Vito Marangelli

Transesophageal Doppler echocardiography evaluation of coronary blood flow velocity in baseline conditions and during dipyridamole-induced coronary vasodilation.

Transesophageal echocardiography allows the evaluation of proximal coronary artery anatomy and coronary blood flow velocity (CBFV). To assess the potential of transesophageal echocardiography in evaluating CBFV and its variations induced by coronary-active drugs, we studied 15 patients by high-quality pulsed wave Doppler recordings of CBFV. In these patients, transesophageal Doppler evaluation of CBFV was performed before, 2 minutes after cessation of dipyridamole infusion (0.56 mg/kg in 4 minutes), and 2 minutes after aminophylline infusion (240 mg injected 4 minutes after cessation of dipyridamole infusion). The following CBFV parameters were evaluated at each of the three steps of the study protocol: maximal and mean diastolic velocities and maximal and mean systolic velocities. Furthermore, the following indexes of coronary flow reserve were evaluated: the ratio between maximal diastolic velocity recorded after and before dipyridamole administration and the ratio between mean diastolic velocity recorded after and before dipyridamole administration. Nine of the 15 patients had a normal left anterior descending coronary artery (group A), whereas the remaining six had significant (less than or equal to 75%) stenosis (group B). In group A patients, all CBFV parameters increased significantly during dipyridamole infusion and returned to near baseline values after aminophylline infusion. In group B patients, on the other hand, none of the CBFV parameters increased after dipyridamole infusion. Dipyridamole/baseline maximal diastolic velocity and mean diastolic velocity ratios were, respectively, 3.22 +/- 0.96 and 3.04 +/- 0.88 in group A and 1.46 +/- 0.45 (p less than 0.01 versus group A) and 1.48 +/- 0.49 (p less than 0.01 versus group A) in group B patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of coronary artery disease by digital stress echocardiography: Comparison of exercise, transesophageal atrial pacing and dipyridamole echocardiography☆

OBJECTIVES This study assessed and compared the diagnostic potential of exercise, transesophageal atrial pacing and dipyridamole stress echocardiography in a clinical setting. BACKGROUND Although they have been widely studied, no data exist with regard to comparisons of these procedures in a head-to-head study in different clinical settings. METHODS One hundred four consecutive patients with suspected coronary artery disease undergoing coronary angiography and with no previous myocardial infarction or rest left ventricular wall motion abnormalities underwent digital posttreadmill, transesophageal atrial pacing and dipyridamole echocardiography. RESULTS Feasibility of digital exercise echocardiography was 84%; 8 of 88 remaining patients had a nondiagnostic exercise echocardiographic test (inadequate exercise or imaging). In 80 patients with feasible and diagnostic digital exercise echocardiography, sensitivity, specificity and accuracy were, respectively, 89%, 91% and 90%. Eighty of the 104 patients underwent transesophageal atrial pacing and dipyridamole echocardiography. Feasibility of the alternative stress procedures was 77% for transesophageal atrial pacing and 96% for dipyridamole. In 60 patients successfully undergoing both alternative stress procedures, sensitivity and specificity were 83% and 76% for atrial pacing and 43% and 92% for dipyridamole echocardiography, respectively. In the group of 24 patients with nondiagnostic exercise echocardiography and consequent indication to alternative stress procedures, accuracy of transesophageal atrial pacing was higher than that of dipyridamole echocardiography (73% vs. 45%, p = 0.06). CONCLUSIONS Because of its higher diagnostic potential and additional functional information, exercise is the stress of choice when stress echocardiography is used to detect the presence of coronary artery disease. Alternative stresses can be used in patients with nondiagnostic exercise echocardiography. Transesophageal and dipyridamole echocardiography differ in feasibility and diagnostic reliability (higher sensitivity of transesophageal atrial pacing, higher specificity of dipyridamole). These characteristics must be considered when selecting procedures to be used as alternatives to exercise.

Doppler echocardiographic evaluation of the effect of atrial pacing-induced ischemia on left ventricular filling in patients with coronary artery disease

Very little is known about the effects of acute myocardial ischemia on left ventricular filling. Previous studies of these effects have been of limited value because they were performed with 1) imaging techniques that, like cineventriculography or radionuclide ventriculography, do not allow beat to beat monitoring of left ventricular filling throughout the entire ischemic attack; and 2) exercise, which, even if effective in inducing myocardial ischemia in patients with coronary artery disease, also considerably shortens cycle length, thus leading to additional nonischemic filling alterations. To overcome these limitations, left ventricular filling was studied by means of Doppler echocardiographic evaluation of transmitral flow velocities before and immediately after rapid atrial pacing in 17 patients. Eight patients had coronary artery disease but did not develop ischemia (ST depression greater than or equal to 1.5 mm) during atrial pacing (Group 1) whereas nine had coronary artery disease and developed ischemia during atrial pacing (Group 2). No differences were observed from rest to postpacing in any of the filling variables considered in Group 1 patients. In contrast, a significant rearrangement of left ventricular filling occurred during ischemia in Group 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Altered two-dimensional strain measures of the right ventricle in patients with Brugada syndrome and arrhythmogenic right ventricular dysplasia/cardiomyopathy

AIMS Brugada syndrome (BrS) is an inherited channelopathy that can be characterized by mild right ventricular (RV) abnormalities that are not detectable with conventional echocardiography. The aim of this study was to evaluate the presence of RV abnormalities in BrS patients when compared with controls and a group of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) using two-dimensional (2D) strain analysis. METHODS AND RESULTS We enrolled 25 BrS, 15 ARVD/C patients, and 25 controls. Right and left ventricular dimension and systo-diastolic function were evaluated by conventional echocardiography. Longitudinal systolic strain (sS) peak, systolic and early diastolic strain rate of lateral RV segments were evaluated by 2D speckle tracking analysis. Left ventricle global and segmental strain measures were also evaluated. A reduced basal or mid-RV lateral sS were the parameters mostly associated with both BrS and ARVD/C. In BrS patients the minimum sS observed in these segments was significantly lower than that of controls (-28.9±3.2% vs. -32.3±3.2%, P: 0.002) but significantly greater than that evaluated in ARVD/C patients (-24.6±6.7%, P<0.001 both vs. BrS and controls). No differences were found between the BrS and the control group when left ventricular strain measures were analysed. CONCLUSION By 2D strain technique it is possible to observe mild abnormalities in RV systolic and diastolic function of BrS patients that are less pronounced than those observed in ARVD/C patients. These results help to better define the phenotypic characteristics of BrS patients and represent the basis for future studies aimed at testing their clinical usefulness in BrS patients.

A Digital Network for Long-distance Echocardiographic Image and Data Transmission in Clinical Trials: The CEDIM Study Experience

A special computer network has been specifically designed and realized to connect 36 Italian cardiological institutions to a central core laboratory. This network, which has been created to run the CEDIM Multicenter Trial (effects of L-carnitine on left ventricular function in patients with myocardial infarction assessed by digital echocardiography), enables automatic verification, via computer, 24 hours a day, of patient eligibility criteria, randomization, transmission, and filing of real-time left ventricular echocardiographic examinations. All the investigators participating in the CEDIM trial underwent several training courses as well as dummy run procedures to achieve optimal performance of all the operational procedures required for the network to function smoothly and correctly. This paper describes the aims of this special network, its technical characteristics, and the investigator training and dummy run procedures.

Left ventricle outflow tract vegetation, embolism and troponin rise: an infective endocarditis case report

Infective endocarditis (IE) incidence increases with advancing age [1], and recently has often shown atypical onset and poor prognosis. The clinical history varies greatly in relation to the different initial clinical manifestations, possible underlying heart disease, the microorganisms involved, the presence of complications and patient characteristics. Nowadays, the ‘‘classic textbook signs’’ [2] may be found almost exclusively in developing countries. In general, the most common expression of IE (20–50% of patients [2]) is often an embolic phenomenon. However, acute coronary syndrome (ACS) is an unusual IE onset form, and, as our case seems to describe, is associated with other particular features in the potential clinical evolution of IE.

Transesophageal echo-Doppler studies of coronary arteries — identification, assessment of flow reserve and value of contrast enhancement

Blood flow in the left coronary artery usually has a biphasic pattern with a greater diastolic and a smaller systolic component. The diastolic component is greater because in diastole coronary resistance is lower and the pressure gradient between the aortic root and left ventricle (i.e. the driving pressure) is higher. The amount of coronary blood flow (or flow velocity), its baseline characteristics and the changes induced by drugs capable of decreasing coronary resistance (and thus increasing forward flow) represent an important aspect of clinical and research cardiology studies. A better understanding of coronary pathophysiology is, in fact, extremely useful for the comprehension of the underlying angina mechanisms in some non “coronary artery diseases” characterized by effort chest pain (patients with reduced coronary flow reserve), for the evaluation of the effects of coronary active drugs and for the assessment of resting flow alterations in coronary arteries produced by different cardiac diseases.

Aortic coarctation: guidelines mismatch across the ocean.

Pseudocoarctation is a rare congenital anomaly characterized by aorta elongation and kinking, without significant obstruction. We report the case of an elderly patient with history of congestive heart failure (CHF) and aortic regurgitation (AR) who was referred for progressive exertional dyspnoea. After multimodal imaging evaluation, aortic coarctation with significant trans-stenosis gradient but mild luminal narrowing was diagnosed; this borderline patient was not addressed to repair, according to ESC guidelines and in spite of AHA ones. He rather met the criteria for pseudocoarctation diagnosis. An integration of functional and anatomical data is essential for a reliable diagnostic process in similar cases.

Coronary anatomy and myocardial perfusion: Role of contrast echocardiography

Coronary stenoses reduce coronary flow and, consequently, myocardial perfusion. This is the main cause of clinical symptoms of coronary artery disease. Though coronary arteriography is the most important diagnostic examination for evaluating this disease, it does have several limitations. It cannot, for example, estimate the actual ‘haemodynamic’ severity of the coronary stenoses and, therefore, its real significance in limiting myocardial perfusion. Interpretation of coronary angiograms is also affected by an intra- and inter-observer variability which cannot be overlooked [1, 2]. Furthermore, coronary arteriography as performed in most institutions gives only qualitative information on the distribution and characteristics of coronary stenoses. Myocardial perfusion is further influenced by many other factors which cannot be evaluated by coronary angiography (the microcirculation, heart muscle conditions, interstitial characteristics, wall stress, collateral circulation etc.).

901-52 Ultrasonic Integrated Backscatter Cyclic Variations During Atrial Pacing in Patients with and without Coronary Artery Disease

Contraction and relaxation of normal myocardium are associated with parallel integrated backscatter cyclic variations (IB CV). It has been demonstrated that IB CV are reversibly reduced in magnitude during coronary occlusion and reperfusion. To evaluate in humans the effects of pacing-induced ischemia on IB Cv, 29 pts were studied with multiplane TEE and simultaneous atrial pacing (up to 150 beats/m’). A prototype (Hewlett-Packard AD system) was used to acquire and analyse IB images. In each pt a transgastric 2 chamber view was acquired at rest, at peak-pacing and 5 cardiac cycles after pacing interruption (recovery). Twenty-one pts had significant coronary stenosis (≥50% narrowing): 8 pts developed myocardial ischemia (chest pain, ECG changes and wall motion abnormalities) during atrial-pacing [Group A], while the remaining 13 pts did not [Group B]. Eight pts had normal coronaries and no myocardial ischemia during pacing [Group C]. IB CV analysis was performed only in myocardial segments perpendicular to ultrasonic beam (anterior and inferior wall in transgastric view). In group A and B pts only segments within a territory supplied by a stenotic coronary artery were considered. Results IB CV are expressed in decibel units Download high-res image (64KB) Download full-size image Conclusion atrial pacing does not affect IB CV in myocardium supplied by normal coronary arteries. During pacing, IB CV are blunted in myocardium supplied by significantly narrowed coronary arteries, even in the absence of traditional signs of ischemia. IB CV have a potential in the identification of stress-induced regional left ventricular dysfunction in pts with coronary artery disease.