Heart adaptations to long-term aerobic training in paraplegic subjects: an echocardiographic study.

STUDY DESIGN: Case-control. OBJECTIVES: To execute an echocardiographic comparison between trained and untrained spinal cord injury (SCI) subjects, and to evaluate whether long-term heart adjustments to endurance training are comparable to those observed in able-bodied (ABL) subjects. SETTING: Italy. METHODS: We enrolled: (1) 17 male SCI patients (lesion level T1-L3, 34±8 years, body mass index (BMI) 23.0±2.8 kg m(-2)), 10 of whom were aerobically trained for >5 years (SCI(T)); (2) 18 age-, sex- and BMI-matched ABL subjects (35±6 years, BMI 23.6±2.8 kg m(-2)), 10 of whom were aerobically trained for >5 years (ABL(T)). Training frequency and volume were recorded by a dedicated questionnaire. All subjects underwent a trans-thoracic echocardiography; SCI subjects also performed an exhaustive incremental exercise test. Comparisons were made between ABL and SCI groups, between trained and untrained subjects within each group (analysis of variance). RESULTS: Effects of SCI-Compared with ABL subjects, SCI patients showed lower end-diastolic volume (76±21 vs. 113±23 ml, P<0.05) and ejection fraction (61±7% vs. 65±5%, P<0.05). Effects of training-Compared with untrained status, the intra-ventricular septum thickness (SCI, +18%; ABL, +4%), the posterior wall thickness (SCI, +17%; ABL, +2%) and the total normalized heart mass (SCI, +48%; ABL, +5%) were higher in both SCI(T) and in ABL(T). VO2peak was higher in the SCI(T) subgroup compared with the SCI(U) group. CONCLUSIONS: Heart seems to positively adapt to long-term endurance training in SCI patients. Regular exercise may therefore increase heart size, septum and posterior wall thickness, which likely contributes to improved VO2peak. These morphological and functional changes may reduce cardiovascular risk in SCI individuals.

Measurement of mitral valve area in mitral stenosis: four echocardiographic methods compared with direct measurement of anatomic orifices.

OBJECTIVES: This study sought to compare the mitral valve areas of patients with rheumatic mitral valve stenoses as determined by means of four echocardiographic and Doppler methods with those obtained by direct anatomic measurements. BACKGROUND: There has been no systemic comparison between Doppler-determined valve areas and the true anatomic orifice in a single cohort. METHODS: In 30 patients with mitral stenosis, the mitral valve areas determined by two-dimensional echocardiographic planimetry, pressure half-time, flow convergence region and flow area were compared with the values directly measured on the corresponding excised specimen by means of a custom-built sizer. RESULTS: The correlation coefficient was r = 0.95 (SE 0.06, p < 0.0001) for two-dimensional planimetry; r = 0.80 (SE 0.09, p < 0.0001) for pressure half-time; r = 0.87 (SE 0.09, p < 0.0001) for flow convergence region; and r = 0.54 (SD 0.1, p < 0.002) for flow area. Two-dimensional echocardiographic planimetry, pressure half-time, flow convergence region and flow area overestimated the actual anatomic orifice by > 0.3 cm2 in 2, 1, 6 and 0 patients, respectively, and underestimated it by > 0.3 cm2 in 0, 4, 1 and 8 patients, respectively. CONCLUSIONS: Mitral valve areas determined by two-dimensional planimetry, pressure half-time and proximal flow convergence region reliably correlated with size of the anatomic orifice. The flow area method provided a less reliable correlation.

Increased echodensity of transiently asynergic myocardium in humans: a novel echocardiographic sign of myocardial ischemia.

OBJECTIVES: This study was conducted to establish whether changes in myocardial texture can be observed in humans by transthoracic echocardiography during ischemic episodes of different severity and duration induced by various pathogenetic mechanisms. BACKGROUND: Increased echo-reflectivity of ischemic myocardium has been detected in experimental animals by epicardial echocardiography and by backscatter evaluation. METHODS: Transthoracic two-dimensional echocardiographic monitoring with a commercially available electronic sector scanner (2.25- or 3.5-MHz transducer) was performed during 35 episodes of transient myocardial ischemia induced by ergonovine in patients with vasospastic angina (n = 9), by dipyridamole in patients with angiographically assessed coronary artery disease (n = 11) and by balloon occlusion during coronary angioplasty (n = 15). Quantitative texture analysis of gray levels was performed off-line on digitized images during rest conditions, ischemia and the recovery phase in regions showing normal contraction at rest, obvious dyssynergy during ischemia and normal contraction in the recovery phase. In each condition, a control region with normal contraction throughout the study was also evaluated. RESULTS: Chest pain occurred in 23 of the 35 episodes; electrocardiographic (ECG) changes were present in 26 episodes, and consisted of ST segment elevation in 13, ST segment depression in 10 and pseudonormalization of a basally negative T wave in 3. The duration of ischemic episodes was 67 +/- 53 s by symptomatic criteria and 91 +/- 52 s by ECG criteria. The risk region showed an increased end-diastolic mean gray level amplitude in a.u. (arbitrary units) during ischemia (57 +/- 19) compared with rest (38 +/- 15) and recovery (38 +/- 18, p < 0.01). No significant changes were detected in the control region (rest 36 +/- 16 vs. ischemia 34 +/- 18 vs. recovery 31 +/- 13, p = NS). The percent increase in mean gray level was similar in the various types of stress employed (ergonovine, dipyridamole or angioplasty) and was not significantly correlated with either the duration of ST segment shift (r = 0.05, p = NS) or the severity of dyssynergy evaluated semiquantitatively by means of the wall motion score (r = 0.28, p = NS). In the 15 balloon occlusions performed in six patients during coronary angioplasty, the increased echoreflectivity of the risk zone was already evident during echocardiographic sampling performed after 10 +/- 4 s of occlusion (rest 35 +/- 9 vs. 53 +/- 10 a.u., p < 0.01) when no dyssynergy could be detected by quantitative wall motion analysis (percent area change by fixed center of mass reference system 31 +/- 10% at rest vs. 32 +/- 11% after 10 s of occlusion, p = NS). CONCLUSIONS: Transient short-lasting myocardial ischemia is associated with an abrupt increase in myocardial echodensity detectable by videodensitometric analysis applied to standard transthoracic echocardiographic images and is largely independent of the underlying pathogenetic mechanism (reduced blood supply or flow maldistribution with coronary stenosis). During controlled coronary occlusion, increased echodensity precedes the onset of regional dyssynergy.

Assessment of left internal mammary artery grafts using dipyridamole Doppler echocardiography.

Color Doppler echocardiography of the left mammary artery was combined with dipyridamole testing in order to assess the presence of significant (>70%) graft stenosis in 87 patients with a mammary artery graft to the left anterior descending coronary artery presenting with chest pain. Occluded grafts are detected by absent diastolic flow velocities at baseline, whereas the response of the diastolic flow velocity to dipyridamole distinguishes patients with critical versus noncritical stenosis of a patent graft.

C-reactive protein elevation and early outcome in patients with unstable angina pectoris.

C-reactive protein, a reactant of the acute phase of inflammation, has been shown to be increased in patients with unstable angina. Moreover, it has recently been found that increased C-reactive protein is associated with a poor outcome during hospitalization in selected patients with severe unstable angina. The aim of this study was to investigate the prognostic value of C-reactive protein elevation in a large population with unstable angina. We measured serum levels of this marker in 140 patients hospitalized with unstable angina (class IIIB of the Braunwald classification, mean time from last anginal episode 5 +/- 5 hours). Thirty-nine of them (28%) had increased serum levels on hospital admission and 33 (24%) experienced an adverse outcome (myocardial infarction or refractory angina) during hospitalization. Kaplan-Meier analysis showed that the probability of developing cardiac events during hospitalization was not different between patients with and without abnormal C-reactive protein levels. Furthermore, the incidence of ischemia at Holter monitoring during the first 72 hours after hospitalization was not different between patients with and without abnormal C-reactive protein. In a representative population of patients with unstable angina, a sizable proportion had increased serum C-reactive protein levels; however, abnormal concentrations of C-reactive protein do not predict an adverse outcome in the early phase after the acute episode.

Value of transthoracic two-dimensional echocardiography in predicting viability in patients with healed Q-wave anterior wall myocardial infarction.

The role of transthoracic echocardiography as a predictor of recovery after revascularization has not yet been established. Two-dimensional echocardiography was performed in 15 patients with a healed anterior wall myocardial infarction and severe, isolated stenosis of the left anterior descending coronary artery before, and 3 to 6 months after angiographically confirmed successful revascularization. The asynergic segments were classified into 2 groups according to 2 different echocardiographic patterns: those showing a normal acoustic reflectance with normal end-diastolic thickness (pattern A segments) and those showing an increase in acoustic reflectance and reduced end-diastolic thickness (pattern B segments). We hypothesized that pattern A segments were more likely to recover (viable myocardium) and that pattern B segments were consistent with irreversibility. A total of 240 segments in the 15 patients were evaluated before and after revascularization. Sixty-seven segments were asynergic; of these, 52 were judged to have pattern A and 15 pattern B. Of the 52 pattern A segments, 27 were hypokinetic and 25 akinetic. All of the pattern B segments were akinetic (n = 9) or dyskinetic (n = 6). Pattern A was predictive of postoperative recovery in 39 of 52 segments (75%) (p < 0.0001); pattern B was predictive of irreversibly damaged tissue in 13 of 15 segments (87%) (p < 0.0001). Thus, in patients with healed anterior wall myocardial infarction, resting transthoracic echocardiography is a simple and reliable predictor of the behavior of asynergic segments after revascularization.

Transthoracic high-frequency echocardiographic detection of atherosclerotic lesions in the descending portion of the left coronary artery.

To assess the ability of transthoracic high-frequency two-dimensional echocardiography to detect atherosclerotic lesions in the descending portion of the left coronary artery, 30 consecutive patients with suspected coronary artery disease underwent two-dimensional echocardiographic examination 24 to 96 hours before coronary angiography. The descending portion of the left coronary artery was arbitrarily divided into a mid segment (the portion of the coronary vessel embedded in the anterior interventricular sulcus) and an apical segment (the portion turning around the cardiac apex into the posterior interventricular sulcus). The mid segment was imaged in 24 and the apical segment in 25 of the 30 patients for a total of 49 out of 60 segments (82%). Comparison of the echocardiographically visualized segments with the corresponding angiographic segments indicated that a correct echocardiographic diagnosis of significant stenosis was made in 11 out of 12 segments. There were no false positive results. Thus the sensitivity and specificity of high-frequency transthoracic echocardiography in the detection of significant stenosis in the imaged segments were 92% and 100%, respectively. Compared with angiography, additional information concerning the status of the arterial wall, the presence of calcific plaques, and the cross-sectional extent of the obstructive lesions was obtained by echocardiography in eight patients.

Prolonged streptokinase infusion in patients with unstable angina: results of a randomized, placebo-controlled clinical trial.

BACKGROUND: The purpose of this study was to assess the efficacy both of prolonged (48 h) and of short-duration (1 h) administrations of streptokinase in patients with unstable angina. In unstable angina, thrombosis is a dynamic process that waxes and wanes for hours and even days. The majority of previous studies have investigated the efficacy of short-duration thrombolytic regimens. METHODS: One hundred patients with acute unstable angina were randomly allocated to receive placebo, 1,500,000 U streptokinase during 1 h or 250,000 U streptokinase during 1 h and then a prolonged infusion of 100,000 U for the next 48 h. All of the treatments included intravenous heparin administration for 72 h. RESULTS: No death occurred in the study population. One of 34 patients treated with placebo (2.9%), three of 33 treated with streptokinase during 1 h (9.0%) and three of 33 treated with streptokinase during 48 h (9.0%) had a myocardial infarction. Refractory angina occurred in nine, three and seven patients receiving placebo, streptokinase during 1 h and streptokinase during 48 h, respectively. Kaplan-Meier analysis showed that the total probability for a patient to be free of cumulative events did not differ among the three groups of patients (NS). Fourteen patients (41%) receiving placebo, 15 patients (45%) receiving streptokinase during 1 h and 14 patients (42%) receiving streptokinase during 48 h had ischaemic episodes detected by Holter monitoring during the first 72 h after hospital admission (NS). Two patients receiving streptokinase during 48 h required blood transfusion, and a greater incidence of minor bleeding (P < 0.05) and adverse events (P < 0.02) was observed in patients receiving prolonged streptokinase administration than in those receiving streptokinase during 1 h or placebo. CONCLUSIONS: In patients with acute unstable angina, the administration of two different regimens of streptokinase significantly reduces the probability neither of developing cardiac events during hospitalization nor of ischaemia detected by Holter monitoring in the early phase after hospital admission. Although the sample size of the study provided sufficient power to exclude only a large difference in effect size, it did allow us to detect a significantly higher incidence of bleeding in the group of patients treated with prolonged streptokinase infusion.

Late reoperations after repair of tetralogy of Fallot.

Twenty-two patients underwent 23 late reoperations after total correction of tetralogy of Fallot from 1965 to 1990. Indications for reoperation included: isolated ventricular septal defect (VSD) in 9 patients (41%), isolated right ventricular outflow tract (RVOT) obstruction in 3 patients (13.7%), VSD associated with a RVOT obstruction in 7 patients (31.8%), aneurysm of the pericardial RVOT patch in 1 patient (4.5%), aortic insufficiency with a residual VSD in 1 patient (4.5%), and tricuspid regurgitation in 1 patient (4.5%). The reoperation consisted of closure of a residual VSD in 17 patients, relief of a RVOT gradient in 11, insertion of a RVOT valve in 4, tricuspid valve replacement in 1 (reoperated twice), aortic valve replacement in 1, and excision of a RVOT aneurysm in 1. Two patients died in hospital (9%) but there were no early deaths in the 11 patients reoperated upon after 1978. Mean follow-up period was 135 months. There were 2 late deaths. The actuarial 20-year survival was 87%. Of the surviving patients, 16 (89%) were in New York Heart Association class I, 1 (5.5%) was in class II, and one (5.5%) was in class III. One patient required a second reoperation for tricuspid bioprosthesis degeneration and 1 patient had moderate recurrent RVOT gradient due to calcified pulmonary bioprosthesis. This study tends to support the policy of recommending reoperation in the presence of surgically significant residual defects. Reoperation is associated with a low early mortality and good long-term results.

Lack of Correlation Between Activation of Hemostatic Mechanism and Inflammation in Unstable Angina Pectoris.

In the acute phase of unstable angina, activation of the hemostatic mechanism is demonstrated by an increase in the plasma levels of markers of thrombin generation (prothrombin fragment 1+2) and thrombin activity (fibrinopeptide A). Increased concentrations of plasma C-reactive protein, an acute-phase reactant, have also been reported in patients with unstable angina. However, whether there is a correlation between the activation of the hemostatic mechanism and the acute-phase reaction of inflammation remains unclear. We measured the plasma levels of prothrombin fragment 1+2, fibrinopeptide A, and C-reactive protein in 91 patients consecutively hospitalized with recent-onset rest angina (Class IIIB Braunwald's classification), finding that they were above the normal limits in 48 (53%), 45 (49%), and 30 (33%) patients, respectively. There was no correlation between prothrombin fragment 1+2 and fibrinopeptide A (P = 0.34), prothrombin fragment 1+2 and C-reactive protein (P = 0.10), or fibrinopeptide A and C-reactive protein (P = 0.75). Plasma levels of prothrombin fragment 1+2 and fibrinopeptide A were both above normal levels in 32% of patients; 19% had both prothrombin fragment 1+2 and C-reactive protein, and 18% both fibrinopeptide A and C-reactive protein levels above the upper normal limits. All three markers were abnormally high in 11% of patients. According to the kappa cofficient test, the agreement between the elevation of the plasma concentrations of the markers was "random." In approximately half of the patients with acute unstable angina, there was an increase in the markers of the activation of the hemostatic mechanism and, in a smaller proportion, an increase in plasma C-reactive protein levels. The activation of the coagulation cascade and the acute-phase reaction of inflammation were infrequently associated in individual patients.

Can pulmonary hypertension be predicted by non-invasive approach? Echocardiographic and haemodynamic study.

41 patients suffering from Chronic Obstructive Lung Disease (COLD) and 44 with Sarcoidosis were studied. Said patients underwent respiratory function tests, echocardiography (M.mode) to assess the right ventricular index ( RVI = diameter of the right ventricular cavity corrected by body surface) and the thickness of the right ventricular anterior wall ( RVAWT ); patients also underwent right heart haemodynamics (Swan-Ganz catheter). These data were further statistically studied by means of multiple regression in order to assess the eventuality of a non-invasive prediction of pulmonary artery mean pressure (PAP): variables taken into consideration were: age, body surface (BS), RVI , RVAWT , arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2) and PAP dependence according to each case group and the interaction of each group itself on the variables. RVI appeared to be the most reliable, in fact, when PaCO2 is also available, the standard error of estimation (SEE) was only 3.84 mmHg and the coefficient of determination was equal to 85.5% with a notable improvement when compared to results seen in previous studies. This behaviour was observed both in patients with early sarcoidosis and in COLD patients with mild pulmonary hypertension. This might be due to the fact that we took the right ventricle into consideration which inevitably feels the increase in pulmonary hypertension.

[Cardiac failure in ischemic cardiopathy]. / L'insufficienza cardiaca nella cardiopatia ischemica.

Heart failure is a major cause of morbidity and mortality and represents an important recognized health problem. Heart (or cardiac) failure is the pathophysiological state in which a myocardial dysfunction is frequently but non always responsible for the inability of the heart to pump blood at a rate commensurate with tissues metabolic requirements. Ischemic heart disease is the commonest cause of heart failure frequently associated with left ventricular systolic dysfunction, although some patients, particularly the elderly, have diastolic dysfunction. Coronary heart disease is responsible for left ventricular systolic dysfunction (and cardiac failure) in the acute and chronic stage. Myocardial dysfunction is usually a consequence of myocardial infarction that may lead to ventricular remodeling with compensatory dilation and hypertrophy and subsequent systolic and diastolic dysfunction resulting in heart failure. Many patients with heart failure and/or left ventricular dysfunction are unknown. The echocardiographic screening of patients with known or suspected left ventricular dysfunction remains an important topic for future clinical epidemiological research and allows for improvement of therapeutic management of patients with cardiac dysfunction.

[Pre- and post-operative echocardiographic evaluations of mitral stenosis]. / Valutazioni ecocardiografiche pre- e post-operatorie della stenosi mitralica.

46 patients, affected by pure mitral stenosis, underwent echocardiographic study before and after mitral commissurotomy. The following echocardiographic parametres were considered: 1) closing velocity of anterior mitral leaflet (E-F slope); 2) amplitude of the mitral valve motion; 3) intensity and number of echoes coming from the mitral leaflet; 4) posterior leaflet motion; 5) left atrial diameter index; 6) right ventricolar diameter index; 7) left atrial and aorta diameter ratio. Moreover mitral diameter, mitral fibrosis or calcification, and possible mitral incontinence were evaluated intraoperatively before and after commissurotomy. The pre-operative echocardiographic examination of the mitral stenosis showed the following specific aspects: 1) reduced E-F slope, significantly correlated with the severity of the stenosis; 2) abnormally moving posterior mitral leaflet; 3) enlargement of the left atrium, directly correlated with the degree of the mitral stenosis. Correspondence was noted between the echocardiographic and the intraoperative evaluation of the anathomical pattern of mitral valve. Postoperatively the echocardiograms showed: 1) improved E-F slope, directly correlated with the surgical dilatation of the valve; 2) persistent abnormal movement of the posterior mitral leaflet; 3) disappeared correlation between the surgical diameter of mitral valve and the left atrial index. The ECHO proved to be a good diagnostic method for both a qualitative and a semiquantitative evaluation of mitral stenosis. The ECHO is also quite usefull in evaluating modifications induced by commissurotomy.

[Rupture of interventricular septum secondary to blunt chest trauma. Report of a case surgically treated with success (author's transl)]. / Rottura del setto interventricolare da trauma chiuso del torace. A proposito di un caso operato con successo

A case of interventricular septal defect secondary to blunt chest trauma is reported. It was characterized by a disconnection of the interventricular muscolar septal in the anterosuperior part of the heart wall. The diagnosis, suspected by clinical and instrumental parameters, was definitely confirmedy by hemodynamic and contrastographic examination. Repair surgery of the defect with a dacron patch was performed, using extracorporea normothermic circulation seven months after the accident. The patient was examined three months and twelve months after the operation; the clinical examinations did not reveal any cardiac murmur and the patient's health was satisfactory. The incidence, mechanism of rupture of interventricular septum and the main surgical and clinical aspects of this type of pathology are discussed.

Transthoracic 2D echo color Doppler assessment of internal mammary artery to left anterior descending coronary artery graft.

For noninvasive evaluation of anatomy and flow characteristics of internal mammary artery graft (IMA-graft), 2D echo-Color-Doppler (CDE) was performed in 60 patients (54 M, 6 F, mean age 54.1 +/- 6.9 y), who underwent coronary angiography 20.1 +/- 13 months after a coronary artery bypass graft (CABG). CDE was performed, using an echocardiographic unit equipped with a 5 MHz linear transducer. In all patients, measurements of IMA-graft diameter (mm), and peak systolic and diastolic flow velocity (cm/sec) were obtained at baseline and also in 16 patients after dipyridamole infusion (0.54 mg/Kg/min) and in 10 patients after sublingual nitroglycerin (NTG) (0.4 mg). Angiography showed the IMA-graft patency in 58/60 patients (96.8%). A typical biphasic flow was displayed by CDE in 49/58 patients (84.4%) with angiographic patency. Dipyridamole infusion increased both IMA-graft diameter and peak diastolic flow velocity (PDFV) from 2.28 +/- 0.51mm to 2.9 +/- 0.42mm and from 19.4 +/- 6.2 cm/sec to 93.9 +/- 29 cm/sec, respectively (p < 0.0001). No significant modifications of peak systolic flow velocity (PSFV) were observed. NTG increased PDFV from 29.11 +/- 8 cm/sec to 41.88 +/- 7.20 cm/sec (p < 0.005), while diameter and PSFV showed no statistically significant modifications. CDE is a useful diagnostic tool for noninvasive evaluation of IMA-graft patency both early after surgery and during long-term follow-up. CDE pharmacological stress improves the sensibility of the technique and it can provide indirect information about pathophysiology of recipient coronary vessel.

[Defects of the interatrial septum: surgical correction without the hemodynamic test. Analysis of 145 cases operated on]. / Difetti del setto interatriale: correzione chirurgica senza esame emodinamico. Analisi su 145 casi operati.

Surgical correction of ostium secundum atrial septal defects may be performed, in most cases, without cardiac catheterization, on the ground of clinical and two-dimensional echocardiographic (2D echo) findings. Consequently it's useful to identify the reliability of 2D echo and the indications for angiography in these patients (pts). One hundred forty-five patients operated in "A. De Gasperis" Division of Cardiac Surgery in Milan from January 1982 to December 1986 are reviewed. Patients with ostium primum atrial septal defects or subjected to cardiac catheterization and angiography in other institutions are excluded. Altogether two-dimensional echocardiography was performed in 131 pts, cardiac catheterization in 78. Sixty-four pts were studied with both 2D echo and angiography. In 35 pts (with only 2D echo examination) radionuclide angiocardiography was performed. The results of the different techniques were compared with intra-operative findings, defining sensitivity and specificity in relation to detection of the site of the defect and of the pulmonary venous return. There were no statistically significative differences between echo 2D and cardiac catheterization (Figs. 1 and 2). Two-dimensional echocardiography confirms its cost effective and psychological advantages, especially in younger patients. Hemodynamic and angiographic assessment should be performed as follows: 1) when associated anomalies are suspected; 2) in cases of non-satisfying quality of the 2D echo examination; 3) when diagnostic incoherence between clinical and instrumental data is present; 4) in patients with pulmonary hypertension.

Value of two-dimensional echocardiography in the identification of pulmonary hypertension in chronic obstructive lung disease.

Thirty-three patients suffering from chronic obstructive lung disease (COLD) were submitted to right heart two-dimensional echocardiographic (2D-ECHO) and hemodynamic study. By the subcostal approach, the right ventricle outflow tract including the pulmonary vessels was visualized in 85% of the patients. Most parameters measured on the right ventricle and pulmonary vessels were significantly higher than those recorded in the healthy control group. Very significant correlations were observed between the mean pulmonary artery pressure (PAP) and the following 2D-ECHO parameters: diameter of the pulmonary artery at valve level (r = 0.62; p less than 0.001); supravalvular diameter of the pulmonary artery (r = 0.44; p less than 0.03); diameter of the left branch of the pulmonary artery (r = 0.48; p less than 0.05); diameter of the right branch of the pulmonary artery (r = 0.39; p less than 0.05), and between the PAP and PaO2 (r = -0.66; p less than 0.001). Furthermore, the sensitivity, specificity, and accuracy of 2D-ECHO measurements were calculated to assess the presence of pulmonary hypertension. Overall sensitivity was 65%, specificity 75%, and accuracy 67%. However, by combining the value of PaO2 with that of the pulmonary valve by means of the multiple regression analysis, sensitivity increased to 84% in identifying pulmonary hypertension. Such data demonstrate that the 2D-ECHO study of the right heart in COLD patients has to carefully measure the dimensions of the pulmonary valve and the great pulmonary vessels, as their modification are mainly linked with the presence of pulmonary hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Activation of the hemostatic mechanism after pharmacological cardioversion of acute nonvalvular atrial fibrillation.

BACKGROUND: Given that the restoration of sinus rhythm after chronic atrial fibrillation is associated with embolic events, anticoagulation is prescribed before and after pharmacological and electrical cardioversion. However, the need for anticoagulation in patients with acute atrial fibrillation (lasting <48 hours) who undergo cardioversion is less clear. In addition, it is not known whether cardioversion to sinus rhythm determines a hypercoagulable state in these patients. METHODS AND RESULTS: In 21 patients with acute nonvalvular atrial fibrillation, plasma median concentrations of thrombin-antithrombin complex, a marker of thrombin generation, significantly increased from 2.8 ng/mL (interquartile range, 2.1 to 4.0 ng/mL) on hospital admission to 3.5 ng/mL (interquartile range, 2.9 to 6.0 ng/mL) after cardioversion to sinus rhythm obtained by means of infusion of antiarrhythmic drugs and decreased to 2.5 ng/mL (interquartile range, 2.0 to 3.5 ng/mL) at the 1-month follow-up visit (P=.04). Similarly, the levels of fibrinopeptide A, a marker of thrombin activity, increased from 1.1 nmol/L (interquartile range, 0.7 to 1.5 nmol/L) at baseline to 1.8 nmol/L (interquartile range, 1.1 to 3.0 nmol/L) after cardioversion and returned to 0.8 nmol/L (interquartile range, 0.6 to 1.1 nmol/L) at the 1-month follow-up visit (P=.02). CONCLUSIONS: A significant increase in plasma levels of the markers of thrombin generation and activity was observed in patients with acute atrial fibrillation early after pharmacological cardioversion to sinus rhythm. This is the first biochemical evidence that cardioversion of recent-onset atrial fibrillation determines a hypercoagulable state.