[Intracoronary ultrasound during recanalization of chronic coronary occlusions: Relation to restenosis and reocclusion after balloon angioplasty or stent implantation]

Chronic coronary occlusions carry a high recurrence rate, and coronary stenting evolves as a preferred therapy of these complex lesions. Insight into the morphology of the occluded segment by intracoronary ultrasound may provide information which may help to improve the interventional strategy and the long-term outcome. After successful recanalization of chronic coronary occlusions (4 weeks to 33 months; median 3.2 months) in 59 patients, 29 patients were treated by balloon angioplasty alone, and 30 patients received one or more coronary stents because of complicated dissections or a high-grade residual stenosis after balloon dilatation. Intracoronary ultrasound was used to assess the lesion morphology and to quantify the angioplasty result. The luminal area, the total vessel area and the extent of the plaque burden were measured proximal and distal to the occlusion and at the narrowest site within the occlusion or the coronary stents, and the elastic recoil was calculated. Plaques in chronic occlusions were predominantly hypodense, and 44% were characterized by a multilayered plaque appearance. The elastic recoil was higher in multilayered plaques than in other plaques (46 +/- 19% vs. 34 +/- 15%; p < 0.05). Based on the quantitative ultrasound measurement after the initial balloon dilatation, it appeared that the initial balloon was undersized in 54%. The lumen area in patients with balloon angioplasty alone was increased from 4.02 +/- 1.34 mm2 to 5.49 +/- 1.47 mm2 and in the stented patients from 3.58 +/- 1.04 mm2 to 7.10 +/- 1.92 mm2. The recurrence rate in patients with balloon angioplasty was 48% with 24% reocclusions. Patients with recurrence had a slightly lower lesion area (3.97 +/- 1.41 mm2 vs. 4.71 +/- 1.44 mm2; n.s.) and minimum diameter (1.82 +/- 0.31 mm vs. 2.14 +/- 0.40 mm; p < 0.05) after dilatation. In stented patients the recurrence rate was 27% with two early stent thrombosis (6.7%) and no late reocclusion. In patients with recurrence the achieved stent area was significantly smaller than in those without restenosis (5.71 +/- 0.90 mm2 vs. 7.59 +/- 1.96 mm2; p < 0.01), and the degree of vascular remodelling at the site of the occlusion was less pronounced. Intracoronary ultrasound showed sonographic plaque characteristics in chronic occlusions which responded poorly to balloon dilatation alone. Stent implantation improved considerably the luminal area gain and could reduce the long-term outcome. To further improve the recurrence rate in stents, an optimized stent expansion should be achieved, and intracoronary ultrasound could provide an ideal tool for this purpose.

Morphology of chronic coronary occlusions and response to interventional therapy--a study by intracoronary ultrasound

OBJECTIVES

Balloon angioplasty of chronic coronary occlusions has a low procedural success and a high recurrence rate. Better tomographic insights into the lesion morphology may improve the interventional strategy and results.

METHODS

Intracoronary ultrasound was used during the recanalizaton procedure of 45 chronic coronary occlusions (2 weeks to 14 months; average 3.4 months) to determine the lesion morphology and to assess the angioplasty result. The luminal area and the plaque burden were measured proximal and distal to the occlusion, and within the occlusion. The ultrasonographic characteristics of the occlusive lesions were compared to 45 nonocclusive lesions of age-matched patients with stable angina pectoris.

RESULTS

Occlusive lesions were more often echodense as compared to nonocclusive lesions (35% vs. 20%; p = 0.10). In chronic occlusions a multi-layered plaque morphology was observed in 22%, and this morphology was not found in nonocclusive lesions. Angiographic characteristics were not related to the ultrasonographic morphology of the lesion. Despite similar vessel areas in occlusive and nonocclusive lesions, the balloon size selected according to the angiographic image was underestimated in occlusive lesions. Based on the quantitative ultrasound measurement the balloon size was increased from 2.6 +/- 0.3 mm to 3.3 +/- 0.5 mm in 53% of the lesions. This resulted in an increase of the luminal area from 3.51 +/- 0.92 to 5.08 +/- 1.43 mm2 (p < 0.001). The acute recoil after balloon angioplasty was similar (34 +/- 18%) in hypodense and echodense plaques, but was significantly higher in lesions with a multi-layered plaque morphology (49 +/- 22%; p < 0.05). In 19 patients with severe dissections or extreme acute recoil (residual stenosis > 50%) the use of a stent increased the luminal area from 3.94 +/- 0.81 to 7.51 +/- 1.71 mm2 (p < 0.001).

CONCLUSIONS

Intracoronary ultrasound demonstrated a multi-layered plaque morphology in one fourth of the chronic occlusions. This type of plaque was associated with a significant acute recoil. The presence of diffuse atherosclerosis in neighbouring segments of chronic coronary occlusions leads to underestimation of the balloon size. Quantitative assessment by intracoronary ultrasound helped to optimize the balloon size leading to a significant luminal area gain. The detection of excessive acute recoil should be considered an indication for stent deployment.

[Embolic complications in bacterial endocarditis]

Embolic complications are a major prognostic determinant in the clinical course of infective endocarditis (IE) with an incidence of about 30-50%. In order to analyze risk factors leading to embolism in native (NVE) and prosthetic valve endocarditis (PVE), we reviewed 177 consecutive patients; 43% were female, 57% male, PVE occurred in 24% of all patients all left-sided, among the NVE were 11% right-sided IE. Major embolic complications occurred in 40% of all patients. In NVE, a higher rate of embolic events (45% vs. 26%; p < 0.05), and a larger vegetation size compared to PVE was observed (14 +/- 6 mm vs. 11 +/- 5 mm; p < 0.05). The most important risk factor for embolic complications in NVE was Staphylococcus aureus (odds ratio 6.4). Furthermore, double valve endocarditis, fever, and mitral valve endocarditis were associated with the risk for embolism. In case of severe regurgitation the rate of embolic complications was reduced (54% vs. 77%; p < 0.05). In PVE, fever was a risk factor for embolic events. Staphylococcus aureus was also a frequent microorganism in embolism (45% vs. 22%). The in-hospital mortality was significantly increased in case of embolism (NVE 40% vs. 11%; p < 0.001; PVE 36% vs. 9% p < 0.05). About 50% of all embolic events occurred before admission. In NVE, due to high in-hospital mortality, the rate of patients with embolism undergoing surgery was lower (57% vs. 72%; p < 0.05); whereas in PVE no significant difference was observed. In patients with NVE, aspirin therapy because of coronary artery disease appeared to reduce the rate of embolic complications (11% vs. 47%). However, the low number of patients on aspirin (9%) does not allow recommendations regarding a potential benefit. In conclusion, identification of risk factors leading to embolism in IE may be useful in considering early surgical therapy. However, the high rate of embolic complications before hospital admission indicates a need for improving the diagnostic delay in the prehospital phase.

Coronary flow analysis during autoperfusion angioplasty

BACKGROUND

Autoperfusion balloons are available for the protection of the myocardium during balloon angioplasty. The aortic pressure is the driving force that delivers blood to the distal vessel during balloon inflation. Autoperfusion balloons can achieve sufficient flow rates in vitro. The use of these devices is recommended in high-risk patients in danger of haemodynamic collapse during balloon inflation. The quantity of the distal blood flow during balloon inflation in vivo is still unknown.

OBJECTIVES

To measure distal coronary perfusion using Doppler guidewires during percutaneous transluminal coronary angioplasty (PTCA) with autoperfusion balloons.

METHODS

Coronary flow velocity was measured with 0.014-inch Doppler guidewires bypassing the autoperfusion balloon in eight patients undergoing elective PTCA (degree of stenosis 74 +/- 7.2%). We used balloons with diameters of 3.0 and 3.5 mm. The coronary diameter at the location of the flow measurements was obtained by quantitative angiography in two planes. Coronary blood flow was calculated as the luminal area multiplied by the average peak flow velocity of the Doppler wire divided by 2. Coronary flow velocity reserve was measured before and after angioplasty by intracoronary injection of adenosine.

RESULTS

Coronary blood flow was 35 +/- 11.6 ml/min before PTCA. During average inflation times of 4.6 +/- 0.9 min, coronary blood flow was 19 +/- 3.8 ml/min (P = 0.002) after withdrawing the guidewire in the autoperfusion balloon. Five minutes after angioplasty it increased to 42 +/- 13.5 ml/min (P < 0.001). Four patients had electrocardiographic changes during balloon inflation; three patients reported chest pain. One patient required a stent because of a local dissection. To achieve satisfactory angiographic results (residual stenosis 11 +/- 8.5%), we performed 2.1 +/- 0.78 inflations on average with a cumulative inflation time of 8.8 +/- 3.35 min. Coronary flow velocity reserve increased from 1.3 +/- 0.20 to 2.2 +/- 0.22 (P < 0.001).

CONCLUSIONS

Using the autoperfusion balloon we measured a coronary blood flow during angioplasty of 56 +/- 10.3% of the distal perfusion before PTCA. In high-risk patients dependent on adequate coronary perfusion, autoperfusion balloons are not able to provide sufficient distal coronary blood flow during balloon inflation. In these patients active coronary or circulatory support devices are recommended.

Evaluation of an active coronary perfusion balloon device using Doppler flow wire during PTCA

The aim of this study was to assess whether active coronary perfusion catheters (APC) can provide a sufficient coronary flow in large caliber vessels during balloon inflation. To prevent myocardial ischemia during PTCA, these APC may be employed. However, it is as yet unknown whether the active flow rate of these devices approaches the flow rate prior to PTCA during balloon inflation. Therefore, we measured the efficacy of the APC during balloon inflation in vessels supplying a large amount of myocardium. In 12 patients (1 female, 11 males, 53 +/- 12.6 yr) with stenosed vessels (average diameter 3.4 +/- 0.26 mm), the coronary flow velocity was measured using a 0.014" Doppler guidewire, which was placed distally bypassing the balloon of the APC. The active perfusion balloon catheter was advanced through a 7F guiding catheter along a 0.014" guidewire. After removal of the guidewire, arterial blood being withdrawn from the side port of the femoral angioplasty sheath was pumped through the catheter to the distal coronary vessel. The perfusion volumes of the pump were set to different levels between 30 to 60 ml/min. Intracoronary flow rate was calculated by the angiographically assessed vessel luminal area [symbol: see text] average peak velocity [symbol: see text] 0.5. The mean coronary flow rate prior to PTCA was 43 +/- 17.7 ml/min. Maximum flow during PTCA was 55 +/- 19.6 ml/min. We found a good correlation between the preset external pump rate and the coronary flow in situ (r = 0.92). Pre-PTCA flow rates were achieved in 11 of 12 patients (92%) during balloon inflation. No relevant decrease in the arterial pressure occurred during dilation times of 4.6 +/- 1.63 min. Only two patients showed significant ECG changes during these balloon inflations. After an average follow-up period of 13 +/- 6.3 mo, only one patient (8%) had a significant re-stenosis requiring the implantation of a stent. The combination of intravascular Doppler velocity measurements with quantitative coronary angiography offers the opportunity of exact online flow registration during angioplasty. Using APC, It is possible to maintain a sufficient coronary flow in the distal vessel during balloon inflation even in large vessels. Therefore, as compared with mechanical circulatory assist devices, coronary assist by APC is a little invasive, but according to our measurements it might be a sufficient tool for performing PTCA also in high-risk patients.

Additional luminal area gain by intravascular ultrasound guidance after coronary stent implantation with high inflation pressure

AIMS

Studies by intravascular ultrasound demonstrated inadequate expansion in a large number of stents, which lead to the increase of inflation pressure for stenting. The present study examined whether routine use of high-pressure inflation would be sufficient for an optimum stent expansion without sonographic guidance.

METHODS AND RESULTS

Two types of single coronary stents (Palmaz-Schatz in 54, and Wiktor in 25) were implanted with inflation pressures of 16-20 atm in 79 nonocclusive coronary lesions. IVUS before stenting was used in 78% to select the adequate stent size. Intravascular ultrasound after stenting was used to asses the minimum stent are and diameter, the reference areas, and the strut apposition to the vessel wall. The difference between the area of the expanding balloon and the stent area was calculated as the luminal deficit of the stent. Completeness of stent expansion required full strut apposition and lesion coverage, and a minimum stent area that was larger than the distal reference, and larger than 60% of the proximal reference. Intravascular ultrasound before stenting lead to an increase of the stent size in 47%. After high-pressure expansion, even with the optimized balloon size, 8% of stents had struts protruding into the lumen. The stent area (6.87 +/- 1.93 mm2) was significantly smaller than both the proximal (9.59 +/- 2.91 mm2; p < 0.001) and distal reference area (8.23 +/- 3.03 mm2; p < 0.001). The criteria for complete expansion were met in 48%. The expansion with a larger high-pressure balloon in 28 stents lead to an increase of the stent area by 19% (8.19 +/- 2.24; p < 0.001), and full stent apposition in all cases. The criteria of stent expansion were met in 82%. A wide range of the luminal deficit upto 48% was observed, which was not related to sonographic lesion characteristics, except in lesions with complete circumferential calcifications. The different stent designs were characterized by a slightly lower luminal deficit in slotted-tube stents (23 +/- 13% vs. 28 +/- 12%; p = 0.11) and a better index of stent symmetry as compared with the coil stent (0.87 +/- 0.08 vs. 0.82 +/- 0.09; p < 0.05).

CONCLUSION

Routine use of high-pressure stent expansion did not lead to a sufficient stent expansion, even when the initial stent size had been guided by intravascular ultrasound. Further stent dilatation with larger balloons under ultrasound guidance would be required to optimize the luminal area gain.

Vasodilation by urapidil in the treatment of chronic congestive heart failure in addition to angiotensin-converting enzyme inhibitors is not beneficial: results of a placebo-controlled, double-blind study

BACKGROUND

The therapeutic benefit of an angiotensin-converting enzyme (ACE) inhibitor in combination with a different type of vasodilator is unknown.

METHODS AND RESULTS

To evaluate the effects of a combined therapy on quality of life, exercise tolerance, and hemodynamic parameters, patients with severe heart failure (New York Heart Association classes III and IV, ejection fraction below 35%) who were on ACE inhibitor therapy were randomly assigned to additional double-blind treatment with urapidil (60-120 mg/d) or placebo for 12 weeks. After enrollment of 36 patients, the study was terminated early because no beneficial effects on exercise tolerance and hemodynamic parameters could be shown for the urapidil treatment, and a trend toward increased mortality of the urapidil group was observed (odds ratio, 4.92 [0.49-49.6]; P = .167).

CONCLUSION

The combination of urapidil with an ACE inhibitor in the treatment of severe chronic congestive heart failure does not seem to offer any advantages over therapy with an ACE inhibitor alone and may have potentially harmful effects.

Causes of failed angioplasty for acute myocardial infarction assessed by intravascular ultrasound

Coronary angioplasty is gaining increased importance as a primary treatment of acute myocardial infarction, but the complication rate of the procedure is higher than in stable coronary artery disease. In a consecutive series of 110 coronary angioplasties in patients with acute myocardial infarction, the cause of initially failed procedures was studied by intravascular ultrasound. The balloon angioplasty was immediately successful in 66%. In those cases with crossing of the lesion but a dissatisfying dilatation result (persistent occlusion, reocclusion, or dissection) an intravascular ultrasound probe could be advanced to 32 of 34 lesions. The information provided by ultrasound guided the subsequent bailout therapy. Persistent occlusions were caused by extensive thrombosis in 4.5% of all cases, subsequently treated by local thrombolysis for 12 to 16 hours, and in 1.8% by a ruptured plaque, which was treated by stenting. In cases with Thrombolysis in Myocardial Infarction (TIMI) flow II, angiography suggested a thrombus in 9.1%, but intravascular ultrasound could detect dissections instead of a thrombus in half the cases. In cases of dissection, stenting was performed. Dissections were observed by angiography in 15.5%, and all cases were confirmed by ultrasound. In vessels >2.5 mm the dissection was treated by stenting. Overall, in 20 of 21 lesions stents were successfully implanted. No stent thrombosis was observed. With the assistance of intravascular ultrasound during bailout therapy, the success of coronary angioplasty to achieve TIMI flow III without residual stenosis in an unselected consecutive patient cohort with acute myocardial infarction was 96%. In direct angioplasty for acute myocardial infarction the procedure is frequently complicated by events such as plaque rupture and extensive vascular thrombosis, which are uncommon in coronary angioplasty for stable angina. Intravascular ultrasound provided insight into the underlying morphologic characteristics of failed angioplasty that enhanced the information provided by coronary angiography and assisted in the selection of the bailout therapy.

Acute papillary muscle rupture in a patient with clostridial sepsis

We describe the clinical course of a 58-year-old man who died from acute papillary muscle rupture as a complication of clostridial sepsis. There was no evidence for myocardial infarction, infective endocarditis, prior chest trauma or other known causes of papillary muscle rupture. Histological specimens taken at autopsy demonstrated clostridial infection of the heart. To our knowledge the occurrence of papillary muscle rupture in the setting of clostridial sepsis has not yet been reported in the literature.

Expansion of Wiktor stents by oversizing versus high-pressure dilatation: a randomized, intracoronary ultrasound-controlled study

Two strategies to achieve optimal expansion of Wiktor stents in coronary arteries, oversizing at normal balloon pressures (group 1) and high-pressure dilatation (group 2), were compared. We randomly assigned 20 symptomatic patients with de novo coronary artery stenoses of <15 mm length to one of the two treatment groups. Intracoronary ultrasound catheter pull-backs after stent implantation showed incomplete stent attachment with one or two struts protruding into the vessel lumen in 3 of 10 patients in group 1 but in no patient after high-pressure dilatation in group 2 (p<0.01). Recross and high-pressure dilatation of the 3 stents in group 1 achieved complete attachment of all stents. Minimal luminal diameter was comparable between the groups (2.61 +/- 0.34 mm in group 1 after stent delivery, and 2.68 +/- 0.45 mm in group 2 after high-pressure dilatation). Minimal luminal area (expressed as a percentage of the reference cross-sectional area) was slightly but insignificantly greater in the high-pressure group (91.1% +/- 25.6% vs 85.5% +/- 15.1%). We conclude that implantation of Wiktor stents at normal inflation pressures does not reliably result in complete attachment of all struts to the vessel wall.

Vessel reconstruction in total coronary occlusions with a long subintimal wire pathway: use of multiple stents under guidance of intravascular ultrasound

A frequent cause of failure of the recanalization of a total coronary occlusion is a subintimal pathway of the guide wire. Three cases of occluded right coronary arteries are presented in which a distal reentry into the true vessel lumen was achieved. Intravascular ultrasound was used to locate the exit and reentry of the guide wire, and to plan the position of multiple stents for the coverage of this subintimal pathway. In all cases antegrade flow to the distal coronary bed was restored.

Cheyne-Stokes respiration and prognosis in congestive heart failure

Patients with congestive heart failure (CHF) frequently demonstrate Cheyne-Stokes respiration (CSR) with repetitive arousals and oxygen desaturations during sleep. Although it was evident from early publications that CSR during the daytime is a poor prognostic indicator in patients with CHF, it was speculated recently that CSR occurring during sleep could impede left ventricular function and even survival. We therefore followed up 36 patients with CHF and a left ventricular ejection fraction < or = 40% who underwent a sleep study at our institution. The patients showed a reduced ejection fraction (20 +/- 8%) and CSR with a median of 19% of total sleep time (lower and upper quartiles 9% and 56%). In 12 +/- 9% of their time in bed, the arterial oxygen saturation was <90%. No patient was lost to follow-up, which lasted for 32 +/- 15 months (range 11 to 53). One-year survival was 86 +/- 6%, and 2-year survival was 66 +/- 8%. Univariate comparisons for survival between groups stratified by the amount of CSR revealed no significant difference (log rank test, p = 0.84). However, the 20 patients with a left ventricular ejection fraction <20% had a shorter mean survival time than patients with an ejection fraction >20% (9.5 vs 28.3 months; log rank test, p = 0.013). Two patients with CSR during the daytime died within 1 month. No other patient had CSR during the daytime, and only 1 patient without daytime CSR died within 1 month (chi-square test, p <0.001). Higher age, reduced carbon dioxide end-tidal partial pressure, and increased transit time were found to be significantly related to the amount of nocturnal CSR. In conclusion, CSR occurring during sleep has no important prognostic impact in patients with CHF, but CSR present during the daytime suggests a high likelihood of dying within a few months.

Human corticotropin-releasing hormone and thyrotropin-releasing hormone modulate the hypercapnic ventilatory response in humans

Human corticotropin-releasing hormone (hCRH) and thyrotropin-releasing hormone (TRH) are known to stimulate ventilation after i.v. administration in humans. In a placebo-controlled, single-blind study we aimed to clarify if both peptides act by altering central chemosensitivity. Two subsequent CO2-rebreathing tests were performed in healthy young volunteers. During the first test 0.9% NaCl was given i.v.; during the second test 200 micrograms of hCRH (n = 12) or 400 micrograms of TRH (n = 6) was administered i.v. Nine subjects received 0.9% NaCl i.v. during both rebreathing manoeuvres. The CO2-response curves for the two tests were compared within the same subject. In the hCRH group a marked parallel shift of the CO2-response curve to the left was observed after hCRH (P < 0.01). The same effect occurred following TRH but was less striking (P = 0.05). hCRH and TRH caused a reduction in the CO2 threshold. The CO2-response curves in the control group were nearly identical. The results indicate an additive effect of both releasing hormones on the hypercapnic ventilatory response in humans, presumably independent of central chemosensitivity.

Prevalence of obstructive sleep apnoea in patients with coronary artery disease

BACKGROUND

Obstructive sleep apnoea (OSA) is characterized by recurring upper airway collapse with continual respiratory effort during sleep, causing apnoea, a fall in arterial oxygen saturation, arousal and excessive daytime sleepiness. It is a common disorder, with an estimated prevalence of about 1-5% in the adult population. OSA is related to arterial hypertension, an essential risk factor for the development of coronary artery disease (CAD). Furthermore, a high dietary intake is a common risk factor for OSA as well as for CAD.

OBJECTIVE

To investigate the prevalence of OSA in CAD patients.

METHODS

A random sample of 50 patients (aged 61 +/- 6 years, body mass index 26.8 +/- 3.8 kg/m2) diagnosed to have CAD by coronary angiography was investigated prospectively. Respiration and nocturnal oxygen saturation were registered during one night. Snoring and daytime sleepiness were evaluated by a questionnaire.

RESULTS

In 25 patients the apnoea index was > 10/h sleep. Excessive daytime sleepiness was exhibited by eight of these patients. Nineteen of the patients with an apnoea index > 10/h participated in a full night polysomnography. The apnoea index was 17.0 +/- 10.9/h and the apnoea-hypopnoea index was 32.4 +/- 16.5/h sleep. The mean nadir oxygen saturation was 87.3 +/- 1.6% and the minimal oxygen saturation was 75.5 +/- 10.6%. For seven patients the apnoea index was > 20/h.

CONCLUSION

CAD patients have a high prevalence of OSA. Since obstructive apnoeas may trigger severe cardiac events such as myocardial ischaemia or ventricular tachycardias in CAD patients, the presence of OSA in these patients should be considered.

Ventilatory response to exercise and to carbon dioxide in patients with heart failure

Patients with heart failure exhibit an increased ventilatory response to exercise; their slope of the overall ventilation/carbon dioxide production ratio (VE/VCO2) is elevated. This elevation is related to impaired exercise performance and is commonly explained by an increased ventilation-perfusion mismatch. However, the concept of afferents to the respiratory centre modulating ventilation during exercise has been raised. In healthy subjects, ventilation during exercise is related to the hypercapnic ventilatory response during rebreathing. This is explained by a similar response of the respiratory centre to different stimuli. The aim of this study was to analyse the relationship between the ventilatory response to exercise and to carbon dioxide in patients with chronic heart failure. The hypercapnic ventilatory response was measured at rest using the rebreathing method in 31 patients with chronic heart failure and a left ventricular ejection fraction < 40% and 25 controls. Thereafter a maximal bicycle exercise test with evaluation of VE/VCO2 was performed. The maximal oxygen uptake during exercise was 13.1 +/- 5.2 ml. min-1.kg-1. The slope of the hypercapnic ventilatory response was normal (1.1 +/- 0.81. min-1. mmHg-1) but minute ventilation breathing room air was increased in the patients as compared to the controls. VE/VCO2 during exercise was positively correlated to the hypercapnic ventilatory response (r = 0.70; P < 0.00001). This relationship supports the concept that in patients with heart failure, ventilation during exercise is not only influenced by an increased ventilation-perfusion mismatch but is in part mediated by the responsiveness of the respiratory centre. Different afferents to the respiratory centre, such as central command or muscle ergoreflex may play a role in modulating ventilation during exercise.

Changes in left ventricular filling during follow-up study in survivors and nonsurvivors of idiopathic dilated cardiomyopathy

The assessment of left ventricular diastolic function by Doppler echocardiography shows both a nonrestrictive and restrictive type of filling in idiopathic dilated cardiomyopathy. These different filling patterns are related to the symptoms of cardiac failure and the prognosis. It remains to be established whether changes of Doppler parameters during follow-up procedures were of clinical relevance. Doppler echocardiography of left ventricular filling was done in 45 patients with idiopathic dilated cardiomyopathy at the time of their diagnosis and repeatedly during a follow-up study of 38 +/- 19 months. The deceleration time of early filling, the maximum early and atrial Doppler velocities and their ratios, as well as echocardiographic parameters of cardiac dimensions and systolic function, were measured. During the follow-up period, seven patients died and four patients underwent heart transplantation because of progressive heart failure. The deceleration time was shorter in patients who died or had to undergo heart transplantation as compared with survivors (119 +/- 43 ms vs 188 +/- 63 ms; P < .005). There was no difference in changes of clinical symptoms in survivors and nonsurvivors. The systolic function improved only in survivors. The difference in deceleration time remained significant between both groups, and it also remained a prognostic discriminator. Peak early velocity increased in nonsurvivors (from 0.66 +/- 0.20 m/s to 0.95 +/- 0.21 m/s; P < .01), while it remained constant in survivors (0.65 +/- 0.17 m/s and 0.67 +/- 0.25 m/s). The peak early/atrial velocity ratio varied widely in either group during the follow-up study, its changes were closely related to the concomitant changes of clinical symptoms (r = .59; P < .005) with a decrease of the peak early/atrial velocity ratio in patients with clinical improvement and an increase of the peak early/atrial velocity ratio in those without clinical improvement. The Doppler echocardiographic deceleration time discriminated between survivors and nonsurvivors in idiopathic dilated cardiomyopathy at the time of the initial diagnostic procedure, and this difference was persistent during the follow-up study. The serial evaluation of patients with idiopathic dilated cardiomyopathy showed a close association of changes in diastolic filling with changes in clinical symptoms.

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990's

Prosthetic valve endocarditis is considered to be associated with a more severe prognosis than native valve endocarditis. Among other factors, inappropriate visualization of vegetations in prosthetic valve endocarditis by transthoracic echocardiography is responsible for this observation. Since the introduction of transoesophageal echocardiography into clinical practice the diagnostic sensitivity and specificity of the detection of vegetations located on prosthetic valves have been enhanced. Therefore we aimed to determine and compare the prognosis of prosthetic valve endocarditis and native valve endocarditis in the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104 patients were seen at our institution between 1989 and 1993. Eighty patients (77%) had native valve endocarditis and 24 (23%) had late prosthetic valve endocarditis. In the latter group two patients had recurrent infective endocarditis. Patients with prosthetic valve endocarditis were older (mean age 64 vs 54 years in native valve endocarditis; P < 0.001) and the majority was female (62% vs 38% in native valve endocarditis; P < 0.05). In prosthetic valve endocarditis, infection of a valve in the mitral position predominated (65% vs 30% in native valve endocarditis; P < 0.01), whereas in native valve endocarditis more than half the cases had isolated aortic valve endocarditis (51% vs 27% in prosthetic valve endocarditis; P < 0.01). In prosthetic valve endocarditis more cases were caused by Staphylococcus aureus (31% vs 14% in native valve endocarditis; P = 0.08), whereas in native valve endocarditis the most frequent organisms were streptococci (29% vs 19% in prosthetic valve endocarditis; P = 0.12). Differences in the clinical features of native valve endocarditis and prosthetic valve endocarditis could not be found except for a higher rate of embolism in native valve endocarditis (40% vs 19% in prosthetic valve endocarditis; P < 0.05). Vegetations could be detected by transthoracic echocardiography more frequently in native valve endocarditis (71% vs 15% in prosthetic valve endocarditis; P < 0.0001). Transoesophageal echocardiography visualized vegetations in 95% of the episodes of native valve endocarditis and in 80% of the episodes of prosthetic valve endocarditis (P = 0.09). Thus, the diagnostic gain by transoesophageal echocardiography was greatest in prosthetic valve endocarditis. Patients with native valve endocarditis had significantly larger vegetations than patients with prosthetic valve endocarditis (P < 0.05 for length, P < 0.001 for width). The median time to diagnosis was similar in native valve endocarditis and prosthetic valve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditis and in 58% of those with prosthetic valve endocarditis; the median time delay between the diagnosis of infective endocarditis and surgery tended to be shorter in prosthetic valve endocarditis than in native valve endocarditis (45 vs 60 days). The in-hospital mortality and the mortality during a follow-up of 22 +/- 10 months did not significantly differ between native valve endocarditis and prosthetic valve endocarditis (21% vs 17%; 28% vs 25%). In summary in the era of transoesophageal echocardiography, late prosthetic valve endocarditis does not seem to carry a worse prognosis than native valve endocarditis. This can be attributed in part to the improved diagnostic accuracy achieved by transoesophageal echocardiography leading to comparable diagnostic latency periods in both patient groups. Finally, better characterization of vegetations on prosthetic valves by transoesophageal echocardiography allows early lifesaving surgery in patients with prosthetic valve endocarditis.

Infective endocarditis in the elderly in the era of transesophageal echocardiography: clinical features and prognosis compared with younger patients

PURPOSE

Advanced age is considered to be associated with a more severe prognosis in infective endocarditis (IE), which is relevance in view of a change in epidemiology of the disease with an increasing proportion of elderly people. We wanted to examine whether in the era of improved diagnostic sensitivity for IE by transesophageal echocardiography the clinical course in elderly persons would be still more severe than in younger patients.

PATIENTS

During the period from 1989 to 1993, 104 patients with 106 episodes of IE were treated at our university hospital. Three groups were compared: group A with 28 patients younger than 50 years, group B with 58 patients aged 50 to 70, and group C with 20 patients older than 70. Transesophageal echocardiography was performed in 78% of the patients; it was not performed in 22% of the patients with a conclusive transthoracic examination. The patients were followed up for an average of 25 months after the diagnosis.

RESULTS

No significant differences were observed among the age groups with respect to the possible source of infection, the frequency of positive blood cultures, and the type of infective organisms. Elderly patients more often had predisposing valvular conditions (eg, degenerative and calcified lesions and prosthetic valves), which decreased the sensitivity of transthoracic echocardiography to 45% as compared with 75% in group A. Transesophageal echocardiography improved the diagnostic yield by 45% in group C and by 47% in group B. Vegetations were smaller in group C and B as compared with group A, whereas other echocardiographic characteristics were similar. Fever and leukocytosis were less frequent in group C (55% and 25%, respectively) than in group A (82% and 61%, respectively). The interval between the onset of symptoms and the diagnosis of IE was similar in all groups. Elderly patients underwent surgical therapy as frequently (65%) as the other groups. The 1-year survival in group C (26%) was comparable with that in group A (22%) and group B (22%). The major determinant of survival was the occurrence of embolic complications.

CONCLUSION

Infective endocarditis in elderly patients caused less severe clinical symptoms than in young patients. The early diagnosis in elderly patients was facilitated by the high sensitivity of transesophageal echocardiography, which enabled the timely initiation of an appropriate medical and surgical therapy. This led to a clinical outcome similar to that for younger patients.

Diagnostic value of transesophageal compared with transthoracic echocardiography in suspected prosthetic valve endocarditis

To compare transthoracic (TTE) and transesophageal (TEE) echocardiography specifically in prosthetic valve endocarditis, 73 consecutive patients (age, 7 to 80 years) with 86 prostheses who had TTE and TEE for suspected endocarditis were analyzed retrospectively. Thirty-four patients proved to have endocarditis according to clinical criteria (pathoanatomical confirmation in 16), the remaining 39 served as controls. In the endocarditis group, a total of 38 (25 mitral, 13 aortic) prostheses were investigated. Vegetations were detected by TTE in 5 (all aortic) and TEE in 28 (20 mitral, 8 aortic) prostheses (13 vs 74%, p < 0.0001). An annular abscess was found on TEE in 1 mitral implant (3%). New perivalvular regurgitation was demonstrated on TTE in 7 (2 mitral, 5 aortic) and on TEE in 16 (10 mitral, 6 aortic) prostheses (18 vs 42%, p = 0.025). All in all, abnormalities suggestive of endocarditis were revealed on TTE in 10 (2 mitral, 8 aortic) and on TEE in 35 (23 mitral, 12 aortic) prostheses (sensitivity 26 and 92%, p < 0.0001). In the control group, TEE was false positive in 1 mitral prosthesis (specificity for TTE and TEE 100 and 97%, respectively; p = NS). These results indicate that TEE is markedly superior to TTE in prosthetic valve endocarditis. The diagnostic advantage is most evident in mitral prostheses. This holds for the detection of both morphologic changes and prosthetic malfunction.

[Sleep-related breathing disorders in patients with coronary heart disease]

INTRODUCTION AND AIM OF STUDY

Obstructive sleep apnoea (OSA) favours the development of arterial hypertension independently of body-weight and may thus have an effect on coronary heart disease (CHD). This study was undertaken to determine the prevalence of OSA in patients with CHD.

PATIENTS AND METHODS

From among all patients in whom left heart catheterization with coronary angiography had provided the diagnosis of coronary heart disease 50 were randomly chosen (47 men, 3 women; mean age 61 +/- 6 years) for further investigations. During the night airway flow, heart rate, body position and arterial oxygen saturation were recorded. The patients also had to fill in a questionnaire concerning tiredness during the day and any snoring. Polysomnography was performed in all those whose apnoea index (AI) was > 10/h.

RESULTS

25 patients had an apnoea index of > 10/h. Eight of them also had increased tiredness during the day. The patients with an AI > 10/h were significantly older than those in whom it was < or = 10/h (63.1 +/- 3.5 vs 58.4 +/- 7.2 years; P < 0.002) and also had a higher body-mass index (27.8 +/- 4.2 vs 25.7 +/- 3.0 kg/m2; P < 0.05). Polysomnography, done in the sleep laboratory, in 19 of the 25 patients with an AI > 10/h registered an average AI of 17.0 +/- 10.9 per hour sleep; in seven patients it was > 20/h.

CONCLUSIONS

The prevalence of obstructive sleep apnoea (OSA) is higher in patients with coronary heart disease (CHD) than in the healthy population. As OSA associated with a marked fall in nocturnal blood oxygen saturation and a rise in blood pressure may cause myocardial ischaemia, OSA should also always be considered when CHD is diagnosed.

Extensive intramural hematoma as the cause of failed coronary angioplasty: diagnosis by intravascular ultrasound and treatment by stent implantation

Dissections after coronary angioplasty are the major cause of ischemic events following percutaneous transluminal coronary angioplasty (PTCA) and may require additional measures such as intravascular stent deployment to relieve or prevent acute vessel closure. We describe a rare type of dissection after PTCA which caused a severe obstruction of the vessel segment proximal to the dilatation site without a visible dissection flap. Intravascular ultrasound was used to elucidate the morphology of the proximal vessel obstruction, which revealed an intramural hematoma extending into the proximal vessel segment as underlying mechanism. A Palmaz-Schatz stent was placed at the entry site of this hematoma, which led to the relief of the proximal vessel obstruction. After 3 months of anticoagulation therapy the repeat coronary angiography showed no significant restenosis. This demonstrates the unique insight into the underlying morphology of failed PTCA by intravascular ultrasound, which can help to manage even rare and unusual complications.

[Prognostic significance of changes in left ventricular diastolic function in follow-up of dilatative cardiomyopathy]

A total of 39 patients with idiopathic dilated cardiomyopathy (IDC) and sinus rhythm were examined for correlations between clinical course, systolic/diastolic cardiac function, and clinical status according to NYHA class (I-IV). Patients were divided in two groups: group 1 included survivors (n = 28, 49 +/- 11 years) and group 2 the nonsurvivors (n = 7) and transplanted patients (n = 4 transplanted; 48 +/- 10 years). Both groups were examined several times, and data at baseline were compared with those of the last examination. The follow-up period was about 3 years (group 1: 41 +/- 22 months, group 2: 24 +/- 13). Baseline conditions were defined at the time when the diagnosis of IDC was established. Diastolic cardiac function was evaluated by Doppler echocardiography parameters of early (VE) and late diastolic peak velocity (VA), the ratio of VE/VA and early deceleration time (EDT). Data for clinical symptoms (NYHA group 1: 2.5 +/- 0.9 vs. group 2: 2.7 +/- 1.3, NS) systolic [fractional shortening (FS) group 1: 0.17 +/- 0.06 vs. group 2: 0.16 +/- 0.06, NS], and diastolic function (VE, VA, VE/VA) showed no differences between the two groups. Only the EDT was significantly shorter in group 2 (group 1: 196 +/- 64 ms vs. group 2: 119 +/- 43 ms, P < 0.001) when diagnosis was established. During the follow-up period there was an improvement in both groups concerning NYNA class (group 1 from 2.5 +/- 0.9 to 1.9 +/- 0.7, P < 0.005; group 2 from 2.7 +/- 1.3 to 2.1 +/- 0.9, NS). There was a nonsignificant deterioration in systolic function in group 2 (FS, from 0.16 +/- 0.06 to 0.15 +/- 0.06, P = 0.07), which contrasted to an improvement in group 1 (from 0.17 +/- 0.06 to 0.20 +/- 0.08, P = 0.06). VE/VA increased in group 2 (from 1.24 to 1.67 +/- 1.21, P = 0.09) essentially due to a significantly increased VE (from 0.66 +/- 0.2 m/s to 0.85 +/- 0.27 m/s, P < 0.05). EDT remained shorter in group 2 (group 1.198 +/- 55 ms vs. 149 +/- 84 ms, P < 0.05). In conclusion, values of VE > 0.8 m/s, VE/VA > 1.6, and EDT < 150 ms during follow-up were predictors of poor prognosis in patients with IDC. Patients with a long EDT (> 150 ms) had a favorable prognosis for survival.

[The clinical importance of scintigraphy with the murine monoclonal antigranulocyte antibody BW 250/183 for the diagnosis of prosthesis-related endocarditis]

Thirty-eight patients (16 men, 22 women; median age 62.5, range 7 to 80 years) were enrolled in a prospective study to assess the clinical utility of radioimaging using the antigranulocyte antibody BW 250/183 in suspected valve endocarditis. Eighteen patients had prosthetic valve endocarditis according to clinical criteria (surgical confirmation in 8 patients), the remaining 20 patients served as controls. All patients underwent transthoracic and transesophageal echocardiography. Eight to 10 MBq of technetium-99m-labeled antibody were intravenously injected and single-photon emission computed tomography (SPECT) of the thorax was performed after 20 to 24 h. Echocardiography revealed pathological findings in 16 of 18 patients with endocarditis (sensitivity 89%) and was false positive in one of 20 control subjects (specificity 95%). Scintigraphy was true positive in 14 of 18 patients with endocarditis (sensitivity 78%) and false positive in three of 20 control subjects (specificity 85%). Scintigraphy was true positive in the patients with false negative echocardiography and vice versa (sensitivity for both methods combined 100%, specificity 80%). In all five follow-up patients, scintigraphy became negative parallel to clinical improvement. This suggests that scintigraphy indicates the floridity of the inflammatory process. In clinically suspected prosthetic valve endocarditis with equivocal echocardiographic findings, SPECT using the antigranulocyte antibody BW 250/183 may provide valuable additional diagnostic information.

[Doppler echocardiographic analysis of diastolic function in dilatative cardiomyopathy for the evaluation of its progression and prognosis]

The relationship between left-ventricular diastolic function and the course of the disease was investigated in a prospective study of 61 patients (44 men, 17 women; median age 51 [26-74] years) with dilated cardiomyopathy. The diastolic function was measured by recording the transmitral Doppler flow profile. During a follow-up period of 33 +/- 23 months, 15 patients died (twelve of progressive heart failure, three suddenly without previous heart failure). Cardiac transplantation was performed in four patients. The overall 1-year mortality rate was 14%. A "restrictive" Doppler echocardiographic filling pattern with a steep early-diastolic maximum and a small atrial filling component predominated in the patients who died from progressive heart failure or had a cardiac transplantation because of it. The deceleration of the early diastolic velocity maximum was clearly shorter than in the survivors (111 +/- 32 ms vs 194 +/- 62 ms; P < 0.001). In a Cox proportional hazard model the deceleration time was the best prognosticator, followed by the end diastolic left-ventricular diameter (LVD). The group of patients with a short deceleration time (< or = 140 ms) had a significantly higher 1-year mortality rate (28% [confidence interval 9-47%]) than those in whom it was longer (3% [0-11%]; P < 0.0001). Taking into account LVD it proved possible to identify a prognostically especially unfavourable group with a 1-year mortality rate of 53% (26-80%), characterized by a LVD > 70 mm and a deceleration time < or = 140 ms. Repeated echocardiography in 26 survivors and nine patients who died later or had been operated on showed that the deceleration time did not change significantly in the course of the disease. On the other hand, the systolic function, as measured by the echocardiographically determined shortening fraction, improved in the survivors (from 0.18 +/- 0.07 to 0.22 +/- 0.08; P < 0.05), but not in those who later on died.

[Bacterial endocarditis of the transvenous lead of an implantable cardioverter/defibrillator]

A 27-year-old patient carrying a transvenous ICD developed infective endocarditis more than 1 year after surgery. Staphylococcus aureus was isolated from blood cultures. A transesophageal echocardiogram revealed a mobile vegetation on a thrombus attached to the ICD lead in the right atrium. The ICD lead was removed by right anterolateral thoracotomy. This raises the issue of the risk of thrombus formation in patients with intravenous ICD leads and the associated susceptibility to infective endocarditis.