Luis Mataix

Accuracy of real-time 3-dimensional echocardiography in the assessment of mitral prolapse. Is transesophageal echocardiography still mandatory?

BACKGROUND Segmental analysis in mitral prolapse is important to decide the chances of valvular repair. Multiplane transesophageal echocardiography (TEE) is the only echocardiographic tool validated for this aim hitherto. The aim of the study was to assess if segmental analysis can be performed with transthoracic real-time 3-dimensional (3D) echocardiography as accurately as with TEE, hence representing a valid alternative to TEE. METHODS Forty-one consecutive patients diagnosed with mitral prolapse underwent TEE and a complete 3D echocardiography study, including parasternal and apical real-time; apical full-volume; and 3D color full-volume. Investigators performing TEE were blinded to the 3D results. RESULTS Three-dimensional echocardiogram was feasible in 40 to 41 patients (97.7%). Ages ranged from 15 to 92 years, and all possible anatomical patterns of prolapse were represented. Thirty-seven patients (90.2%) had mitral regurgitation of any degree. The level of agreement was k = 0.93 (P < or = .0001), sensitivity of 96.7%, specificity of 96.7%, likelihood ratio for a positive result of 29.0%, and likelihood ratio for a negative result of 0.03%. Four false positives were found, corresponding to scallops A2 (1), A3 (2), and P3 (1). Four false negatives were found, corresponding to scallops A1 (2) and P1 (2). Sensitivity and specificity in the scallop P2 were 100%. CONCLUSION Segmental analysis in mitral prolapse can be performed with transthoracic real-time 3D echocardiography as accurately as with TEE. False negatives tend to appear around the anterolateral commissure, whereas false positives tend to appear around the posteromedial commissure. Highest accuracy was reached in central scallops.

Quantification of Aortic Valve Area Using Three-Dimensional Echocardiography

INTRODUCTION AND OBJECTIVES To determine whether the reproducibility of left ventricular outflow tract (LVOT) area measurement is greater with three-dimensional echocardiographic (3D-echo) planimetry than with conventional 2D-echo. To determine the LVOT circularity index by means of 3D-echo. To determine the usefulness of measuring the LVOT area by 3D-echo for quantifying the severity of valvular aortic stenosis. METHODS The study included 40 patients, of whom 22 had an aortic stenosis. The LVOT area was measured using both 2D-echo and 3D-echo, and the circularity index, using 3D-echo alone. In addition, the severity of valvular aortic stenosis was categorized using both 2D-echo and 3D-echo. RESULTS The levels of inter- and intra-observer agreement on LVOT area measurements were better with 3D-echo. The circularity index was 1.50 (0.25), and there was a very poor linear correlation with LVOT area (r=-0.34; P=.47). Patients with valvular aortic stenosis were categorized according to the severity of their stenoses using both 2D-echo and 3D-echo. The level of agreement between the two techniques was poor (kappa=0.36). CONCLUSIONS Measurements of the LVOT area made using 3D-echo were more reproducible than those made using 2D-echo. Consequently, 3D-echo may be a better technique for assessing the LVOT area. In addition, 3D-echo showed that the LVOT is elliptical in form and that its size is not related to its circularity. Moreover, 3D-echo could also be helpful in classifying the severity of valvular aortic stenosis.

Diastolic heart failure in the elderly: In-hospital and long-term outcome after the first episode

Our aim was to describe the incidence and predictors of in-hospital mortality and long-term mortality and morbidity in elderly patients after a first admission due to diastolic HF (DHF). Six hundred and seventy nine consecutive elderly patients with a first admission to hospital due to DHF comprised our study group. Mean age was 83.3+/-6.7 (464 women--68.3%). A history of dilated cardiomyopathy was associated to increased in-hospital mortality and age and pulmonary artery systolic pressure were identified as independent markers of bad long-term outcome. Thus, patients with DHF have high mortality during and after the first admission.

Espasmo coronario tras infusión de propranolol durante un ecocardiograma de estrés con dobutamina

Dobutamine stress echocardiography, a highly useful and safe challenge test for myocardial ischemia, is being used increasingly. We report the case of a 37-year-old man with rest angina, repolarization abnormalities in precordial leads and normal coronary arteries who was referred for dobutamine-atropine stress echocardiography, which was negative for ischemia. However, after testing, upon injection of propranolol, the patient suffered chest pain associated with ST elevation and severe regional systolic abnormalities. After intravenous nitroglycerin administration, chest pain and electrocardiographic abnormalities disappeared quickly, and systolic motion became normal. This complication was interpreted as a coronary spasm. We discuss the causes for the spasm and the role that might have been played by the drugs employed.

Contrast agents provide a faster learning curve in dipyridamole stress echocardiography

Aim: Interobserver variability is an important limitation of the stress echocardiography and depends on the echocardiographer training. Our aim was to evaluate if the use of contrast agents during dipyridamole stress echocardiography would improve the agreement between an experienced and a non-experienced observer in stress echo and therefore if contrast would affect the learning period of dypyridamole stress echo. Methods and results: Two independent observers without knowledge of any patient data interpreted all stress studies. One observer was an experienced one and the other had experience in echocardiography but not in stress echo. Two observers analysed 87 non-selected and consecutive studies. Out of the 87 studies, 46 were performed without contrast administration, whereas i.v. contrast (2.5 g Levovist® by two bolus at rest and at peak stress) was administered in 41. In all cases, second harmonic imaging and stress digitalisation pack was used. The agreement between observers showed a κ index of 0.58 and 0.83 without and with contrast administration, respectively. Conclusions: The use of contrast agents provides a better agreement in the evaluation of stress echo between an experienced and a non-experienced observer in stress echo. Adding routinely contrast agents could probably reduce the number of exams required for the necessary learning curve in stress echocardiography.

Isovolumic Contraction Time by Pulsed-Wave Doppler Tissue Imaging in Aortic Stenosis

BACKGROUND Doppler Tissue Imaging (DTI) has been evaluated in ischaemic heart disease and some cardiomyopathies. In patients with aortic stenosis (AS), left ventricular contraction is slowered. This study aimed to evaluate the possible role of the measurement of isovolumic contraction time (ICT) by DTI in the evaluation of AS severity. METHODS The study population constitutes 30 patients: 15 with AS (nine severe and six non-severe) and 15 control subjects. All of them had normal systolic function, sinus rhythm, and absence of ischaemic heart disease of conduction abnormalities. ICT was defined as the time from the onset of the QRS complex to the beginning of the DTI systolic wave. The correlation between ICT and aortic area obtained by continuity equation, as well as the diagnostic value of ICT in the identification of severe AS were studied. RESULTS ICT was significantly increased in patients with severe AS (98+/-27 versus 65+/-21 ms, p=0.024). There was a significant correlation between ICT and aortic area (r=-0.56; p=0.035). The receiver operator characteristic curve of ICT in the identification of severe AS yielded an area under the curve of 0.852 (95% confidence interval: 0.665-1.0). The two best cut-points were >73 ms (88% sensitivity, 77% specificity) and >85 ms (78% sensitivity, 83% specificity). A value of >41 ms had a 100% sensitivity, but only a 17% specificity, and >91 ms showed a 100% specificity, but only a 44% sensitivity. CONCLUSIONS ICT measured by pulsed-wave DTI is increased in patients with aortic stenosis.

Prognostic factors and predictors of in-hospital mortality of patients with heart failure with preserved left ventricular ejection fraction.

Background and aim To date, in-hospital mortality predictors of patients with heart failure and depressed left ventricular ejection fraction are well known. Nevertheless, this is not the case of patients suffering from heart failure with preserved left ventricular ejection fraction. Our aim is to describe the incidence and predictors of in-hospital mortality in patients during the first admission due to preserved left ventricular ejection fraction. Methods Seven hundred and seventy-one consecutive patients with a first admission to hospital due to preserved left ventricular ejection fraction between January 2002 and September 2003 comprised our study group. Cardiovascular risk factors, clinical, electrical and echocardiographic variables were studied. Univariate and multivariate logistic regression analysis was performed to obtain those factors independently associated with in-hospital mortality. Results The mean age was 82.6 ± 43.6 years (551 women, 66.3%). Variables in both groups were similar except for the history of ischaemic heart disease, dilated cardiomyopathy and the presence of normal sinus rhythm. Multivariate logistic regression analysis showed that a history of ischaemic heart disease, dilated cardiomyopathy and a cardiac rhythm different from normal sinus rhythm are associated with an increased in-hospital mortality. Conclusion Patients with preserved left ventricular ejection fraction have high in-hospital mortality during the first admission. A history of ischaemic heart disease, a history of dilated cardiomyopathy and the presence of a cardiac rhythm different from the normal sinus rhythm (atrial fibrillation or flutter or paced rhythm) are independent predictors of in-hospital mortality in these patients. These factors must especially be considered during the admission of such patients.

Transesophageal echocardiographic right atrial findings during prosthetic hip replacement

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Myocardial perfusion in real-time using power modulation: In vivo evidence for microcirculatory damage after acute myocardial infarction

BACKGROUND AND OBJECTIVES In addition to the myocardium, the microvasculature may be also damaged in acute myocardial infarction. The aim was to evaluate the capability of myocardial contrast echocardiography in the detection of microvasculature damage after myocardial infarction. PATIENTS AND METHODS Twelve patients with recent acute myocardial infarction and five control subjects with normal coronary arteries and without history of myocardial infarction were studied. Myocardial contrast echocardiography with power modulation was performed, and quantitative data were measured off-line. Power modulation uses a combination of low (0.1) and high (1.7) mechanical indexes, allowing a real-time evaluation of myocardial perfusion. Contrast agent was administered as a 3-min bolus. The quantitative analysis was performed off-line by a different blinded investigator. The refilling velocity was calculated as the difference between the peak myocardial refilling value and the value at 1 s after the impulse divided by the time from the first second after the impulse to the peak refilling value. RESULTS Eighty-one myocardial segments (75%) were analysed qualitatively and quantitatively in AMI patients, and 18 (60%) in control subjects (P=NS). The peak refilling intensity was not significantly different in patients and control subjects (6.62+/-5.85 vs. 7.53+/-4.06 dB, respectively). However, time to peak refilling intensity was significantly longer (5.25+/-1.57 vs. 4.00+/-0.53, P=0.004) and the velocity of refilling was significantly lower (2.74+/-5.34 vs. 6.58+/-8.02, P=0.028) in patients with myocardial infarction. CONCLUSION There is microvasculature damage after myocardial infarction that is reflected as a delayed velocity of refilling in myocardial contrast echocardiography.

Evaluation of myocardial perfusion with grey-scale ultra-harmonic and multiple-frame triggering. The need for quantification

BACKGROUND AND OBJECTIVE Contrast echocardiography has been recently introduced as a new technique for evaluating myocardial perfusion in a qualitative basis. The objective of this study was to test whether a visual subjective evaluation of myocardial perfusion by myocardial contrast echocardiography adequately matches the data obtained with an off-line quantification of myocardial perfusion. METHODS Sixty-one myocardial segments were evaluated by myocardial contrast echocardiography with Ultra-harmonic and Multiframe Triggering in 11 patients 3-7 days after an anterior myocardial infarction, using SH-U 563A (Levovistâ, Schering AG, Berlin, Germany) as contrast agent. Myocardial perfusion was classified as grade 1 (absent), 2 (patchy or incomplete) and 3 (complete) in each segment. The quantitative analysis was performed off-line by a different investigator blinded to the qualitative evaluation, using a commercially available software. The quantitative data on grey-scale obtained were compared between grade 1, 2 and 3 segments. RESULTS Of the 61 segments, 45 (73.8%) were classified as grade 3, whereas the remaining 16 (26.2%) were considered to be abnormally perfused (grade 2: n=12, 19.6%; grade 1: n=4, 6.6%). Segments with grade 1 perfusion had a significantly higher grey-scale value (123.6 +/- 41.3 vs. 70.1 +/- 34.3, p=0.004). However, there were no significant differences between segments with perfusion grade 2 and 3 (76.8 +/- 33.2 vs. 68.3 +/- 34.8, p=0.452). CONCLUSION Qualitative assessment of myocardial perfusion by Ultra-harmonic and Multiframe Triggering is of limited value, since only myocardial segments with absent perfusion may be reliably identified. This findings support the need of quantification in the evaluation of myocardial perfusion by contrast echocardiography.