Horacio A. Prezioso

Estimation of the Ejection Fraction in Patients with Myocardial Infarction Obtained from the Combined Index of Systolic and Diastolic Left Ventricular Function: A New Method

UNLABELLED The index of myocardial performance combining systolic and diastolic time intervals (Index) is a useful method, already explained in past studies, that offers new values that have not been widely known among clinical cardiologists. The aim of this study is to obtain from this Index a measurement of the ejection fraction (EF), which is a very well-known value. The study involved 97 patients with myocardial infarction, 55 of whom were studied retrospectively (group A, aged 46-62 years, 50 men) to obtain and test the formula EF = 60 - (34 x Index). The second group (group B, aged 47-63 years, 40 men) included 42 patients who were evaluated prospectively. The EF obtained was compared with that reached through the use of radionuclide angiography (EF-RNA). The Index was obtained through the use of the formula (a - b)/b, where a is the interval between cessation and onset of the mitral inflow, and b is the ejection time. In group A the EF obtained by the Index (EF-Index) was 37.5% +/-.8%, and the EF-RNA was 37.7% +/- 11% (r = 0.76). In group B the EF-Index was 41.6% +/- 7%, and the EF-RNA was 41.2% +/- 10% (r = 0. 75). CONCLUSION Through the new formula described here it is possible to obtain a reliable measurement of the EF in patients with myocardial infarction, a well-known and extremely useful value, especially for those patients with poor acoustic windows.

Intermittent acute aortic regurgitation of a mechanical bileaflet aortic valve prosthesis: diagnosis and clinical implications

Intermittent aortic regurgitation (AR) is an unusual complication after a mechanical prosthetic replacement. We describe a rare case of intermittent dysfunction of a bileaflet mechanical aortic prosthetic valve in a 41-year-old man with a 21 mm Tri-technologies prosthetic valve implanted 4 years before. Transthoracic echocardiography (TTE) before discharge was normal and prosthesis-patient mismatch was ruled out. He was admitted to our hospital because of mild dyspnoea at effort. TTE revealed acute and severe intermittent AR. The patient underwent surgery, during which abnormal proliferation of subvalvular pannus overgrowth on the inflow aspect of the prosthesis was found impeding the normal closure of one of the discs of the prosthesis. The pannus formation was resected, the Tri-technologies prosthetic valve was prophylactic explanted and a 23 mm St Jude Medical bileaflet mechanical prosthesis valve was implanted. We describe the role of TTE and the limitation of the cinefluoroscopy in the diagnosis of Tri-technologies prosthetic dysfunction.

Impaired Myocardial Function in Hypertrophic Cardiomyopathy

Background: Tissue Doppler imaging (TDI) parameters of peak myocardial velocities (S′, E′, and A′) has been employed to assess the regional left ventricular myocardial function. The global function index (GFI) derived from TDI has been recently employed to distinguish the different etiologies of left ventricular hypertrophy. Objective: To analyze whether the GFI or individual TDI parameters of peak myocardial velocities (S′, E′, and A′) allows detecting different degrees of regional myocardial dysfunction in the most frequent forms of hypertrophic cardiomyopathy (HCM). Methods: GFI = (E/E′)/S′ (where E is the peak transmitral flow velocity, E′ is the early diastolic myocardial velocity, and S′ is the peak systolic myocardial velocity) and TDI peak myocardial velocities was measured in the septal and lateral mitral annulus in 101 patients with HCM (mean age 47.5 ± 14 years, 58 women) and in age‐matched group of 30 healthy controls (mean age 46 ± 6 years, 16 women). Results: Forty‐five patients had nonobstructive asymmetric septal HCM, 20 patients had a subaortic gradient ≥ 30 mm Hg, 21 p. had apical HCM, and 15 p. had other forms of HCM (midventricular, symmetric, and biventricular). All patients with HCM exhibited a decrease in early diastolic (E′) and systolic (S′) myocardial velocities, both in the lateral and septal‐mitral annulus border, but more pronounced in septal‐mitral annulus. Septal GFI was higher in HCM patients than in healthy subjects (1.8 (1.1–2.5) and (0.57 (0.31–0.92), respectively, P < 0.001), but no differences were seen when different forms of HCM were compared. Conclusions: In a selected population of patients with HCM and a preserved left ventricular(LV) systolic function, GFI and individual TDI parameters of peak velocity (S′, E′, and A′) and E/E′ ratio were similar in different forms of HCM, indicating that in all patients with HCM there is regional systolic and diastolic myocardial dysfunction, regardless of the location of hypertrophy. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Papillary fibroelastoma: clinical and echocardiographic features and initial approach in 54 cases.

Papillary fibroelastoma (PFE) is a benign cardiac tumor that is currently detected more often due to the technological improvements in echocardiography.

Subaortic and mid-ventricular obstructive hypertrophic cardiomyopathy with an apical Aneurysm: a case report

BackgroundMost patients with hypertrophic cardiomyopathy (HCM) have asymmetric septal hypertrophy and among them, 25% present dynamic subaortic obstruction. Apical HCM is unusual and mid-ventricular HCM is the most infrequent presentation, but both variants may be associated to an apical aneurysm. An even more rare presentation is the coexistece mid-ventricular and apical HCM. This case is a combination of obstructive HCM with mid-ventricular HCM and an apical aneurysm, which to date, has not been reported in the literature.Case presentationThe patient is a 49 year-old lady who presents a combination of septal asymmetric hypertrophic cardiomyopathy (HCM) and midventricular HCM, a subaortic gradient of 65 mm Hg and a midventricular gradient of 20 mm Hg, plus an apical aneurysm. Her clinical presentation was an acute myocardial infarction in June 2005. One month after hospital discharge, the electrocardiogram (ECG) showed a right bundle branch block (RBBB) with no Q waves or ST segment elevation. Coronary angiography revealed normal coronary arteries, left ventricular hypertrophy and an apical aneurysm.ConclusionThis case is a rare example of an asymptomatic patient with subaortic and mid-ventricular hypertrophic cardiomyopathy, who presents a myocardial infarction and normal coronary arteries, and during the course of her disease develops an apical aneurysm.

Recurrent systemic embolism caused by thrombosis in a stenotic bicuspid aortic valve

Thrombosis in a native aortic valve is a rare complication which may lead to systemic embolization. A few cases of aortic thrombosis in previously abnormal valves have been described. In this report, we describe a 42-year-old male who suffered two acute ischaemic attacks, one in the upper right limb and another in the cerebral territory supplied by the left sylvian artery, from a thrombus that developed in a bicuspid and stenotic aortic valve. The diagnosis was made with transthoracic and transoesophageal echocardiography, and the patient subsequently underwent surgery. In cases of bicuspid aortic valves, we should think of thrombosis as a possible complication with its resulting risk of embolism, and assess such patients with transthoracic and transoesophageal echocardiography, thus enabling their early detection and treatment.

Contrast echocardiography in the non-invasive diagnosis of giant aneurysm of the right atrial appendage

A 57 year-old male patient was admitted to our echocardiography laboratory to rule out thrombus in left atrium before electrical cardioversion of atrial fibrillation. Transoesophageal echocardiography (TEE) demonstrated in the bicaval view, the right atrial appendage measured 10 x 5 cm, area: 42 cm(2), volume: 229 mL (Figure, left). A quick injection of 15 cc of echo-contrast fluid (shaken saline/1 cc air), delivered via an antecubital vein, showed filling the right atrial appendage aneurysm (Figure, right). Idiopathic giant congenital aneurysm of the right atrium appendage is a very rare malformation. TEE with contrast echocardiography is very useful in the non-invasive diagnosis of giant right atrial appendage aneurysm.

Usefulness of Myocardial Contrast Echocardiography Early After Acute Myocardial Infarction

Objectives: (1) Evaluate wall motion and perfusion abnormalities after reperfusion therapy of the culprit lesion, (2) delineate the ability of myocardial contrast echocardiography (MCE) to evaluate the microvasculature after reperfusion, in order to distinguish between stunning and necrosis in the risk area. Methods: We analyzed 446 segments from 28 patients, 10 normal controls (160 segments), and 18 with a first AMI (286 segments). MCE was obtained with Optison and a two‐dimensional echocardiography was performed at 3 months post acute myocardial infarction (AMI). Results: In the group with AMI, we analyzed 286 segments, of which 107 had wall motion abnormalities (WMA) related to the culprit artery. Two subgroups were identified: Group I with WMA and normal perfusion (50 segments, 47%) and Group II with WMA and perfusion defects (57 segments, 53%). According to the 2D echocardiogram at 3 months, they were further subdivided into: Group IA: with wall motion improvement (stunning): 18 segments, 36%, Group IB: without wall motion improvement: 32 segments, 64%, Group IIA: with wall motion improvement: 12 segments, 21%, Group IIB: without wall motion improvement (necrosis): 45 segments, 79%. Conclusions: (1) The presence of myocardial perfusion in segments with WMA immediately after AMI reperfusion therapy predicts viability in most patients. Conversely, the lack of perfusion is not an absolute indicator of the presence of necrosis. (2) Perfusion defects allow to detect patients with thrombolysis in myocardial infarction (TIMI) 3 flow and “no‐reflow” phenomenon who will not show improved wall motion in the 2D echocardiogram. However, some patients with initial no‐reflow could have microvascular stunning and their regional contractile function will normalize after a recovery period.

Continuing Medical Education Activity in Echocardiography December 2016.

Accreditation and Designation Statement Blackwell Futura Media Services designates this journalbased CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Transesophageal Echocardiography During Ventricular Fibrillation

Sudden cardiac death is most frequently caused by spontaneous onset of ventricular fibrillation (VF), during which the rhythmic heart contractions transform into chaotic, vermiform, and inefficient activity of the myocardium while the pulsatile pulmonary and systemic blood flow circuits stop. Little information is available on the anatomical and hemodynamic changes that occur during VF. These changes could be seen in humans with transesophageal echocardiography (TEE). In the present report, we describe an 81-year-old man with a history of hypertension and upper gastrointestinal bleeding who was admitted with paroxysmal atrial fibrillation with high ventricular response (160 bpm) and heart failure. Given the impossibility of anticoagulation and to control hemodynamic compromise, TEE …