapid-filling fraction in any of the study subjects (r = -0.092, P > 0.2). Mean CK-DI was significantly lower in the restrictive group (34.2% ± 4.3%) compared with the normal group (70.6% ± 7.4%), the impaired relaxation group (50.5% ± 7.7%), and the pseudonormal group (42.3% ± 7.5%). The reduction of mean CK-DI was found to be associated with the progression of LV diastolic dysfunction. CONCLUSION: We conclude that the analysis of diastolic CK by using ICK software is a useful technique that can be applied to quantitative evaluation of LV global diastolic function.

Relationship between spontaneous echo contrast in the thoracic aorta and plasma von Willebrand factor.

PURPOSE: To clarify the relationships between spontaneous echo contrast (SEC) detected by transesophageal echocardiography (TEE) and coagulopathy, ultrasonographic findings that may correlate to biochemical coagulation markers were examined. METHODS: TEE was performed on 49 consecutive patients (mean age 64 ± 14 years; 28 men, 21 women). Blood samples were taken at the same time as TEE was carried out. Aortic SEC (Ao-SEC) and left atrial SEC (LA-SEC) were classified into three grades: absent, mild and marked. Levels of von Willebrand factor (vWF), thrombin antithrombin III complex (TAT), prothrombin fragments 1+2 (F1+2) and fibrinopeptide A (FPA) were measured. RESULTS: Mean plasma vWF levels by Ao-SEC grade were 144 ± 39% for absent, 177 ± 55% for mild and 210 ± 73% for marked, with significantly higher levels in the Ao-SEC marked group than in the Ao-SEC absent group (P < 0.05). Mean plasma vWF levels by LA-SEC were 185 ± 73% for absent, 180 ± 49% for mild and 201 ± 62% for marked, with no significant differences apparent between groups. Moreover, no relationships were identified between Ao-SEC grade and plasma levels of coagulation indicators TAT, F1+2 and FPA. CONCLUSION: Plasma vWF levels correlated to grade of aortic SEC. Characteristics of the coagulation system differ between Ao-SEC and LA-SEC. Ao-SEC offers a clinical indicator of platelet thrombus formation.

Widening of the excitable gap and enlargement of the core of reentry during atrial fibrillation with a pure sodium channel blocker in canine atria.

BACKGROUND: This study aimed to assess the effects of pilsicainide, a pure sodium channel blocker, on electrophysiological action and wavefront dynamics during atrial fibrillation (AF). METHODS AND RESULTS: In a newly developed model of isolated, perfused, and superfused canine atria (n=12), the right and left endocardia were mapped simultaneously by use of a computerized mapping system. AF was induced with 1 to 5 micromol/L acetylcholine. The antifibrillatory actions of pilsicainide on AF cycle length (AFCL), refractory period (RP), conduction velocity (CV), excitable gap (EG), and the core of the mother rotor were studied. The RP was defined as the shortest coupling interval that could capture the fibrillating atrium. The EG was estimated as the difference between the AFCL and RP. At baseline, multiple wavefronts were observed. After 2.5 microg/mL infusion of pilsicainide, all preparations showed irregular activity, and AF was terminated in 2 preparations. The AFCL and RP were prolonged, and CV was decreased significantly. The EG was widened (147%; P<0.01), and the core perimeter was increased (100%; P<0.01). Increasing the dosage either terminated AF (6 preparations) or converted to organized activity (ie, atypical atrial flutter) (4 preparations). On the maps, all "unorganized" AFs were terminated with the excitation of the core of the mother rotor by an outside wavefront, whereas in preparations with atrial flutter, pilsicainide did not terminate its activity. CONCLUSIONS: Widening of the EG by pilsicainide facilitates the excitation of the core of the mother rotor, leading to the termination of AF. In some experiments, pilsicainide converts AF to persistent atrial flutter.

Chlamydia pneumoniae immunoreactivity in coronary artery plaques of patients with acute coronary syndromes and its relation with serology.

BACKGROUND: An association between Chlamydia pneumoniae (Cpn) infection and coronary artery disease has been reported and examined by different techniques. However, its immunoreactivity in coronary artery plaques of patients with acute coronary syndrome (ACS) and its relation with serology are less well defined. METHODS: We divided 40 coronary plaque specimens from 40 patients who underwent thrombectomy or directional coronary atherectomy into an ACS group (n = 22) and a non-ACS group (n = 18). Cpn in specimens was detected immunohistochemically and compared quantitatively. Serum immunoglobulin (Ig)A and IgG antibodies to Cpn and high-sensitivity C-reactive protein (hs-CRP) were measured. The relation between serology and immunohistochemical analysis was also investigated. RESULTS: Cpn immunopositive cells per square millimeter (Cpn+ cells/mm2) in the ACS group were significantly more numerous than in the non-ACS group (median 7.44 vs 1.50, P = .0018). Cpn IgA seropositivity rates and titers in the ACS group were significantly higher than those in the non-ACS group (86.3% vs 22.2%, P = .0002; median titer 1.403 vs 0.545, P = .003). There were no differences in IgG antibodies between the 2 groups. The hs-CRP values (in milligrams per liter) in ACS group were significantly higher than in non-ACS group (median 2.8 vs 1.2, P = .0019). Serum IgA titers in patients with at least 5 Cpn+ cells/mm2 in the specimens were significantly higher than in patients with fewer Cpn+ cells (median 1.52 vs 0.86, P = .026). There was no difference in serum hs-CRP values in patients with more Cpn+ cells but a trend to an increase. CONCLUSION: Immunohistology frequently detected Cpn in coronary plaques; Cpn+ cells were more prevalent in plaques associated with ACS, and Cpn IgA but not IgG titers were increased with ACS and with high densities of Cpn+ cells within plaque.

A case of chronic dissecting aortic aneurysm complicated with rupture into the right atrium: Diagnosis by transesophageal echocardiography.

Although rupture of a dissecting aortic aneurysm into the pericardial sac, pleural cavities, or mediastinum is a frequently encountered complication of this entity, rupture into a right-sided cardiac chamber is extremely rare. An 80-year-old woman was admitted to this institution because of dyspnea and facial edema. One year before admission, a diagnosis of dissecting aortic aneurysm (Stanford A type) was made based on results of magnetic resonance imaging and transesophageal echocardiography (TEE); however, the patient and her family refused surgical therapy. On admission, blood pressure was 120/60 mmHg, and a Levine 3/6° continuous murmur was audible at the third and fourth intercostal spaces of the right sternal border. Chest x-ray film showed moderate cardiomegaly, congested lung fields, and bilateral pleural effusion. A two-dimensional echocardiogram revealed severe aortic root dilatation 80 mm in diameter with the intimal flap. Color flow Doppler imaging demonstrated abnormal flow toward the back space in dilated ascending aorta. Continuous wave Doppler imaging showed the peak velocity of this flow to be 4.8 m/s. This high-velocity flow strongly suggested that the dissecting aortic aneurysm had ruptured into the right-sided cardiac chamber, and shunt flow from the false lumen of the aortic aneurysm into the right atrium was directly visualized by TEE. Our diagnosis, based on these findings, was chronic dissecting aortic aneurysm with communication into the right atrium. In view of the patient's deteriorating clinical condition, cardiac catheterization was not performed before surgery. Surgery revealed an aneurysm of the ascending aorta measuring 90 mm in diameter and multiple fistulas approximately 2 to 3 mm in diameter arising from the false lumen of the aorta into the right atrium at the base of the atrial appendage. The patient underwent successful replacement of the ascending aorta and closure of the aorto-right atrial fistulas. She had an uneventful postoperative course and was discharged 7 weeks after surgery.

Presence and severity of Chlamydia pneumoniae and Cytomegalovirus infection in coronary plaques are associated with acute coronary syndromes.

Although an association between Chlamydia pneumoniae (Cpn) or Cytomegalovirus (CMV) infection and coronary atherosclerosis has been reported, such an association is less clear for acute coronary syndromes (ACS). The purpose of this study was to investigate the pathogenic roles of Cpn and CMV infection of coronary plaques in ACS. We divided 38 coronary plaque specimens obtained from 38 patients who underwent directional coronary atherectomy or thrombectomy into an ACS group (n = 21) and a non-ACS group (n = 17). Cpn and CMV in specimens were stained using immunohistochemical techniques and analyzed quantitatively. The detection rate for either Cpn- or CMV-positive cells in ACS patients was slightly higher compared with non-ACS patients. Detection rates for both Cpn- and CMV-positive cells were significantly higher in ACS patients than in non-ACS patients (P = 0.010). Furthermore, the density of Cpn- and CMV-positive cells in plaques was significantly higher in ACS patients than in non-ACS patients (P < 0.003). The results indicate that the presence and severity of Cpn and CMV infection in coronary plaques are greater in patients with ACS compared with non-ACS patients. We conclude that infection with Cpn and CMV in coronary plaques may be involved in the pathogenesis of ACS.

Left atrial thrombus causing pulmonary embolism by passing through an atrial septal defect.

A 66-year-old woman admitted with dyspnea on exertion had atrial fibrillation and left ventricular dysfunction. Echocardiography revealed an atrial septal defect (ASD) and a soft, easily deformable thrombus in the dilated left atrium. The atrial mass suddenly disappeared on the 10th day after admission, and contrast-enhanced chest computed tomography and pulmonary blood flow scintigraphy showed that the thrombus had detached from the left atrium, floated into the right atrium through the ASD and caused pulmonary embolism. This is the first documented case of a left atrial thrombus causing pulmonary embolism by passing through an ASD. When an ASD is present, it is important to consider not only paradoxical thromboembolism (from the right to the left atrium), but also pulmonary embolism caused by thromboembolism from the left to the right atrium.

[Hypertrophic cardiomyopathy with mid-ventricular obstruction complicated with apical left ventricular aneurysm and ventricular tachycardia: a case report].

A 69-year-old man was admitted with palpitations and syncope. His medical history included hypertension and left ventricular hypertrophy. Arterial pulsation was not palpable on admission. Electrocardiography revealed ventricular tachycardia, and cardioversion restored normal sinus rhythm. An electrophysiological study reproducibly induced polymorphic ventricular tachycardia, so a cardioverter defibrillator was implanted. Echocardiography revealed mid-ventricular obstruction and an apical aneurysm, and Doppler color flow imaging showed a diastolic paradoxic jet from the apex toward the base. Coronary angiography showed no stenosis of the extramural coronary arteries. Ventricular tachycardia on admission showed a right bundle branch block pattern and a superior axis deviation, so the arrhythmia was thought to originate from the apical aneurysm. Apical aneurysm can result from elevated intraventricular pressure or relative myocardial ischemia. This is a rare case of hypertrophic cardiomyopathy with mid-ventricular obstruction complicated with apical aneurysm and polymorphic ventricular tachycardia.

Percutaneous bare Z-stent implantation as an alternative to surgery for acute aortic dissection with visceral ischemia.

We describe a case of Stanford type B acute aortic dissection causing visceral ischemia. An aortogram showed an hourglass-like narrowing of the true lumen at the diaphragm with a 60 mm Hg pressure gradient. Placement of a self-expanding metallic Z-stent under intravascular ultrasound guidance restored blood flow to the viscera.