H. Lethen

Standardized Guidelines for the Interpretation of Dobutamine Echocardiography Reduce Interinstitutional Variance in Interpretation

Subjective interpretation of dobutamine echocardiograms provides only moderate interinstitutional observer agreement if nonunified data acquisition and assessment criteria are applied. The present study was undertaken to evaluate parameters associated with low interinstitutional observer agreement in the interpretation of dobutamine echocardiograms and to analyze whether standardized interpretation criteria improve interinstitutional observer agreement. One hundred fifty dobutamine echocardiograms (dobutamine up to 40 microg/kg/min body weight and atropine up to 1 mg) were evaluated at 5 centers. Clinical, procedural, and echocardiographic parameters were included in the analysis of variables with significant impact on interinstitutional agreement. Standardized interpretative criteria were established, and 90 dobutamine echocardiograms were reanalyzed by 3 observers using a standardized image display. Multivariate analysis demonstrated low image quality (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08 to 0.45, p=0.0002), low severity of induced wall motion abnormality (OR 0.17, 95% CI 0.07 to 0.40, p <0.0001), and a low peak rate-pressure product (OR 0.93, 95% CI 0.43 to 2.27, p=0.0382) to result in a low interinstitutional agreement. Standardization of image display in cine loop format and of dobutamine stress echo interpretation criteria resulted in improvement in test result categorization as normal or abnormal, with a kappa value of 0.50, compared with 0.39 using the original subjective interpretation. In conclusion, image quality, the severity of induced wall motion abnormalities, and the obtained rate-pressure product have a significant impact on the interpretation homogeneity of dobutamine echocardiograms. Standardization of image display in cine loop format and of reading criteria results in improved interinstitutional agreement in interpretation of stress echocardiograms.

Evidence for Cardioembolic Stroke in a Case of Kearns-Sayre Syndrome

BACKGROUNDnCerebral infarction is a known complication in patients with mitochondrial encephalomyopathies (MELAS, MERRF, Kearns-Sayre syndrome), but the etiology in the different types remains uncertain.nnnCASE DESCRIPTIONnA 33-year-old woman who had suffered from ophthalmoplegia, bilateral ptosis, ataxia, retinitis pigmentosa, and epilepsy since childhood was diagnosed to have Kearns-Sayre syndrome. The diagnosis was confirmed by muscle biopsy when she was 17 years old. A pacemaker was implanted because of the occurrence of bradyarrhythmias when she was 24 years old. The patient was admitted to the hospital with left-sided hemiparesis of sudden onset due to right striatocapsular infarction. Results of Doppler sonography of the carotid arteries were normal; however, transesophageal echocardiography revealed a thrombus in the left atrial appendage.nnnCONCLUSIONSnStroke in Kearns-Sayre syndrome is likely to be due to cardiac embolism. Anticoagulant therapy should be considered even for mild forms of cardiomyopathies leading to left ventricular dysfunction.

735–5 Role of Patent Foramen Ovale and Deep Venous Thrombosis in 220 Patients with Unexplained Stroke or Transient Ischemic Attack: A Prospective Transthoracic and Transesophageal Echocardiographic Study

To evaluate the additional value of biplane transesophageal (TEE) compared to transthoracic (TTE) echo and the role of patent foramen ovale (PFO) and deep vein thrombosis (DVT) in the work-up of embolic events, patients (pts) with presumed cardiac embolic stroke or transient ischemic attack (TIA) (neurovascular etiology was excluded by dopplersonography) were prospectively studied by transthoracic and transesophageal contrast echo and phlebography if PFO was present. Results 220 pts, 136 men (60xa0±xa015 years) were studied. In 140 of 220 pts neuroimaging showed evidence of manifest stroke. TEE identified a potential cardiac source of embolism (left atrial thrombus [LAT], PFO, atrial septal aneurysm [ASA], spontaneous contrast [SC] endocarditic valve lesions, mitral valvular disease [MVD] and prosthetic head valves) in 43% of pts compared with only 18% by TTE (pxa0lxa00.01). TEE was especially superior compared to TTE for identifying LAT (10 versus 0 pts), SC (26 vs 6 pts), PFO associated with ASA (16 vs 6 pts) and PFO alone (34 vs 20 pts). Phlebography was performed in 50 pts with PFO. Of those pts 32 showed brain infarct xa0≥xa01xa0cm diameter on neuroimaging, 18 pts had TIA. Phlebography revealed clinically silent DVT only in pts with brain infarct (4 cases, 12.5%), no pt with TIA had positive phlebography. Conclusion In this prospective study TEE detected significantly more potential sources of embolism than TTE; moreover, phlebography in the presence of PFO and a clear-cut ischemic brain lesion on neuroimaging revealed a 12.5% incidence of clinically unsuspected deep venous thrombosis. These findings strongly suggest paradoxical embolism as an important mechanism of stroke and support phlebography to define the relevance of PFO in the stepwise work-up of pts with suspected cardiogenic stroke.