Stefano De Castro

Morphological and Functional Characteristics of Patent Foramen Ovale and Their Embolic Implications

Background and Purpose Transesophageal echocardiography (TEE) has detected a high prevalence of patent foramen ovale (PFO) in stroke patients, but the clinical implications of the distinctive characteristics of this patency are still a matter of debate. Methods We studied 350 patients with acute ischemic stroke or transient ischemic attack (TIA) within 1 week of admission. Of these, 101 (29%) were identified by contrast TEE to have a PFO; 86 patients (25%) were cryptogenic stroke patients, and 163 were excluded because of the presence of a definite or possible arterial or clinical evidence of a source of emboli or small-vessel disease. Thirteen PFO subjects without a history of embolism were designated as the control group. All PFO and cryptogenic stroke patients were followed up by neurological visits. Results Compared with controls, PFO patients with acute stroke or TIA more frequently presented with a right-to-left shunt at rest and a higher membrane mobility (P <0.05). Patients with these characteristics were considered to be at high risk. During a median follow-up period of 31 months (range, 4 to 58 months), 8 PFO and 18 cryptogenic stroke patients experienced recurrent cerebrovascular events. The cumulative estimate of risk of cerebrovascular event recurrence at 3 years was 4.3% (95% confidence interval [CI], 0% to 10.2%) for “low-risk” PFO patients, 12.5% (95% CI, 0% to 26.1%) for “high-risk” PFO patients, and 16.3% (95% CI, 7.2% to 25.4%) for cryptogenic stroke patients (high-risk PFO versus low-risk PFO, P =0.05). Conclusions The association of right-to-left shunting at rest and high membrane mobility, as detected by contrast TEE, seems to identify PFO patients with cerebrovascular ischemic events who are at higher risk for recurrent brain embolism.

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.

Modification of cardiac function in cirrhotic patients with and without ascites

OBJECTIVES: Abnormalities in cardiac function have been reported in liver cirrhosis, suggesting a latent cardiomyopathy in these patients. In this study we investigated cardiac function in cirrhotic patients and in controls. METHODS: A total of 20 cirrhotic patients without previous or ongoing ascites, 20 cirrhotic patients with moderate-to-severe ascites, and 10 healthy controls were studied by two-dimensional Doppler echocardiography. Cardiac dimensions and left and right ventricular function were evaluated. The left ventricular geometric pattern was calculated according to Ganau’s criteria. Diastolic function was evaluated by the peak filling velocity of E wave and A wave, E/A ratio, and deceleration time of E wave. The pulmonary systolic arterial pressure was also estimated in patients with tricuspid insufficiency. RESULTS: Right and left atrium and right ventricle diameters were significantly enlarged in cirrhotic patients versus controls. E/A ratio was decreased (p < 0.05) in patients with ascites (0.9 ± 0.2) versus those without ascites (1.3 ± 0.4) and controls (1.3 ± 1). The estimated pulmonary systolic arterial pressure was slightly elevated in patients with ascites (35 ± 5 mm Hg, six patients) versus those with no ascites (28 ± 5, 10 patients) and controls (27 ± 8, 6 controls, analysis of variance, p < 0.05). The pattern of left ventricular geometry was normal in the majority of patients. Nitrite and nitrate levels were increased in cirrhotics irrespective of the presence of ascites. CONCLUSIONS: Liver cirrhosis is associated with enlarged right cardiac chambers. Diastolic dysfunction and mild pulmonary hypertension are evident in cirrhotic patients with ascites. These changes do not depend on variations in the left ventricular geometry.

Frequency of development of acute global left ventricular dysfunction in human immunodeficiency virus infection

OBJECTIVES This study evaluated prospectively the frequency, clinical outcome and pathologic findings of acute global left ventricular dysfunction in human immunodeficiency virus (HIV) infection during the various stages of the disease. BACKGROUND Acute global left ventricular dysfunction in the course of HIV infection is still a poorly defined clinical entity, and little is known about the outcome after the acute onset. METHODS Between January 1988 and June 1992, 136 HIV-positive (HIV+) patients without clinical, electrocardiographic or echocardiographic evidence of cardiovascular dysfunction on admission were prospectively studied with serial echocardiograms. Patients were assigned to three groups: 1) anti-HIV+ asymptomatic (17 patients, 12.5%); 2) acquired immunodeficiency syndrome (AIDS)-related complex (26 patients, 19.1%); 3) AIDS (93 patients, 68.4%). RESULTS During a mean follow-up period of 415 +/- 220 days, seven patients, all in the AIDS subgroup, developed clinical and echocardiographic findings of acute global left ventricular dysfunction; of these, six (85%) died of congestive heart failure. Mean survival time from symptom onset was 41 +/- 13 days. Necropsy findings in five patients revealed acute lymphocytic myocarditis in three, cryptococcal myocarditis in one and interstitial edema and fibrosis in one. In only one patient was left ventricular dysfunction reversible with treatment. CONCLUSIONS Although infrequent, acute global left ventricular dysfunction is not rare in the course of HIV infection. It seems to occur exclusively during the AIDS stage. Acute global left ventricular dysfunction is often fatal but may be reversible and is mainly associated with the pathologic findings of acute myocarditis.

Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS).

OBJECTIVE:The implantation of a transjugular intrahepatic portosystemic shunt (TIPS) has been shown to exacerbate the hyperdynamic circulation and might induce a significant cardiac overload. We investigated cardiac function before and 1, 3, 6, and 12 months after the TIPS procedure in cirrhotic patients.METHODS:Eleven patients with nonalcoholic cirrhosis were evaluated. Cardiovascular parameters were assessed by two-dimensional Doppler echocardiography.RESULTS:After TIPS, the left ventricular diastolic diameter increased from 26.5 ± 1.8 mm (basal) to 30.0 ± 2.8 mm (6 months) (p < 0.05), whereas the ejection fraction showed a slight increase (basal, 64.5 ± 3.3; 6 months, 68.1 ± 3.2). The left ventricular pre-ejection period and the isovolumetric relaxation time decreased transiently at 1 month (p < 0.05). An increased velocity in all of the components of pulmonary venous flow (systolic, diastolic, and atrial) documented the accelerated fluxes induced by the procedure. The estimated pulmonary systolic arterial pressure also increased at 1 month (29.5 ± 1.4 vs 44.1 ± 1.4 mm Hg, p < 0.05). All of these modifications reverted after 6 months.CONCLUSIONS:Our study demonstrates that nonalcoholic cirrhotic patients, without cardiovascular pathologies, show transient modifications in cardiac dimension and function for 3–6 months after TIPS caused by the increased volume load shunted to the heart.

Left ventricular remodelling index (LVRI) in various pathophysiological conditions: a real-time three-dimensional echocardiographic study

Background: Various studies have reported a close correlation between real-time three-dimensional echocardiography (RT3DE) and cine magnetic resonance imaging studies for the assessment of cardiac volumes and mass. Objective: The aim of our study was to evaluate changes in left ventricular volumes and mass in subjects with different pathophysiological conditions. A ratio between left ventricular mass and end-diastolic volume (LVRI), detected by RT3DE, was used to describe various patterns of left ventricular remodelling. Methods: RT3DE was performed to calculate left ventricular end-diastolic (LVEDV) and end-systolic volume (LVESV), ejection fraction (LVEF) and mass in 220 selected subjects. Of these, 152 were healthy volunteers, 19 top-level rowers, 23 patients with dilated cardiomyopathy and 26 patients with hypertrophic cardiomyopathy. Off-line analysis was performed by two independent operators by tracing manual endocardial and epicardial borders of the left ventricle through eight cutting planes. Inter- and intra-observer variability were calculated. Results: Despite the increase in LV volume and mass in the rowers, LVRI remained unchanged compared with control subjects (p = 0.455), while significantly lower values were found patients with dilated cardiomyopathy (p<0.001) and significantly higher values in patients with hypertrophic cardiomyopathy (p<0.001). There was inter- and intra-observer variability. Conclusion: The LVRI may serve as a simple and useful indicator of left ventricular adaptation to physiological and pathological conditions.

Long-term prognostic significance of three-dimensional echocardiographic parameters of the left ventricle and left atrium

AIMS We sought to investigate the long-term prognostic significance of two- and three-dimensional echocardiography. METHODS AND RESULTS One hundred and seventy-eight consecutive outpatients underwent two-dimensional echocardiography and three-dimensional echocardiography for the assessment of LV volumes, mass, ejection fraction, and LA maximum and minimum volumes. After 45 months of follow-up, 31 patients (17%) had major cardiovascular events (death, myocardial infarctions, or stroke). From the two-dimensional echocardiography data, a significant time relationship to cardiovascular events was achieved only by LV end-systolic volume [hazard ratio (HR): 1.047; 95% confidence interval (CI): 0.994-1.083; P = 0.031] and mass (HR: 1.038; CI: 0.993-1.082; P = 0.019), whereas from three-dimensional echocardiography, all the examined variables: LV end-diastolic (HR: 1.014; CI: 1.003-1.025; P = 0.014) and end-systolic volume (HR:1.018; CI: 1.006-1.029; P = 0.003), ejection fraction (HR: 0.032; CI: 0.002-0.565; P = 0.019), mass (HR: 1.030; CI: 1.016-1.045; P < 0.001), LA maximum (HR: 1.055; CI: 1.031-1.080; P < 0.001) and minimum (HR: 1.049; CI: 1.028-1.070; P < 0.001) volumes, were found to bear a significant relationship to cardiovascular events. By multivariate analysis, three-dimensional echocardiography derived LA minimum volume was identified as the best independent predictor of adverse cardiovascular events (HR: 1.217; CI: 1.075-1.378; P = 0.002). CONCLUSION Owing to a superior accuracy, three-dimensional echocardiography derived parameters and most notably LA minimum volume provide more relevant information on outpatient prognosis.

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.

Noninvasive Assessment of Mitoxantrone Cardiotoxicity in Relapsing Remitting Multiple Sclerosis

Multiple sclerosis is the most common cause of neurologic disability in young adults. Recent reports have suggested that Mitoxantrone might be a candidate for clinical trials in multiple sclerosis patients. The authors studied 20 patients with relapsing remitting multiple sclerosis to evaluate cardiac toxicity during a one‐year follow‐up period. Patients were divided into 2 groups: group A, mitoxantrone treated patients (cumulative dose of 96 mg/m2); group B, placebo patients. The clinical course of multiple sclerosis was assessed using the Expanded Disability Status Scale and the number of relapses during the follow‐up. Each patient had an electrocardiogram and a spectral and color flow Doppler echocardiographic examination at enrollment, and 6 and 12 months later, to investigate cardiac toxicity. The mean exacerbation rate was reduced significantly in group A patients. No significant differences in the electrocardiograms or the echocardiographic parameters of systolic and diastolic function were noted between the two groups or in group A during the follow‐up. Mitoxantrone treatment seems able to improve the clinical course of relapsing remitting multiple sclerosis patients. It does not show any cardiac toxicity in selected patients at this dosage.

Determinants of plasma levels of brain natriuretic peptide after acute ischemic stroke or TIA

Plasma levels of brain natriuretic peptide (BNP) are frequently elevated after an acute stroke and have been shown to be an independent predictor of mortality. However, the relationships between stroke and BNP concentrations have not yet been systematically investigated. Plasma BNP assay and echocardiography were performed in 48 patients with ischemic stroke or TIA with a mean delay of 12.7 h after onset. Median BNP concentration was 88.6 pg/mL (range 5-1270). Older age, chronic heart failure, atrial fibrillation, stroke severity, lower hemoglobin levels, lower left ventricular ejection fraction, and abnormalities of left atrium or appendage (LA/LAA) were univariately associated with increased BNP levels. At multivariable analysis, the presence of at least one LA/LAA abnormality (atrial dilatation, low flow velocity, spontaneous echocontrast or thrombus) had the strongest association with BNP, explaining 38.9% of the variance in the whole sample and 28.5% in patients without atrial fibrillation. In acute ischemic stroke patients, elevated plasma BNP levels have multiple determinants, among which left atrial disease appears to be the stronger, even in patients without atrial fibrillation. These results encourage further investigation of plasma BNP concentration as a potential marker of the presence of left atrial sources of emboli.