Carlos Velasco

Comparison of Myocardial Contrast Echocardiography and Low-Dose Dobutamine Stress Echocardiography in Predicting Recovery of Left Ventricular Function After Coronary Revascularization in Chronic Ischemic Heart Disease

BACKGROUNDnDobutamine stress echocardiography (DSE) and myocardial contrast echocardiography (MCE) can predict recovery of left ventricular function after myocardial infarction. DSE also has been shown to predict left ventricular functional recovery after revascularization in chronic ischemic heart disease, whereas MCE has not been evaluated in such patients. This study was performed to compare DSE and MCE in the prediction of left ventricular functional recovery after revascularization in patients with chronic ischemic heart disease.nnnMETHODS AND RESULTSnMCE and DSE were performed in 35 patients with chronic coronary artery disease and significant wall motion abnormalities (mean ejection fraction, 0.36 +/- 0.09). Regional wall motion was scored by use of a 16-segment model wherein 1 = normal or hyperkinetic, 2 = hypokinetic, 3 = akinetic, and 4 = dyskinetic. Each segment was evaluated for contractile reserve by DSE and perfusion by MCE. Revascularization (coronary artery bypass graft [n = 13] and percutaneous transluminal coronary angioplasty [n = 10]) was successful in 23 patients. Follow-up echocardiograms were done to assess wall motion 30 to 60 days later. In 238 segments with resting wall motion abnormalities, perfusion was more likely to present than contractile reserve (97% versus 91%, P < .02). Revascularization resulted in functional recovery in 77 of 95 hypokinetic segments (81%) but only 18 of 57 akinetic segments (32%, P < .0001). DSE and MCE were not significantly different in predicting functional recovery of hypokinetic segments. In akinetic segments, DSE and MCE had similar sensitivities (89% versus 94%, respectively) and negative predictive values (93% and 97%, respectively) in predicting functional recovery. However, DSE had a higher specificity (92% versus 67%, P < .02) and positive predictive value (85% versus 55%, P < .02) than MCE in predicting functional recovery.nnnCONCLUSIONSnBoth contractile reserve by DSE and perfusion by MCE are predictive of functional recovery in hypokinetic segments after coronary revascularization in patients with chronic coronary revascularization in patients with chronic coronary artery disease. In akinetic segments, myocardial perfusion by MCE may exist in segments that do not recover contractile function after revascularization. Thus, contractile reserve during low-dose dobutamine infusion is a better predictor of functional recovery after revascularization in akinetic segments than perfusion.

Peripheral intravenous myocardial contrast echocardiography using a 2% dodecafluoropentane emulsion : identification of myocardial risk area and infarct size in the canine model of ischemia

OBJECTIVESnThis study assessed the accuracy of 2% dodecafluoropentane (EchoGen), an intravenous echocardiographic contrast agent, in identifying myocardial area at risk and infarct size in the canine model of myocardial ischemia.nnnBACKGROUNDnMyocardial contrast echocardiography allows determination of myocardial area at risk and infarct size but requires intracoronary injection in humans. The development of agents that can be delivered by peripheral intravenous injection could enable bedside myocardial contrast echocardiographic assessment of risk area, infarct size and reperfusion.nnnMETHODSnTwo protocols were used. Protocol 1 assessed the accuracy of myocardial contrast echocardiography using intravenous dodecafluoropentane in defining myocardial area at risk and infarct size in the canine model of regional myocardial ischemia versus gross pathologic specimens stained with monastral blue to determine area at risk and triphenyltetrazolium chloride to determine the area of necrosis. Protocol 2 assessed the effects of repeated injections of dodecafluoropentane (0.5 ml/kg body weight, four doses 30 min apart or eight doses 10 min apart) on myocardial blood flow and hemodynamic variables.nnnRESULTSnMyocardial contrast echocardiography accurately defined area at risk and infarct size (r = 0.96 vs. triphenyltetrazolium chloride). Myocardial blood flow remained stable after multiple serial injections of dodecafluoropentane. However, a significant increase in pulmonary artery pressure and pulmonary vascular resistance, along with a decrease in arterial oxygen saturation and cardiac output, was seen in dogs that received eight injections at 10-min intervals.nnnCONCLUSIONSnMyocardial contrast echocardiography using intravenous dodecafluoropentane accurately defined myocardial area at risk and infarct size. Hemodynamic variables and regional myocardial blood flows remained stable when dodecafluoropentane was injected at 30-min intervals for up to four doses; more frequent administration led to cardiopulmonary deterioration. Dodecafluoropentane offers the potential for reliable, noninvasive assessment of reperfusion after therapeutic interventions.

Glucose variability negatively impacts long-term functional outcome in patients with traumatic brain injury

PURPOSEnSignificant glycemic excursions (so-called glucose variability) affect the outcome of generic critically ill patients but has not been well studied in patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the impact of glucose variability on long-term functional outcome of patients with TBI.nnnMATERIAL AND METHODSnA noncomputerized tight glucose control protocol was used in our intensivist model surgical intensive care unit. The relationship between the glucose variability and long-term (a median of 6 months after injury) functional outcome defined by extended Glasgow Outcome Scale (GOSE) was analyzed using ordinal logistic regression models. Glucose variability was defined by SD and percentage of excursion (POE) from the preset range glucose level.nnnRESULTSnA total of 109 patients with TBI under tight glucose control had long-term GOSE evaluated. In univariable analysis, there was a significant association between lower GOSE score and higher mean glucose, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL but not POE 80 to 110. After adjusting for possible confounding variables in multivariable ordinal logistic regression models, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL were significantly associated with lower GOSE score.nnnCONCLUSIONSnGlucose variability was significantly associated with poorer long-term functional outcome in patients with TBI as measured by the GOSE score. Well-designed protocols to minimize glucose variability may be key in improving long-term functional outcome.

Predictors of outcome and different management of aortobronchial and aortoesophageal fistulas

OBJECTIVEnAortoesophageal and aortobronchial fistulas are uncommon but life-threatening conditions. The present study aimed to identify potential differences in outcomes, depending on the etiology, type, and management of the fistulas, and to determine mortality predictors.nnnMETHODSnWe retrospectively reviewed a series of 26 consecutive patients with thoracic aorta fistulas admitted to our institution from 1998 to 2013 (18 aortobronchial, 7 aortoesophageal, and 1 combined fistula).nnnRESULTSnThe mean age was 61.5 ± 13.4 years, with 22 men. Management was thoracic endovascular aortic repair (TEVAR) in 8, open repair in 7, and conservative in 11. The TEVAR and nonoperative patients were significantly older and presented with more comorbidities. Shock developed in 15 patients and sepsis in 9. The most common radiologic findings were intramural hematoma (65.4%), pseudoaneurysm (53.8%), and bronchial compression (46.20%). Active contrast extravasation (23.1%) and ectopic gas (19.2%) were associated with a worse prognosis. In-hospital mortality was 100% in the conservative group, 37.5% in the TEVAR group, and 14.3% in the open repair group (P = .04). Septic shock was the most common cause of death. The risk factors for in-hospital mortality were hemodynamic instability on admission (P = .02), sepsis (P = .04), and conservative management (P < .001). The overall long-term survival in surgical patients at 1 and 5 years was 66% and 58.7%, respectively. Infectious and malignant etiologies resulted in the worst prognosis.nnnCONCLUSIONSnThe outcomes are ultimately conditioned by the etiology of the fistula. Both open and endovascular management of aortic fistulas can prevent death by exsanguination; however, patients remain at high risk of infectious complications. Failure to treat the underlying cause will result in poor midterm outcomes.

Efficacy and safety of transcatheter valve-in-valve replacement for Mitroflow bioprosthetic valve dysfunction

Bioprostheses with pericardial leaflets mounted externally on the stent pose a high risk for valve‐in‐valve (ViV) procedures. This study analyzed the efficacy and safety of ViV procedures for treating structural valve deterioration (SVD) in Mitroflow bioprostheses.

Spontaneous Left Atrial Hematoma Mimicking an Acute Aortic Syndrome The Utility of High-Resolution Computed Tomography

A 69-year-old man with no history of chest trauma was admitted to our institution complaining of blunt and severe central chest pain of cataclysmic onset radiating to the back. His medical history was remarkable only for a chronic atrial fibrillation treated with warfarin and amiodarone. On arrival, his ECG showed atrial fibrillation at 120 bpm with no signs of myocardial ischemia. Laboratory examination was uneventful except for an international normalized ratio of 7. With the presumptive diagnosis of acute aortic syndrome, a thoracoabdominal high-resolution contrast-enhanced computed tomography scan was performed that showed a large mass at the level of the left atrium (LA) and a moderate pericardial effusion (Figure 1 and Movie I in the online-only Data Supplement). Linear attenuation coefficients of the LA mass and pericardial fluid were suggestive of acute clot and blood (60 and 50 Hounsfield units, respectively). No signs of malignancy, pulmonary embolism, or aortic disease were found. During evaluation, our patients clinical condition …

Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows

OBJECTIVESnThe objective of this study is to compare early and long-term results in terms of survival and aortic complications for traumatic aortic injuries depending on the initial management strategy.nnnMETHODSnFrom January 1980 to January 2017, 101 patients with aortic injuries were divided into 3 groups according to management strategy at admission: 60 patients, conservative management; 26 patients, open surgery and 15 patients, endovascular repair. The groups were similar in terms of gender and trauma severity scores.nnnRESULTSnAll but 1 aortic-related complications and aortic-related mortality occurred in the conservative group (11.6% conservative vs 2.4% in both surgical and endovascular groups, Pu2009=u20090.091). Total follow-up was 1109.27 patient-years. Survival in the conservative, surgical and endovascular group was 71.7%, 80.8% and 79.4% at 1u2009year, 68.2%, 80.8% and 79.4% at 5u2009years and 63.9%, 72.7% and 79.4% at 10u2009years, respectively (log-ranku2009=u20090.218). The rate of aortic-related complications was 58.3% in the conservative cohort. Cox regression identified the following risk factors for aortic-related complications: aortic injuries grade >I [odds ratio (OR), 3.05; Pu2009=u20090.021], Trauma Injury Severity Score >50% (OR 1.21; Pu2009=u20090.042) and the decade of treatment (OR 0.49; Pu2009=u20090.011).nnnCONCLUSIONSnMinimal aortic injuries seem to be an amenable target for medical management, but patients remain at risk of developing aortic-related complications. Close, long-term imaging surveillance is mandatory to detect such complications at an early stage.

Combined Aortic and Pulmonic Stenosis in an Octogenarian Findings From Echocardiography, Catheterization, and Pathology

Combined aortic and pulmonic stenosis is a very rare condition, with only a few patients reported in the literature.1 Moreover, most of those cases are children and young adults, and thus, the pathogenesis has been often considered congenital.2,3 We report an 81-year-old man with a diagnosis of severe aortic and pulmonic stenosis who underwent successful aortic and pulmonic valve replacement, and we comment on the echocardiographic and pathological findings and speculate on the most likely cause. To the best of our knowledge, this is the first report of this condition in an octogenarian patient.nnAn 81-year-old man with a medical history of smoking, arterial hypertension, dyslipidemia, mild renal …

764-6 Effect of a New Phase Shift Echo Contrast Agent on Myocardial Blood Flow and Hemodynamics

We have demonstrated the accuracy of myocardial area at risk and infarct size determinations with an emulsion of dodecafluoropentane (EchoGenxa0=xa0EG) which is liquid at room temperature and a gas at body temperature (AHA meeting). To determine the effect of EG on myocardial blood flow (MBF), 10 fully anesthetized dogs received 4 (30 min apart) or 8 (10 min apart) peripheral intravenous injections of EG 0.5 ml/kg. HR, BP, T, PAP, PCWP, and CO were monitored. MBF was assessed with radiolabeled microspheres. Echo images were recorded with TEE. MBF (ml/min/g,xa0±xa0SEM) was determined in four slices of the left ventricle (LV). Serial assessments of LV wall motion were performed. MBF base MBF final Anterior wall 1.4xa0±xa00.05 1.2xa0±xa00.2 Septal wall 1.2xa0±xa002 1.2xa0±xa00.2 Lateral wall 1.5xa0±xa00.1 1.2xa0±xa00.2 Posterior wall 1.5xa0±xa00.2 1.2xa0±xa00.2 PCWP, CO, and MBF were unchanged following 4 doses of EG. Systemic hypotension was seen, similar to that observed during administration of other perfluorochemicals in dogs. Pulmonary hypertension and deterioration in LV function were seen with 8 doses at 10 min intervals (cumulative dose: 4.0xa0ml/kg). Conclusion Administration of EG at frequent intervals can lead to a significant increase in PAP and myocardial dysfunction. However, EG does not produce significant alteration of MBF or PAP when administered at 30 min intervals at dosages that permit determination of myocardial area at risk and infarct size in our canine preparation.