Mark N. Allen

Myocardial perfusion imaging by contrast echocardiography with use of intracoronary sonicated albumin in humans.

Sonicated albumin has been proposed as a near ideal echocardiographic contrast agent with little myocardial toxicity or hemodynamic effect. Its use has not yet been reported in humans, partly because of difficulties in preparation. With use of the newly modified sonication method, 10 ml of 5% albumin was sonicated for 75 s with a 5.0 ml slow infusion of air. This resulted in microbubbles with a mean diameter (+/- SD) of 5 +/- microns). Fourteen patients undergoing routine coronary angiography were studied. One patient had normal coronary arteries; the other 13 had significant coronary artery disease. In a subgroup of nine patients, sonicated albumin and sonicated diatrizoate meglumine sodium (microbubble diameter 9 +/- 3 microns) were injected several minutes apart, using the same technique. Videodensity-time curves were obtained from a region of interest in the myocardium. Corrected peak contrast intensity (baseline contrast intensity subtracted from peak contrast intensity, gray scale U/pixel) for sonicated albumin and for sonicated diatrizoate meglumine sodium was 51 +/- 26 and 52 +/- 19, respectively (p = 0.89). Washout half-time (T1/2) for the two agents was 5.5 +/- 4.5 and 16.0 +/- 12.2 s, respectively (p = 0.01). One patient with unstable angina experienced transient chest pain after repeated albumin injections. No electrocardiographic changes, blood pressure changes or wall motion abnormalities were observed. Administered by intracoronary injection, sonicated 5% albumin is a safe and effective echocardiographic contrast agent for myocardial perfusion imaging, yielding excellent myocardial contrast with physiologic washout time.

Quantitative assessment of the immediate results of coronary angioplasty by myocardial contrast echocardiography.

A low pressure gradient across the residual lesion and a minimal percent residual stenosis are markers of a successful coronary angioplasty. A more physiologic method of assessing the results of coronary angioplasty would involve assessment of myocardial perfusion in the affected coronary bed. Contrast two-dimensional echocardiography provides information about regional myocardial perfusion. To assess the correlation between pre- to postcoronary angioplasty changes in gradient or percent stenosis and the increase in peak contrast intensity, 23 consecutive patients were studied during coronary angioplasty. In 19 of the 23 patients, the coronary angioplasty was successful and in 15 (79%) of the 19, an adequate echocardiographic study was obtained. Mild and transient side effects of echo contrast were observed in 3 of the 15 patients. The gradient across the residual lesions decreased from 52 +/- 12 to 11 +/- 4 mm Hg (mean +/- SD), the diameter of the stenotic lesion decreased from 89 +/- 10 to 25 +/- 16% and corrected peak contrast intensity (peak contrast - baseline contrast in gray level U/pixel) increased from 15 +/- 16 to 50 +/- 26. All these differences were significant at the p less than 0.001 level. Corrected peak contrast intensity correlated exponentially with the decrease in pressure gradient (r = 0.82, p less than 0.001). The correlation curve had a greater increase in peak contrast intensity at gradient decreases greater than 45 mm Hg. Corrected peak contrast intensity did not correlate with decrease in diameter of the stenotic lesion (r = 0.19).

Lactobacillus isolated pulmonic valve endocarditis with ventricular septal defect detected by transesophageal echocardiography

Endocarditis resulting from Lactobacillus species, an anaerobic, nonsporulating, gram-positive bacilli, is rare. Forty-two cases have been reported in the literature.l, 2 Lactobacillus species are generally considered nonpathogenie flora of the mouth, gut, and female genital tract.l They have been mostly reported in patients with prior structural heart disease (83 % ), congenital (bicuspid aortic valve, ventricular septal defect [VSD]) or acquired (prior endocarditis, rheumatic heart disease, prosthetic valves).3 The aortic, mitral, and tricuspid valves have been infected by Lactobacillus species. From our review of the literature isolated Lactobacillus pulmonary valve endocarditis has not been previously reported. We present such a case in a young woman with subarterial VSD and emphasize the role of transesophageal echocardiography (TEE) in establishing the diagnosis. A 21-year-old white woman arrived at the University of Rochester Medical Center with a l-week history of chills, fever, and dry cough. One day before admission, she noted the onset of a pleuritic left-sided chest pain and dyspnea. She denied recent weight loss or genitourinary or gastrointestinal symptoms. Her medical history was significant for congenital supracristal VSD and clinically insignificant pulmonary stenosis diagnosed by cardiac catheterization at the age of 6. Surgical correction was not required. She had no history of diabetes or hypertension. She denied intravenous drug or alcohol abuse. She had no recent dental work or teeth cleaning. She reported a broken molar 1 month before admission. Physical examination on admission was notable for a temperature of 40.2” C, blood pressure of 130/75 mm Hg, heart rate of 150 beats/ mm, and a respiratory rate of 36 breaths/min. Fundoscopic examination revealed no Roth spots or retinal hemorrhages. The oral cavity had teeth with multiple caries. There was no lymphadenopathy. No skin lesions were noted. The jugular venous pressure was estimated at 6 cm water above the right atrium. The lungs had decreased breath sounds and rales over the left lower lobe but were

Blunt Trauma Causing Delayed Cardiac Tamponade Echocardiographic Diagnosis

A 17-year-old patient suffered multiple trauma from a motor vehicle accident that involved blunt chest trauma. During the initial hospitalization and laparotomy for abdominal injuries, the cardiac silhouette remained normal on chest roentgenogram and there were no signs of pericardial tamponade. He went home and returned 2 weeks later with a 3 to 4-day history of increasing dyspnea and findings of cardiac tamponade. A loculated, blood-filled mass was found by echocardiography and at surgery, compressing the right heart. This type of delayed pericardial tamponade after blunt trauma has not previously been described.

Variability in the transtricuspid gradient by continuous wave doppler echocardiography

In order to examine the day-to-day variability in the tricuspid regurgitant velocity jet and to determine the degree of physiological changes under exercise and volume loading, repeated echo cardiographic Doppler measurements in 1 single subject were performed.