Ysabel Conde

Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography

PURPOSE Coronary angiography is the gold standard for imaging the coronary tree, but the relation of coronary artery fistulas to other structures, and their origin and course, may not be apparent. We evaluated the ability of multiplane color Doppler transesophageal echocardiography to identify coronary fistulas. PATIENTS AND METHODS Twenty-one patients with angiographically confirmed coronary artery fistulas were investigated by transesophageal echocardiography in four Italian hospitals between January 1997 and May 2001. RESULTS Transesophageal echocardiography correctly diagnosed fistulous connection in all 21 patients. This included 6 patients with connections from the left circumflex artery (into the right chambers of the heart in 5 patients, and into the left ventricle in 1 patient), 10 patients with a fistula arising from the left anterior descending artery or left main coronary artery (with drainage into the right ventricle or main pulmonary artery), and 5 patients with a fistula from the right coronary artery (with drainage sites in the lateral aspect of the right ventricle, the low posterior right atrium, or the superior vena cava). In 4 of the 21 patients, angiography did not identify the precise site of a fistula into the coronary sinus or right ventricle. CONCLUSION Color Doppler transesophageal echocardiography is useful in the diagnosis and in the precise localization of coronary artery fistulas.

Assessment of right ventricular function by strain rate imaging in chronic obstructive pulmonary disease

The purpose of the current study was to compare right ventricular (RV) myocardial wall velocities (tissue Doppler imaging) and strain rate imaging (SRI) parameters with conventional echocardiographic indices evaluating RV function in chronic obstructive pulmonary disease (COPD) patients. In total, 39 patients with COPD and 22 healthy subjects were included in the current study. Seventeen patients had pulmonary artery pressure <35 mmHg (group I) and 22 patients had pulmonary artery pressure >35 mmHg (group II). Tissue Doppler imaging, strain and strain rate (SR) values were obtained from RV free wall (FW) and interventricular septum. Respiratory function tests were performed (forced expiratory volume in one second/vital capacity (FEV1/VC) and carbon monoxide diffusion lung capacity per unit of alveolar volume (DL,CO/VA)). Strain/SR values were reduced in all segments of group II patients compared with group I patients and controls with lowest values at basal FW site. A significant relationship was shown between peak systolic SR at basal FW site and radionuclide RV ejection fraction. A significant relationship was shown between peak systolic SR at basal FW site and DL,CO/VA and FEV1/VC. In conclusion, in chronic obstructive pulmonary disease patients, strain rate imaging parameters can determine right ventricular dysfunction that is complementary to conventional echocardiographic indices and is correlated with pulmonary hypertension and respiratory function tests.

Assessment of ascending aorta distensibility after successful coarctation repair by strain Doppler echocardiography.

BACKGROUND Increased arterial stiffness may participate in the genesis of hypertension and increase of left ventricular (LV) mass after surgical correction of coarctation of the aorta. The purpose of the current study was to assess the aortic elastic properties using Doppler tissue imaging and strain rate imaging in patients after coarctoplasty. METHODS Echocardiography with Doppler tissue/strain rate imaging capabilities was performed in 26 adult normotensive patients who had successful repair of coarctation of the aorta in infancy and in 24 control subjects. Transesophageal aortic transverse sections were imaged at the level of the proximal and distal segments to the repair site. Doppler tissue imaging wall velocities during systole (S(w)), early relaxation (E(w)), and atrial systole (A(w)) and peak systolic strain (ps epsilon) were measured in both groups. Transthoracic ascending aorta (AAo) measurements were also obtained. RESULTS In the patients with coarctoplasty, S(w) velocities and ps epsilon were significantly decreased in the proximal segments compared with control subjects. Both peak systolic blood pressure after exercise (P < .001) and pulse pressure after exercise (P < .001) were directly related to AAo wall strain. LV annular early diastolic velocity was significantly reduced compared with control subjects in patients with decreased AAo wall strain and exercise-induced hypertension (P < .001) and related to AAo wall velocity (P < .005) and strain (P < .001). In multiple linear regression analysis, only weight, study group, and AAo wall strain were correlated to LV mass index. CONCLUSIONS Patients with coarctation of the aorta have reduced proximal aortic wall velocities and strain and increased stiffness even after successful repair. This amplifies stress-induced hypertension and increases LV burden.

Early Myocardial Deformation Changes in Hypercholesterolemic and Obese Children and Adolescents: A 2D and 3D Speckle Tracking Echocardiography Study

AbstractDyslipidemia and obesity are considered strong risk factors for premature atherosclerotic cardiovascular disease and increased morbidity and mortality and may have a negative impact on myocardial function.Our purpose was to assess the presence of early myocardial deformation abnormalities in dyslipidemic children free from other cardiovascular risk factors, using 2-dimensional speckle tracking echocardiography (2DSTE) and 3-dimensional speckle tracking echocardiography (3DSTE).We studied 80 consecutive nonselected patients (6–18 years of age) with hypercholesterolemia (low-density lipoprotein [LDL] cholesterol levels >95th percentile for age and sex). Forty of them had normal weight and 40 were obese (body mass index >95th percentile for age and sex). Forty healthy age-matched children were selected as controls. Left ventricular (LV) global longitudinal, circumferential, and radial strains were calculated by 2DSTE and 3DSTE. Global area strain (GAS) was calculated by 3DSTE as percentage of variation in surface area defined by the longitudinal and circumferential strain vectors. Right ventricular (RV) global and free-wall longitudinal strain and LV and RV diastolic strain rate parameters were obtained. Data analysis was performed offline.LV global longitudinal strain and GAS were lower in normal-weight and obese dyslipidemic children compared with normal controls and reduced in obese patients compared with normal-weight dyslipidemic children. LV early diastolic strain rate was lower compared with normals. RV global and free-wall longitudinal strain was significantly reduced in obese patients when compared with the control group. A significant inverse correlation was found between LV strain, LDL cholesterol levels, and body mass index.2DSTE and 3DSTE show LV longitudinal strain and GAS changes in dyslipidemic children and adolescents free from other cardiovascular risk factors or structural cardiac abnormalities. Obesity causes an additive adverse effect on LV strain parameters and RV strain impairment.

Assessment of regional left ventricular function during exercise test with pulsed tissue Doppler imaging.

To investigate whether mitral annular velocity, measured by tissue Doppler imaging (TDI), is able to get a feasible quantitative evaluation of global and regional left-ventricular function during exercise test, 29 patients with previous uncomplicated myocardial infarction were studied by exercise echocardiography. All patients underwent coronary arteriography within 10 days of stress echocardiography. All of them were in sinus rhythm and had no right or left bundle branch block or significant mitral regurgitation as observed by left ventriculography. A total of 12 patients had anteroseptal and/or posteroseptal wall asynergies and left anterior descending involvement; 9 patients had lateral and/or posteroinferior asynergies and left circumflex coronary artery involvement; 8 patients had inferior and posteroseptal wall asynergies and right coronary artery involvement. Twelve subjects of same age and sex with normal cardiovascular findings were selected as a control group. TDI sample volumes were set on the mitral annuli corresponding to anteroseptal, posterior, posteroseptal, lateral, anterior, and inferior wall in 4-chamber, 2-chamber, and long-axis views. There was a significant correlation between the left-ventricular ejection fraction (0.41 +/- 0.8) and the means of the systolic (S) values (6.1 +/- 0.9 cm/sec, r = 0.83, p < 0.01). The mean S at the sites corresponding to the infarct regions (5.5 +/- 0.4 cm/sec) was significantly lower than the control group (11 +/- 0.8 cm/sec, p < 0.001). After stress, in patients with multivessel disease, S values corresponding to remote regions were significantly lower (p < 0.01) compared with control subjects. Thus, the parameters obtained from mitral annular velocities with pulsed TDI in patients with previous myocardial infarction reflect left ventricular asynergy corresponding to the infarct regions and reversible regional dysfunction after exercise.

Transesophageal dobutamine stress echocardiography with tissue Doppler imaging for detection and assessment of coronary artery disease.

Abstract Background Transesophageal dobutamine stress echocardiography (T-DSE) has been shown to be a sensitive and specific technique for the detection of myocardial ischemia. A major limitation of echocardiographic study interpretation, however, is the subjective visual analysis of endocardial motion and wall thickening, which is only semiquantitative. Methods To analyze whether T-DSE with the use of tissue Doppler imaging (TDI) during graded dobutamine infusion may be useful to detect and quantify stress-induced myocardial ischemia by changes in myocardial velocities, 70 patients undergoing coronary arteriography were studied with T-DSE and TDI. Midesophageal and transgastric short- and long-axis images were obtained at each level of dobutamine infusion. T-DSE was successful in 67 patients (96%). Baseline resting pulsed and color peak systolic (S) and early diastolic (E) velocities of the anterior, septal, lateral, and inferior walls were examined. Results Pulsed and color TDI correlated well at rest and after stress. Fifteen patients had a normal response to dobutamine, and 52 patients had inducible ischemia by two-dimensional criteria. In the normal group, there was a significant dose-dependent increase in S and E velocities. Compared with those in the normal group, patients with coronary artery disease (CAD) had lower resting S and E velocities and blunted S wave increase or E wave decrease during DSE. Conclusions T-DSE with TDI is a feasible and accurate test for the quantitative assessment of patients with CAD who have impaired augmentation of systolic and diastolic myocardial velocities during dobutamine infusion.

Radiotherapy-Chemotherapy Related Heart Diseases in Surgical Setting

Introduction: The numbers of healed or long term survivor’s cancer patients are increasing. Radiotherapy and chemotherapy can induce heart damages even after many years. Cancer patient is a chronic patient and frequently requires prolonged anti-cancer therapies and repeated interventions of oncologic surgery during the course of his disease. According to Guideline on “Perioperative Cardiovascular Evaluation and Management of Patients Undergoing non-cardiac Surgery”, the perioperative cardiologic management can determine changes that can take time and that can include the decision to change medical therapies, the decision to perform further cardiovascular interventions or the decision to recommend alternative therapeutic strategies. The consequent delay of the planned surgery to allow the assessment and significant changes in cardiologic management, will negatively affect outcome also with a negative impact on the costs for the time extension of the hospitalization. Case report: We present a male caucasian patient of 51 years, smoker, hypertensive, with an history of resection of the right lung for lung microcytoma at age 27 years, treated with chemotherapy and radiotherapy (1988). He was admitted (2012) into our Institute to undergo total surgical laryngectomy for laryngeal cancer. At the perioperative cardiovascular assessment for non-cardiac surgery we found a total atrio-ventricular block and triple vessel coronary artery disease. The planned surgery was delayed, a dual-chamber pacemaker was implanted and the patient underwent surgical myocardial revascularization with triple coronary artery bypass grafting. Consequently, according to the decision of surgeons and oncologists the patient underwent radiation therapy instead of laryngeal surgery. Conclusion: In cancer patients we recommend the cardiologic surveillance, also for several years, after radiotherapy and chemotherapy to detect and treat in time heart damages. This appears clinically and economically cost-effective because it can reduce the hospitalization time in surgical setting for oncologic time-sensitive procedures.

Dobutamine stress echocardiography with automated border detection and color kinesis identifies improved diastolic left ventricular function and viable myocardium in ischemic cardiomyopathy

Since the effects of dobutamine on left ventricular systolic and diastolic function are related to the presence of myocardial viability, we attempted to establish if improvement of diastolic wail motion abnormalities assessed with automated border detection (ABD) and color kinesis (CK) has an adjunctive value in detecting hibernating but viable myocardium. 21 patients (pts) with ischemic cardiomyopathy (left ventricular ejection fraction -LVEF-: 0.31-+0.11) were studied with low dose (5-10 mcg/Kg/min) dobutamine stress echocardiography (DSE). ABD waveforms of LV area change and the rate of area change were displayed along with the electrocardiogram and the concurrent cross sectional image. CK digitized LV end-systolic and end-diastolic images were evaluated by reviewing the stored loops obtained in all pts. Endocardial tracking was considered adequate when the visually assessed systolic excursion matched the colorencoded images. Viability was defined as akinetic or hypokinetic segments becoming normokinetic with systolic wall thickening. At baseline and during peak infusion LVEF, peak ejection rate (PER: ml]s), peak filling rate (PFR: ml/s) and mean time of diastolic endocardial motion (tDEM: ms) were calculated. In 10 pts viability was present (group 1), in 11 pts viability was absent (group 2). In group 1 pts there was a significantly increase from baseline to peak infusion in LVEF (0.28-+0.11 vs 0.42_+0.8, p<0.005), PER (1.64-+0.61 vs 2.98--0.97, p<0.005), PFR (1.52--0.53 vs 2.69+0.92, p<0.005) and significant decrease in mean tDEM (304_+41 vs 205--23, p<0.001). In group 2 pts a significantly increase was shown in LVEF (0.27-+0.9 vs 0.38+0.10, p<0.05) and PER (1.41 -+0.72 vs 2.I 1-+0.83, p<0.05); no significant difference was found in PFR (1.39-+0.61 vs 1.74_+0.73, p=NS) and tDEM (315_+39 vs 304_+31, p=NS). Thus, ABD and CK parameters of diastolic function (PFR, tDEM) improved only in pts with hibernating but viable myocardium whereas global systolic function can improve in the presence of both viability and non viability.