Giuseppina Magni

Two- and Three-Dimensional Transesophageal Echocardiography in Patient Selection and Assessment of Atrial Septal Defect Closure by the New DAS–Angel Wings Device Initial Clinical Experience

BACKGROUND Transcatheter closure of atrial septal defects (ASDs) has been feasible and successful. Two-dimensional echocardiography (2DE) was applied to patients before selection and during device deployment. Three-dimensional echocardiography (3DE) can provide unique anatomic perspectives that might aid in improving device closure of ASDs. METHODS AND RESULTS Twenty-two consecutive patients were enrolled in an initial protocol for ASD device closure by the new DAS-Angel Wings occluder device. On the basis of transesophageal (TEE) 2DE and 3DE, 13 patients were considered eligible for device closure (9 secundum ASDs and 4 with patent foramen ovale associated with a cerebral vascular accident). Maximal ASD diameter and surrounding rim tissues were compared by TEE 2DE and 3DE and with balloon sizing measurements at catheterization. ASD size measured by TEE 2DE and 3DE correlated well (y = 1.0x + 0.049, r = .95), with good limits of agreement. However, balloon-stretched diameter measurements were systematically larger than echocardiographic measurements. Rim tissue measurements correlated well; however, TEE 3DE could demonstrate the entire shape and perimeter of the defect. Two-dimensional imaging provided reliable information during device deployment and for closure of small ASDs. However, 3DE was superior for imaging the device, especially when abnormally placed. CONCLUSIONS Three-dimensional imaging provides unique images and projections that were essential for understanding the spatial relationship of the device to the atrial septum. Three-dimensional echocardiography significantly enhanced our understanding of two-dimensional images and provided an imaging conceptualization that should aid in future development of device closures.

Role of transthoracic and transesophageal echocardiography in predicting embolic events in patients with active infective endocarditis involving native cardiac valves

Some studies describe an increased risk for emboli in infective endocarditis patients with large (>10 mm) and mobile vegetations. Other studies fail to demonstrate the above relation. Most studies have been performed using transthoracic echocardiography or with a monoplane transesophageal approach. The present study examines whether distinctive characteristics of vegetative lesions detected by transthoracic and multiplane transesophageal echocardiography are predictive of embolic risk. We reviewed both transthoracic and transesophageal echocardiograms of 57 patients with diagnosis of acute infective endocarditis and no documented or suspected previous embolic events. We evaluated site, length, width, mobility, and echodensity of vegetations. Twenty-five patients (44%) had embolic events. No statistical differences in age, sex distribution, location of endocarditis, or offending pathogens between embolic (n = 25) and nonembolic (n = 32) patients were found. There were no differences in any of the echo characteristics of vegetations detected by transthoracic and transesophageal approach in embolic and nonembolic groups. Thus, transthoracic and transesophageal characteristics of vegetations are not helpful in defining embolic risk in patients with infective endocarditis.

No difference in emergence time and early cognitive function between sevoflurane-fentanyl and propofol-remifentanil in patients undergoing craniotomy for supratentorial intracranial surgery.

Balanced anesthesia with sevoflurane-fentanyl has been widely accepted as anesthetic management for neurosurgery. Propofol-remifentanil regimen has been successfully used in various surgical settings, but a comprehensive comparison of sevoflurane-fentanyl and propofol-remifentanil anesthesia in patients undergoing craniotomy for supratentorial intracranial surgery has not yet been done. The aim of this prospective, randomized, open-label clinical trial was to compare clinical properties of sevoflurane-fentanyl with propofol-remifentanil anesthesia in patients undergoing supratentorial intracranial surgery. The primary endpoint was to compare early postoperative recovery and cognitive functions within the two groups; we also evaluated hemodynamic events, vomiting, shivering, and pain. One hundred twenty patients (64 males; age 15-75 years) were randomized to either total intravenous anesthesia (group T) or sevoflurane anesthesia (group S). Emergence and extubation times and cognitive function (Short Orientation Memory Concentration Test [SOMCT]) were compared in the two groups. Brain swelling, incidence of hypotensive and hypertensive episodes, postoperative vomiting, shivering, and pain were also analyzed. The mean emergence time (12.2 ± 4.9 minutes for group S versus 12.3 ± 6.1 minutes for group T; P = 0.92) and extubation time (18.2 ± 2.3 minutes for group S versus 18.3 ± 2.1 minutes for group T; P = 0.80) were similar in the two groups. Average SOMCT scores, both 15 minutes after extubation (25.6 ± 4.9 in group S versus 23.9 ± 7.5 in group T; P = 0.14) and 45 minutes after extubation (27.3 ± 2.2 in group S versus 26.0 ± 5.1 in group T; P = 0.07) were also comparable. Brain swelling was present in seven and five patients in groups S and T, respectively (P = 0.76). Hypotension was present in 12% (group S) and 28% (group T) of patients (P = 0.02). Hypertension was present in 17% of patients in group S and 40% of patients in group T (P = 0.0046). Shivering was present in 18% and 25% of patients in groups T and S (P = 0.37). Our study demonstrates that there is no patient benefit of using total intravenous anesthesia with an ultra-short-acting opioid over the conventional balanced volatile technique in terms of recovery and cognitive functions.

Three-Dimensional Echocardiographic Estimation of Infarct Mass Based on Quantification of Dysfunctional Left Ventricular Mass

BACKGROUND Two-dimensional echocardiography is useful for estimating the extent of infarct-related wall motion abnormalities. Such estimation, however, is based on a few selected views and extrapolated for the whole left ventricle (LV). This approach does not provide us with the actual amount of dysfunctional myocardium. Volume-rendered three-dimensional echocardiography (3DE) might overcome these limitations. In this study we explored (1) how well volume-rendered 3DE delineates regional dysfunction of the infarcted LV and (2) how well dysfunctional myocardial mass quantified by 3DE reflects the actual anatomic infarct mass. METHODS AND RESULTS 3DE was performed before and 3 hours after coronary occlusion in 16 dogs. With the LV viewed in equidistant short-axis slices, the region of dysfunction was demarcated, and the dysfunctional myocardial mass was derived from this. With triphenyltetrazolium chloride staining, anatomic infarct regions were delineated, dissected, and weighed. The anatomic infarct mass was 16.3+/-7.7 g (mean+/-SD) (range, 6.4 to 31.4 g); the dysfunctional mass estimated by 3DE was 17.4+/-9.1 g (range, 5.2 to 39.0 g). The mean difference was 1.0 g. The correlation between dysfunctional mass (y) and infarct mass (x) was y=l.lx-0.6, r=.93 (P<.0001). The percentage of LV involved in infarction was 18.2+/-5.8% (range, 9.1% to 26.1%); the percentage of LV involved in regional dysfunction was 18.3+/-6.9% (range, 7.9% to 31.2%). The mean difference was 0.1%. The correlation between percentage of LV involved in infarction (x) and percentage of LV involved in dysfunction (y) was y=1.0x-1.1, r=.92 (P<.0001). CONCLUSIONS Volume-rendered 3DE crisply displays regional dysfunction of infarcted LV. 3DE-measured dysfunctional mass accurately reflects the anatomic infarct mass.

Valvular perforation in left-sided infective endocarditis: A prospective echocardiographic evaluation and clinical outcome☆☆☆★★★♢

We undertook this study to determine the use of transthoracic and transesophageal echocardiography in detecting valvular perforation and the clinical impact of the latter on the outcome of left-sided infective endocarditis. Transthoracic echocardiography was performed in 58 consecutive patients with infective endocarditis. According to the study protocol, a subgroup of 42 patients also underwent transesophageal echocardiogrophy. At referral, 20 (34%) of 58 patients had echocardiographic evidence of valvular perforation (group A). No valvular perforations were found in the remaining 38 patients (group B). During a follow-up period of 27 +/- 16 months, a major complication occurred in 18 of 20 patients in group A and in 11 of 38 patients in group B (p < 0.0001). Univariate analysis indicated previous infective endocarditis, aortic involvement, and New York Heart Association functional class had a predictive value for valvular perforation (p < 0.001). Stepwise regression analysis confirmed aortic valve perforation as the only independent predictive variable for surgery and death. Valvular perforation is a common complication of infective endocarditis and is associated with an adverse outcome. Transthoracic echocardiography can detect or suggest valvular perforation in infective endocarditis, but transesophageal echocardiography better defines this complication and predicts severe heart failure or the need for early surgical management.

A comparison between sevoflurane and desflurane anesthesia in patients undergoing craniotomy for supratentorial intracranial surgery.

BACKGROUND: Desflurane in neurosurgery may be beneficial because it facilitates postoperative early neurologic evaluation. However, its use has been debated because of its capacity to promote cerebral vasodilatation. Sevoflurane has been extensively used in neurosurgical patients. In this prospective clinical trial, we compared early postoperative recovery and cognitive function in patients undergoing craniotomy for supratentorial expanding lesions and receiving sevoflurane or desflurane anesthesia. METHODS: One hundred twenty patients, ASA physical status I–III (66 men), Glascow Coma Scale 15, undergoing craniotomy for supratentorial expanding lesions were enrolled in the study. Patients were randomly allocated to two anesthetic regimens. In Group S (60 patients, 52 ± 16 yr), anesthesia was maintained using sevoflurane with end-tidal of 1.5%–2% and was age adjusted to obtain approximately 1.2 minimum alveolar anesthetic concentration. In Group D (60 patients, 60 ± 14 yr), anesthesia was maintained using desflurane with end-tidal of 6%–7% and was age adjusted to obtain approximately 1.2 minimum alveolar concentration. Emergence time was measured as the time from drug discontinuation to the time at which patients opened their eyes; tracheal extubation time was measured as the time from anesthetic discontinuation and tracheal extubation. Recovery time was measured as the time elapsing from discontinuation of anesthetic and the time when patients were able to recall their name and date of birth. Cognitive behavior was evaluated with the Short Orientation Memory Concentration Test. In the postanesthesia care unit, a blinded observer monitored the patients for 3 h; the incidence of hemodynamic events, pain, nausea, and shivering requiring rescue medication was recorded. RESULTS: The mean emergence time (12.2 ± 4.9 min in Group S vs 10.8 ± 7.2 min in Group D; P = ns) was similar in the two groups, whereas the mean extubation time and recovery time were longer in Group S (15.2 ± 3.0 min in Group S vs 11.3 ± 3.9 min in Group D and 18.2 ± 2.3 min in Group S vs 12.4 ± 7.7 min in Group D, respectively; P < 0.001). The Short Orientation Memory Concentration Test score differed between the two groups only at the earliest assessment (15 min after extubation). No difference between the two groups was found in pain, shivering, nausea, vomiting, and incidence of postoperative hemodynamic events. CONCLUSION: Patients who received desflurane had a shorter extubation and recovery time but similar intraoperative and postoperative incidence of complications compared with those who received sevoflurane.

Volume-rendered, three-dimensional echocardiographi determination of the size, shape, and position of atrial septal defects: Validation in an in vitro model

Accurate evaluation of atrial septal defect (ASD) size and shape is very important for the selection of patients for transcatheter occlusion. The ability of volume-rendered, three-dimensional echocardiography (3DE) in displaying ASDs in a dynamic mode has been demonstrated; however, its accuracy in sizing ASDs is unknown. To assess this, we performed 3DE of 10 explanted pig hearts in which ASDs of various locations, sizes, and shapes had been experimentally created. From en face 3DE views of the atrial septum containing the defects, major and minor diameters of the defect were measured by a blinded observer, and these data were compared to direct anatomic measurements. The correlations between 3DE and anatomy for the major and minor ASD diameters were y = 0.83x + 3.4 (r = 0.97, p < 0.0001) and y = 0.92x + 1.3 (r = 0.92, p < 0.0001) respectively. The correlation between the measures for major and minor axis ratio was y = 1.06 x - 0.052, r = 0.91, p < 0.0002. Good agreement between both methods of measurements was demonstrated for all measurements. In addition, 3DE portrayed the location and shape of the defects accurately. Thus 3DE provides excellent visualization of ASD and is able to accurately define the size of the defects. These qualitative and quantitative capabilities enhance the clinical potential of this technique in the appraisal of ASDs for decisions regarding application of closure devices.

The Natural Course of Cardiac Conduction Disturbances in Myotonic Dystrophy

In this study we noninvasively followed for a mean period of 46 months 21 patients with different grades of myotonic dystrophy to evaluate the course of the involvement of the cardiac conducting system. Six patients (28.6%), 1 affected by a mild and 5 by a severe form of the neuromuscular disorder, showed appearance or deterioration of conduction disturbances suggesting a serious derangement of the specialized tissue; in 3 of them a permanent demand pacemaker was implanted. Conduction defects are the most frequent cardiac manifestations in myotonic dystrophy and become worse with time, mainly in patients with higher degrees of the disease. Furthermore, first-degree atrioventricular block may represent an early sign of developing of more advanced conduction defects.

Early postoperative complications after intracranial surgery: comparison between total intravenous and balanced anesthesia.

This prospective study was performed to compare the incidence of complications occurring after neurosurgical procedures in patients anesthetized with either sevoflurane-fentanyl or propofol-remifentanil anesthesia. We enrolled 162 American Society of Anesthesiologists (ASA) I to III patients (82 females and 80 males, Glasgow 15) undergoing elective neurosurgical procedures. Anesthesia was conducted using either propofol-remifentanil (T group; n=80 patients) or sevoflurane-fentanyl (S group; n=82 patients). All patients were monitored in the postanesthesia care unit for 6 hours after extubation. We analyzed and compared in both groups the incidence of high severity complications such as respiratory events (PaO2 <90 mm Hg; PaCO2 >45 mm Hg) and neurologic events (seizures, new motor or sensory deficit, unexpected delay of awakening) and the incidence of low severity complications such as hypertension (mean arterial pressure increase above 30% of baseline), hypotension (mean arterial pressure decrease below 30% of baseline), pain, shivering, nausea, and vomiting. A total of 162 complications occurred in 92 patients (57%) with 50 patients (31%) having had 1, 26 patients (16%) having had 2, and 16 patients (10%) having had 3 or more events. The most frequent complication was respiratory impairment (28%) which was frequently reported only in the first postoperative hour. Out of the total number of complicating events, 77 (48 %) were found in group S, and 85 (52%) in group T (P=ns). Severe complications were rarely reported and evenly distributed in the 2 anesthetic groups. Similarly, no difference could be demonstrated in the composite incidence of less serious complications between the 2 anesthetic regimens tested in this study. This study confirms that the recovery period after neurosurgical procedures remains a time of great potential danger to patients given the high incidence of postoperative complicating events independently from the anesthetic strategy.

Limitations of the electrocardiographic diagnosis of left ventricular hypertrophy: the influence of left anterior hemiblock and right bundle branch block

We analysed the performance of the electrocardiogram in diagnosing left ventricular hypertrophy in 70 patients with isolated left anterior hemiblock and in 75 patients with right bundle branch block, either isolated (44 cases) or associated (31 cases) with left anterior hemiblock. Left ventricular hypertrophy defined as an echocardiographically determined left ventricular mass greater than 261 g in men and 172 g in women or left ventricular mass index greater than 125 g/m2 in men and 112 g/m2 in women was present in 48 subjects (57%) with isolated left anterior hemiblock and 33 subjects (44%) with right bundle branch block. In patients with isolated left anterior hemiblock the best results were obtained using the SV1 or SV2 + (RV6 + SV6) greater than 25 mm with 74% in sensitivity and 67% in specificity; the criterion SIII + (R + S) maximal in a precordial lead greater than or equal to 30 mm showed a sensitivity of 74% but a specificity of 47%. In the whole group of patients with right bundle branch block none of the criteria nor combination of criteria achieved an acceptable performance (sensitivities ranged from 17% to 41% and specificities ranged from 54% to 85%). When these patients were divided according to the presence or absence of concomitant left anterior hemiblock the electrocardiographic indexes mostly showed, in comparison to whole group, higher values in sensitivity and lower values in specificity in right bundle branch block plus left anterior hemiblock and an opposite behaviour in isolated right bundle branch block.(ABSTRACT TRUNCATED AT 250 WORDS)