Fibrin-modulating nanogels for treatment of disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a pathological coagulopathy associated with infection that increases mortality. In DIC, excessive thrombin generation causes symptoms from formation of microthrombi to multiorgan failure; bleeding risks can also be a concern because of clotting factor consumption. Different clinical events lead to DIC, including sepsis, trauma, and shock. Treatments for thrombotic episodes or bleeding presentation in DIC oppose each other, thus creating therapeutic dilemmas in management. The objective of this study was to develop fibrin-specific core-shell nanogels (FSNs) loaded with tissue-type plasminogen activator (tPA) to treat the microcirculatory complications of DIC, which would facilitate targeted clot dissolution to manage microthrombi and the potential consumptive coagulopathy that causes bleeding. FSNs enhance formation of actively polymerizing clots by crosslinking fibrin fibers, but they can also target preexisting microthrombi and, when loaded with tPA, facilitate targeted delivery to lyse the microthrombi. We hypothesized that this dual action would simultaneously address bleeding and microthrombi with DIC to improve outcomes. In vivo, tPA-FSNs decreased the presentation of multiorgan microthrombi, recovered platelet counts, and improved bleeding outcomes in a DIC rodent model. When incorporated with human DIC patient plasma, tPA-FSNs restored clot structure and clot growth under flow. Together, these data demonstrate that a fibrinolytic agent loaded into fibrin-targeting nanogels could improve DIC outcomes.

WITHDRAWN: Prognostic Value of Pharmacologic Stress Echocardiography in Diabetic Patients

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 202-208, . The duplicate article has therefore been withdrawn.

Prognostic value of pharmacological stress echocardiography in diabetic patients

Our study was undertaken to assess the prognostic significance of pharmacological stress echocardiography in 325 diabetic patients. Pharmacological stress echocardiography was performed for diagnosis of coronary artery disease in 128 patients, and for risk stratification in 197 patients. Follow-up was 34 months. Cardiac-related death and non-fatal myocardial infarction were considered hard events. During the follow-up period, there were 38 deaths and 23 acute non-fatal myocardial infarctions. By univariate analysis, a pharmacological stress echocardiography positive response for ischaemia indicated an increased risk of cardiovascular death. However, by multivariate analysis, advanced age and peak ejection fraction <40% were the only independent predictors of cardiac death. The same peak ejection fraction (EF) <40%, rest wall motion score index and previous myocardial infarction were independent predictors of hard events. After dividing the population into two subgroups on the basis of EF at rest, only a peak EF <40% and a pharmacological stress echocardiography positive test were powerful independent predictors of cardiovascular mortality.

Right ventricular myocardial diastolic dysfunction in different kinds of cardiac hypertrophy: analysis by pulsed Doppler tissue imaging

BACKGROUND

Right ventricular (RV) chamber involvement has been demonstrated in hypertrophic cardiomyopathy (HCM) as well as in hypertensive left ventricular hypertrophy (LVH) but little is known about RV myocardial dysfunction occurring in these two pathologies. The aim of this study was to compare Doppler tissue imaging (DTI) of the right ventricle in HCM and LVH in relation to DTI of the left ventricle and Doppler standard of the RV and left ventricular (LV) inflow.

METHODS

Thirty controls, 20 hypertensives with LVH, and 23 patients with HCM involving the interventricular septum underwent Doppler echocardiography and pulsed DTI of the LV lateral mitral annulus and the RV lateral tricuspid annulus.

RESULTS

Patients with HCM had a higher blood pressure, septal thickness and LV mass in comparison with the other two groups. The RV wall thickness did not differ between HCM and LVH. The fractional shortening, but not the tricuspid annular plane excursion, was higher in HCM. After adjusting for the mean blood pressure, the Doppler-derived global LV and RV diastolic functions were more impaired in HCM than in LVH. Also the majority of DTI LV and RV diastolic measurements were altered more in HCM. At the RV tricuspid annulus, myocardial diastolic indexes were impaired in HCM and LVH in comparison with controls but the deceleration and relaxation times distinguished also HCM and LVH, being much longer in HCM (p < 0.0001). In the overall population, the RV myocardial relaxation time was positively related to the septal wall thickness and the RV wall thickness, even after adjusting for age, heart rate, diastolic blood pressure, fractional shortening and DTI mitral relaxation time.

CONCLUSIONS

The impairment of RV myocardial relaxation is much more evident in HCM than in LVH, its degree being independently associated with the extent of both the septal and RV wall thickness. Pulsed DTI may be useful to distinguish the extent of RV myocardial dysfunction in different types of cardiac hypertrophy.

Assessment of absolute risk of death after myocardial infarction by use of multiple-risk-factor assessment equations: GISSI-Prevenzione mortality risk chart

AIMS

To present and discuss a comprehensive and ready to use prediction model of risk of death after myocardial infarction based on the very recently concluded follow-up of the large GISSI-Prevenzione cohort and on the integrated evaluation of different categories of risk factors: those that are non-modifiable, and those related to lifestyles, co-morbidity, background, and other conventional clinical complications produced by the index myocardial infarction.

METHODS

The 11-324 men and women recruited in the study within 3 months from their index myocardial infarction have been followed-up to 4 years. The following risk factors have been used in a Cox proportional hazards model: non-modifiable risk factors: age and sex; complications after myocardial infarction: indicators of left ventricular dysfunction (signs or symptoms of acute left ventricular failure during hospitalization, ejection fraction, NYHA class and extent of ventricular asynergy at echocardiography), indicators of electrical instability (number of premature ventricular beats per hour, sustained or repetitive arrhythmias during 24-h Holter monitoring), indicators of residual ischaemia (spontaneous angina pectoris after myocardial infarction, Canadian Angina Classification class, and exercise testing results); cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, systolic and diastolic blood pressure, blood total and HDL cholesterol, triglycerides, fibrinogen, leukocytes count, intermittent claudication, and heart rate. Multiple regression modelling was assessed by receiver operating characteristic (ROC) analysis. Generalizability of the models was assessed through cross validation and bootstrapping techniques.

POPULATION AND RESULTS

During the 4 years of follow-up, a total of 1071 patients died. Age and left ventricular dysfunction were the most relevant predictors of death. Because of pharmacological treatments, total blood cholesterol, triglycerides, and blood pressure values were not significantly associated with prognosis. Sex-specific prediction equations were formulated to predict risk of death according to age, simple indicators of left ventricular dysfunction, electrical instability, and residual ischaemia along with the following cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, blood HDL cholesterol, fibrinogen, leukocyte count, intermittent claudication, and heart rate. The predictive models produced on the basis of information available in the routine conditions of clinical care after myocardial infarction provide ready to use and highly discriminant criteria to guide secondary prevention strategies.

CONCLUSIONS AND IMPLICATIONS

Besides documenting what should be the preferred and practicable focus of clinical attention for today's patients, the experience of GISSI-Prevenzione suggests that periodically and prospectively collected databases on naturalistic' cohorts could be an important option for updating and verifying the impact of guidelines, which should incorporate the different components of the complex profile of cardiovascular risk. The GISSI Prevenzione risk function is a simple tool to predict risk of death and to improve clinical management of subjects with recent myocardial infarction. The use of predictive risk algorithms can favour the shift from medical logic, based on the treatment of single risk factors, to one centred on the patient as a whole as well as the tailoring of medical interventions according to patients' overall risk.

Association between myocardial right ventricular relaxation time and pulmonary arterial pressure in chronic obstructive lung disease: analysis by pulsed Doppler tissue imaging

This study assessed right ventricular function in chronic obstructive lung disease and pulmonary hypertension by Doppler tissue imaging. Doppler echocardiography of the right ventricle and Doppler tissue imaging of the tricuspid annulus were performed in 63 subjects: 20 healthy controls, 20 with lung disease, and 23 with both lung disease and pulmonary hypertension. Two-dimensional tricuspid systolic plane excursion was lower in patients with pulmonary hypertension than in the other 2 groups. Doppler tricuspid inflow measurements distinguished patients in both of the diseased groups from the control subjects, but they did not differentiate patients with pulmonary hypertension from those without it. The ratio of peak E-wave to peak A-wave velocities derived by Doppler tissue imaging was significantly lower and the myocardial acceleration time longer in both groups of lung disease than in the control group. Only myocardial relaxation time distinguished the 3 groups (all P <.01); a gradual increase in time occurred, with the shortest time seen in controls, a longer time in patients with chronic obstructive lung disease without pulmonary hypertension, and the longest time in patients with lung disease and pulmonary hypertension. In the overall population including subjects with at least minimal tricuspid regurgitation, myocardial relaxation time was positively related to pulmonary systolic pressure. In conclusion, Doppler tissue imaging distinguishes subsets of patients affected by lung disease with or without pulmonary hypertension and identifies patients with different levels of pulmonary artery systolic pressure.

Impact of myocardial diastolic dysfunction on coronary flow reserve in hypertensive patients with left ventricular hypertrophy

BACKGROUND

The aim of the study was to assess the possible association, in hypertensive patients, between left ventricular myocardial diastolic dysfunction and coronary flow reserve (CFR) in relation to the presence of left ventricular hypertrophy (LVH).

METHODS

Twenty-eight untreated hypertensives (22 males, 6 females, mean age 53.1 years), free of coronary artery disease, were enrolled in the study. Standard Doppler echocardiography, color Doppler tissue imaging of the posterior septum during dobutamine stress and second harmonic Doppler of the distal left anterior descending coronary vessel, at baseline and after maximal hyperemia induced by dipyridamole, were performed. CFR was estimated as the ratio between hyperemic and baseline diastolic velocities. Hypertensives were divided into two groups according to the left ventricular mass index: 15 without LVH (left ventricular mass index < 51 g/m2.7) and 13 with LVH (left ventricular mass index > 51 g/m2.7). The two groups were comparable for sex prevalence, age, body mass index, baseline heart rate and blood pressure.

RESULTS

Color Doppler tissue imaging did not show any significant difference of both the baseline and high-dobutamine septal systolic peak velocities between the two groups. The ratio between myocardial early and atrial peak velocities (Em/Am ratio) was lower in patients with LVH, either at baseline (p < 0.01) or at high-dose dobutamine (p < 0.0001). Also, CFR was lower in the presence of LVH (p < 0.01). After adjusting for age, body mass index, left ventricular mass index, diastolic blood pressure and high-dose dobutamine heart rate by a multiple linear regression analysis, the high-dose dobutamine Em/Am ratio was an independent contributor of CFR in the overall hypertensive population (beta = 0.65, p < 0.0001) (cumulative r2 = 0.38, p < 0.0001).

CONCLUSIONS

The combined use of second harmonic Doppler and color Doppler tissue imaging identifies, in arterial hypertension, an association between myocardial diastolic properties and CFR, independent of the presence of LVH. In hypertensive patients free of coronary artery stenosis, left ventricular myocardial diastolic dysfunction may be a determinant in the impairment of the coronary microvessel vasodilation capacity or a marker of silent ischemia involving the microvascular circulation.

Surgery of rheumatic mitral stenosis: comparison of different techniques

OBJECTIVE

The breakthrough of percutaneous transvenous mitral commissurotomy (PTMC) has dramatically changed the indications for the surgical treatment of rheumatic mitral stenosis over the last decade. No recent studies comparing long-term results of PTMC, open mitral commissurotomy (OMC) and mitral valve replacement (MVR) with bileaflet prostheses are available in medical literature.

METHODS AND RESULTS

Between January 1991 and December 1997, 313 patients with pure and isolated rheumatic stenosis were treated in our department. One hundred and eleven patients underwent PTMC, 82 OMC and 120 MVR. There was no statistical difference (p>0.05) between the mortality rates of the three groups of patients. No cases of hospital mortality were observed in the patients who underwent PTMC and OMC, whereas two patients (1.6%) died within 30 days after MVR. Seven year actuarial survival results are: 95.41+/-2(SE)% (PTMC), 98.05+/-1% (OMC) and 92.82+/-33% (MVR) (p=NS). Freedom from embolism was 98.78+/-1% in PTMC, 98.78+/-1% in OMC and 92.52+/-2% in MVR (p>0.05); freedom from reoperation was 88.43+/-8% in PTMC, 96.35%+/-2% in OMC and 97.72+/-1% in MVR (p>0.05). The mean NYHA class at the end of follow-up was lower in OMC (1.14+/-0.3) versus PTMC (1.39+/-0.6) and MVR (1.41+/-0.71) (p=0.001).

CONCLUSIONS

Even though conservative techniques are the first option to consider in treating mitral valve stenosis, valve replacement with bileaflet prostheses no longer represents a limiting factor to survival and quality of life.

Long-term prognostic value of dipyridamole and dobutamine stress echocardiography in patients with known or suspected coronary artery disease

BACKGROUND

Pharmacological stress echocardiography (PSE) is increasingly used for cardiac risk stratification. Our study was undertaken to assess the long-term prognostic significance of PSE in patients with known or suspected coronary artery disease.

METHODS

We studied 622 consecutive patients who underwent PSE with either dobutamine or dipyridamole. Outcome was finally assessed in 448 patients for a mean period of 32.9 months. Death and hard events (death and myocardial infarction) were considered as endpoints.

RESULTS

PSE was positive for ischemia in 192 patients (42.9%). During the follow-up, 53 hard events occurred, including 28 deaths and 25 acute non-fatal myocardial infarctions. With multivariate analysis, peak ejection fraction < 40% appeared to be the strongest predictor of cardiac-related deaths and of hard endpoints (chi2 28.4 and 32.0, respectively). Peak wall motion score index revealed a strong predictive value of the same events (chi2 8.6 and 16.3, respectively). An ischemic pattern at PSE predicted a 2.4 higher cardiac mortality rate over a 5-year follow-up (9.4 vs 3.9%, p < 0.01; log rank 5.68), while patients with a peak ejection fraction < 40% had a cardiac-related mortality 4 times higher (16.3 vs 4.1%, p < 0.00001; log rank 21.16). Hard events occurred in 6.7% of patients with a negative test vs 18.8% of patients with a positive test (p < 0.001; log rank 15.8), while hard event rate was 8.4% in patients with a peak ejection fraction > 40% vs 27.5% in patients with a peak ejection fraction < 40% (p < 0.00001; log rank 38.64).

CONCLUSIONS

The ischemic response to PSE showed a sustained prognostic value for cardiac events, especially in patients considered at either intermediate or high risk on the basis of recognized clinical risk factors. However, only the evaluation of both descriptors of global left ventricular performance and of the extension of induced ischemia may better help to select patients at higher risk of cardiac death.

Involvement of right ventricle in left ventricular hypertrophic cardiomyopathy: analysis by pulsed Doppler tissue imaging

AIMS

This study uses pulsed Doppler tissue imaging to analyse right ventricular myocardial function and its interaction with left ventricle in hypertrophic cardiomyopathy involving ventricular septum.

METHODS AND RESULTS

Thirty-four patients with septal hypertrophic cardiomyopathy and 30 normal subjects, comparable for sex, age, body mass index and heart rate, underwent complete standard Doppler echocardiography and pulsed Doppler tissue imaging of both posterior septum and right ventricular free wall, calculating myocardial velocities and both systolic and diastolic time intervals. Except for peak velocity A, the other Doppler tricuspid inflow measurements were significantly impaired in hypertrophic cardiomyopathy, without changes of tricuspid annular systolic excursion. Right ventricular Doppler tissue imaging showed longer right ventricular myocardial relaxation time in hypertrophic cardiomyopathy than in controls (P<0.00001), without a significant difference from other myocardial diastolic and systolic measurements. In the overall population, Doppler measurements of right and left ventricular inflow were not significantly associated, while (with the exception of myocardial deceleration time) all the other myocardial systolic and diastolic measurements derived by tissue imaging were directly related to the homologous septal myocardial indexes. In addition, a significant inverse relation was found between septal wall thickness and myocardial relaxation index (right-left myocardial relaxation time/right ventricular relaxation time x 100).

CONCLUSIONS

This study shows the usefulness of pulsed Doppler tissue imaging to detect impairment of right ventricular myocardial function and to provide evidence about ventricular interaction in forms of hypertrophic cardiomyopathy which involve interventricular septum.

Pulsed Doppler tissue imaging in endurance athletes: relation between left ventricular preload and myocardial regional diastolic function

The aim of this study was to assess the effects of endurance training on myocardial regional systolic and diastolic function by pulsed Doppler tissue imaging (DTI). Twenty male water polo players and 20 male control subjects underwent standard Doppler echocardiography and pulsed DTI, performed in apical views by placing a sample volume on left ventricular (LV) basal septal and inferior walls. Age, body surface area, and blood pressure were comparable between the 2 groups, with lower heart rate in athletes (p <0.001). They had significantly increased LV mass index (due to both higher wall thickness and end-diastolic diameter), greater endocardial fractional shortening, higher transmitral early/atrial (E/A) peak velocities ratio. In athletes, DTI analysis showed significantly prolonged myocardial deceleration time and greater myocardial E/A peak velocity ratio of septal and inferior walls, whereas myocardial early peak velocity was increased (p <0.01) only at the inferior wall. In the overall group, we found univariate relations of septal and inferior E/A peak velocity ratio and myocardial deceleration time with LV mass levels, and, in particular, with the sum of wall thickness. By separate multivariate analyses, however, these relations disappeared, being dependent on heart rate degree. Another association found between LV end-diastolic diameter and myocardial early diastolic wave peak velocity of the inferior wall (r = 0.68, p <0.0001) remained significant (standardized beta coefficient 0.60, p <0.00001), even after adjusting for heart rate, body surface area, age, and stroke volume (R(2) = 0.71, p <0.00001). In conclusion, DTI is a useful tool for detecting regional changes in myocardial function induced by training, because athletes present with an improvement in diastolic passive properties of myocardium. The higher early diastolic velocity of the inferior wall and its relation to increased preload may represent an indicator of aerobic training, allowing quantification of the degree of LV adaptation to endurance exercise.

Reduction of coronary flow reserve non-invasively determined by transthoracic Doppler echocardiography as a predictor of left anterior descending coronary artery stenosis

BACKGROUND

The aim of this study was to evaluate if a reduced coronary flow reserve determined by transthoracic echocardiography alone or combined with contrast agents may represent a predictive index of significant left anterior descending coronary artery (LAD) stenosis.

METHODS

Thirty-four patients (mean age 59+/-9 years) undergoing coronary angiography for coronary artery disease were studied. Coronary stenosis was classified (according to visually determined percent narrowing) as severe (> 75%), moderate (40 to 75%) and mild (< 40%). Coronary blood flow velocities were recorded in each patient at baseline and after low-dose dipyridamole administration by use of a 3.5 MHz transducer with a machine equipped with second harmonic capability and nondirectional color Doppler software. Coronary flow reserve was defined as the ratio of hyperemic to basal diastolic peak velocity.

RESULTS

Adequate Doppler recordings in the LAD were obtained by transthoracic echocardiography in 26/34 patients (76%); the infusion of Levovist allowed for the visualization of LAD flow in a further 7 patients, with an overall feasibility of 97%. Coronary flow reserve was significantly higher in the group of patients with mild coronary lesions (2.3+/-0.3) than in patients with moderate (1.68+/-0.29, p = 0.0004) or severe (1.49+/-0.39, p = 0.0005) LAD stenosis.

CONCLUSIONS

By use of transthoracic echocardiography combined with contrast agents it is possible to visualize blood flow velocities in the LAD and to evaluate coronary flow reserve after dipyridamole infusion with a non-invasive approach. Combined with angiographic findings, this diagnostic approach could be useful in giving additional information to assess the functional significance of a stenotic coronary lesion.

[The ethics of appropriateness and the appropriateness of ethics. Comments on a current topic of which we know little and which we discuss even less]

Doctors and patients "alone on a desert island or in health market?". Antinomy is strongly paradoxical and provocative to invite us to think on two extreme lines of thinking modalities about fragile, variable, and changed relationship between doctors and patients in the light of the new health business administration. Probably, the balance point exists and may be found only introducing three main elements into the complex problem: patient in the middle, health care accuracy, ethical behavior, not only of the single doctor but also of the overall health system.

Noninvasive assessment of left and right internal mammary artery graft patency with high-frequency transthoracic echocardiography

OBJECTIVES

The aim of this study was (1) to visualize internal mammary artery grafts (IMAG) on coronary artery by transthoracic echocardiography and (2) to assess the patency of the grafts.

METHODS

Twenty-three patients (21 men, 56 +/- 6 years) with previous coronary artery bypass grafting were studied at baseline and after they underwent low-dose dipyridamole infusion. The parameters obtained were systolic (SPV) and diastolic (DPV) peak velocities and their ratio (DPV/SPV); the dipyridamole infusion to baseline ratio of DPV was an index of IMAG blood flow reserve (FR). Two groups of patients were selected at baseline: group A, (n = 12) with a DPV/SPV >1, and group B (n = 11), with a DPV/SPV <1.

RESULTS

The IMAG was identified in all patients. Intraluminal flow signals obtained with pulsed wave Doppler showed a biphasic pattern (1 systolic and 1 diastolic wave). After dipyridamole infusion was administered, flow velocities increased in 11 of 12 patients in group A and in 5 of 11 patients in group B. In group A the DPV/SPV increased from 1.79 +/- 0.47 to 1.8 +/- 0.43 (P = not significant), and the FR was 1.8 +/- 0.4. In group B the DPV/SPV increased from 0. 46 +/- 0.05 to 0.5 +/- 0.09 (P = not significant), and the FR was 1. 3 +/- 0.41. Coronary angiography showed the graft patency in all patients in group A and in 5 patients in group B with increased flow velocity after dipyridamole infusion. In the identification of graft stenosis at baseline, DPV/SPV showed 100% sensibility and 58% specificity, and FR showed 92% sensibility and 84% specificity.

CONCLUSION

Doppler echocardiographic evaluation of the IMAG is a simple noninvasive method to assess the functional impairment of the vessel.

[Therapy with nitro derivatives and the development of tolerance: a comparative study with stress ECG and dipyridamole ECG]

The ECG stress test represents the most commonly-used technique to evaluate the occurrence of nitroglycerin tolerance. It acts by increasing cardiac O2 demand with resulting insufficient blood flow through a stenotic coronary artery and development of cardiac ischemia. However, other tests are also potentially suitable, such as the ECG-dipyridamole test. The aim of the present study was to evaluate the acute response of ECG-dipyridamole and ECG-stress tests to nitroglycerin. In particular, the development of nitroglycerin tolerance during chronic therapy was evaluated with both tests in patients with stable angina. Eleven patients (8 men and 3 women) with CAD proven by a previous coronarography, a known history of stable angina within at least six months and a positive response to both the tests were studied. At the end of a seven-day wash-out period, all patients were positive to initial ECG-stress and ECG-dipyridamole tests; after 3 days a new evaluation was carried out (Effort 0 and Dip 0) and this confirmed the previous results. We performed a randomized trial in two phases: acute and chronic therapy. In the acute phase, all patients underwent ECG-stress and ECG-dipyridamole tests (Effort 1 and Dip 1) in a randomized fashion one day apart, four hours after administration of a 10 mg/24 h nitroglycerin patch. The chronic phase consisted of 25 days of continuous treatment with a nitroglycerin patch. The two tests (Effort 2 and Dip 2) were always repeated after four hours of the morning therapy. Nitroglycerin does not modify the hemodynamic response to dipirydamole in either acute or chronic treatment. Lastly, our data confirm the efficacy of nitroglycerin on stress and dipyridamole tests after acute administration. Nitroglycerin tolerance is confirmed by both tests although with different patterns. ECG stress test showed nitroglycerin tolerance because time to ischemia and max ST deteriorated during chronic therapy. Moreover, the ECG-dipyridamole test showed nitroglycerin tolerance because five patients with a negative acute test (Dip 1) became positive during chronic therapy (Dip 2).

Myocardial diastolic impairment caused by left ventricular hypertrophy involves basal septum more than other walls: analysis by pulsed Doppler tissue imaging

OBJECTIVE

To assess regional diastolic function in patients with hypertension with or without left ventricular hypertrophy using Doppler tissue imaging, a new tool that analyzes myocardial wall motion 'on-line'.

METHODS

Ten normotensive subjects, 20 hypertensive patients without hypertrophy and 20 with hypertrophy (left ventricular mass index >50 g/m2.7), all men, underwent Doppler echocardiography and Doppler tissue imaging, which was performed in apical view by placing pulsed sample volume at the level of the basal and middle septum, basal and middle lateral wall, and infero-posterior wall. Peak velocities and time-velocity integrals of myocardial early (Em) and late (Am) waves and their ratios, regional deceleration time and regional relaxation time were measured in each segment.

RESULTS

Transmitral peak E/A ratio was 1.37 in normotensive subjects, 1.01 in hypertensive patients without hypertrophy and 0.77 in those with hypertrophy (P < 0.00001). The myocardial diastolic indexes derived by Doppler tissue imaging worsened at all levels in hypertensive patients without hypertrophy compared with normotensive subjects. In hypertensive patients with hypertrophy, the majority of myocardial diastolic indexes were further impaired at the basal septal level, but only marginal differences were found in other regions, compared with indexes in hypertensive patients without hypertrophy. The main diastolic indexes were found, using separate intra-group analyses, to be more compromised at the basal septum than at other levels only in hypertrophic hypertensive patients. The prevalence of regions having peak Em/Am ratios < 1 increased significantly from normotensive subjects to hypertensive patients without hypertrophy, but not significantly from these to the hypertrophic group. Among pooled hypertensive patients, after adjusting for heart rate and diastolic blood pressure using multivariate models, the septal wall thickness was shown to be an independent determinant of the diastolic indexes of the basal and middle septum.

CONCLUSIONS

In hypertensive patients without hypertrophy, diastolic dysfunction is uniform along the ventricular walls, whereas in those with hypertrophy it is more evident at the basal septal level than in other walls. Overall among hypertensive patients, the diastolic properties of the interventricular septum worsen as the thickness of the septal wall increases, in the presence and in the absence of hypertrophy.

Use of pulsed Doppler tissue imaging to assess regional left ventricular diastolic dysfunction in hypertrophic cardiomyopathy

In this study, regional diastolic patterns and their relations with transmitral Doppler inflow were investigated in hypertrophic cardiomyopathy (HC) by pulsed Doppler tissue imaging (DTI). Doppler echocardiography and DTI of basal septum and lateral wall (apical 4-chamber view) were performed in 20 patients (15 men and 5 women) with HC and in 10 healthy subjects (7 men and 3 women). Diabetes, hypertension, coronary artery and valvular disease, mitral regurgitation, New York Heart Association functional classes III to IV, sinus tachycardia, atrial fibrillation, and inadequate echocardiograms were exclusion criteria. Peak velocity and time-velocity integral of early and late waves and their ratios, and deceleration and isovolumic relaxation times were determined by standard Doppler and by DTI at the septal and lateral wall levels. The 2 groups were comparable for age, heart rate, blood pressure, and ejection fraction. Transmitral peak velocity and time-velocity integral E/A ratios were reduced (both p <0.05) and deceleration and isovolumic relaxation times prolonged (both p <0.00001) in HC. Septal DTI showed lower peak velocity and time-velocity integral e/a ratios (p <0.00001 and p <0.001, respectively) and lengthened regional deceleration (p <0.01) and isovolumic (p <0.001) relaxation times. DTI of the lateral wall showed a prolongation of deceleration and isovolumic relaxation times (both p <0.01). By dividing HC according to transmitral E/A, 8 patients with E/A <1 had lower DTI septal e/a ratio (p <0.01) and prolonged septal deceleration and isovolumic relaxation times (both p <0.01) but no changes in DTI pattern of lateral wall than 12 patients with E/A > 1. In conclusion, DTI is useful and complementary to standard Doppler imaging to characterize diastolic properties in HC, reflecting a typical pattern of intramyocardial impaired relaxation at the level of hypertrophied septum and also providing information about the degree of this regional impairment. The lateral wall presents minor changes in diastolic times, which indicate how diastolic asynchrony is not confined to the hypertrophied segment in HC.

[Early detection of heart involvement using serial cardiologic controls in the follow-up of patients with AIDS]

New effective therapies have been producing longer survival times for HIV-patients. Thus non-infectious complications of late stage of HIV infection (such as the development of left ventricular dysfunction) have emerged; in fact cardiac involvement has been identified frequently at autopsy and is described in 80% of patients with acquired immunodeficiency syndrome (AIDS) as an evidence of the virus cardiotrophism, while clinical findings of left ventricular dysfunction were only detected in about 15% of the patients. It is possible that the development of heart failure had been underestimated in those years; in fact signs and symptoms of cardiac involvement had been often misinterpreted as the results of non cardiac causes (pulmonary failure or infections) also determining a delay in the beginning of cardiac therapy. The aim of this study was to follow 16 human immunodeficiency-virus positive patients during a 3-year period to evaluate the usefulness of early detection of heart failure in order to start a specific therapy as soon as possible. The follow-up consisted of a clinical and electrocardiographic control every 4 months. Echocardiography was carried out when involvement of the cardiac muscle was suspected. During the follow-up we could reveal an early involvement in 5/16 patients (31.2%) and in 2 of them (40%) early therapy caused clinical and echocardiographic regression of left ventricular dysfunction. The present study demonstrates that periodical clinical and echocardiographic controls are useful in patients with HIV infection.

Diagnostic value of transesophageal echocardiography in the assessment of congenitally corrected transposition of the great arteries in adult patients

This study was designed to evaluate the relative diagnostic values of transthoracic (TTE) and transesophageal (TEE) echocardiography in the assessment of congenitally corrected transposition of the great arteries in adult patients. Twelve patients (mean age 29 years, range 21 to 39 years) with congenitally corrected transposition of the great arteries underwent both TTE and TEE examinations to assess this complex cardiac lesion. Of the 12 patients evaluated, situs solitus and inversus were present in 8 and in 4 patients, respectively. TTE correctly identified atrial situs in only 10 patients, whereas TEE, directly evaluating the morphologic features of either appendage, correctly determined situs in every patient. In all 11 patients with intact inlet ventricular septum, the spatial relationship between the septal leaflets of atrioventricular valves was correctly evaluated by both techniques. However, the chordal attachments of both valves were clearly elucidated by TEE in all patients, whereas TTE could obtain images of these in only three patients. TTE was able to evaluate the discordant connection between the right ventricle and the anterior vessel (aorta) in 10 patients, whereas the connection between the left ventricle and the posterior vessel was clearly shown only in 7 patients. Transesophageal longitudinal planes better elucidated these two discordances in all patients irrespective of the position of the heart in the chest and atrial situs. Four patients had an associated ventricular septal defect (inlet defect in one, perimembranous in two, and muscular in one); the inlet defect was unrestrictive and could be easily detected by either imaging technique, whereas the membranous was detected by TTE and by the horizontal transesophageal planes; the muscular defect was recognized only by TTE. Three patients had an associated pulmonary stenosis; Doppler transthoracic echocardiography showed a left outflow peak gradient of 100 mm Hg in two patients and of 80 mm Hg in one but failed to adequately assess the morphologic features of the stenosis, whose features were clearly visualized by transesophageal longitudinal planes in all patients. In conclusion, in our experience TEE is superior to transthoracic imaging in studying congenitally corrected transposition of the great arteries in adult patients; the horizontal plane is best suited to the evaluation of atrial situs and the atrioventricular junction, whereas the longitudinal plane is most valuable in the study of the morphologic features of the ventriculoarterial connections. These findings should be equally applicable to multiplane transesophageal studies.

Regional diastolic function in normotensive versus hypertensive subjects: comparison using Doppler myocardial imaging

BACKGROUND

Pulsed Doppler myocardial imaging (DMI) is a new technique that makes it possible to obtain an on-line quantitative assessment of wall motion in different myocardial segments through sample-volume placement. Therefore, this tool is suitable for identifying changes in regional diastolic function in uncomplicated arterial hypertension. In this study, we examined standard Doppler-derived indexes of global left ventricular diastolic function and regional diastolic parameters obtained by pulse-wave DMI in a population of hypertensive patients, comparing them with the indexes found in a control group of normotensive subjects.

METHODS

Thirty-six patients with uncomplicated hypertension and 10 normotensive subjects (all males) underwent a complete Doppler echocardiographic examination and a pulsed DMI assessment of 4 different myocardial segments: basal and middle septum, basal and middle lateral wall.

RESULTS

The 2 groups were comparable in age and heart rate, but body mass index, systolic and diastolic blood pressure and left ventricular mass index were higher in hypertensives. All of the transmitral diastolic measurements were impaired in hypertensives, without any difference in the Doppler indexes of global systolic function. While there were no changes in the regional systolic measurements, most of the DMI parameters for diastolic function changed significantly in all 4 of the segments examined, with a greater statistical difference at the basal and middle septum. We found a relationship between the number of segments involved in the diastolic dysfunction (ie with peak velocity E/A < 1) and the degree of impairment of the transmitral E/A ratio solely in the hypertensive population.

CONCLUSIONS

DMI is a useful tool for distinguishing left ventricular diastolic function in hypertensive patients and it provides information about the extent and degree of diastolic impairment in different myocardial segments. The basal and middle septum present more evident diastolic alterations. Minor but significant changes can be identified at the basal and middle lateral walls. The higher the prevalence of the myocardial segments involved in diastolic dysfunction, the greater the impairment of the global diastolic function of the left ventricle will be.

[Value of transesophageal echocardiography in the diagnosis of paravalvular aortic abscess]

Paravalvular abscesses are a serious complication of aortic endocarditis. Echocardiography is the method of choice for the visualization of the valve-attached vegetations, however the detection of endocarditis-associated abscesses by transthoracic approach is extremely difficult. Recently transesophageal echocardiography has been proved as an excellent tool to correctly detect these lesions. We report on two patients with endocarditis-associated abscesses in whom transesophageal echocardiography allowed us to diagnose paravalvular abscesses not recognized by transthoracic echocardiography; furthermore in the first patient, performing two successive transesophageal examinations before and after antibiotic therapy, we could follow the evaluation of aortic abscess which became a fistula draining into the left ventricular outflow tract. In conclusion these two cases suggest that transesophageal echocardiography should be always performed in patients suspected or known to have endocarditis and that a following examination is indicated to assess any evolving echocardiographic finding.

[Reference values for the echocardiographic calculation of left ventricular mass in normal children between the ages of 0 and 6]

BACKGROUND

Echocardiographic assessment of left ventricular mass (LVM) and mass/volume ratio (LVM/V) is an accurate method for evaluating left ventricular hypertrophy. However, reference values for LVM and left ventricular volume (V) in children under 6 years of age have not been well established.

METHODS

Therefore, we evaluated 106 consecutive children (60 males, 46 females, mean age +/- SD 35 +/- 28 months, range 0-72) free of cardiovascular disease by clinical, electrocardiographic and echocardiographic examination. LVM and V were determined by M-mode echocardiography.

RESULTS

The 5th and 95th percentile values of LVM were: 7 and 21 grams for infants aged 0 to 6 months; 13 and 32 grams for 7 to 24 months; 23 and 41 grams for 25 to 36 months; 23 and 59 grams for 37 to 48 months; 30 and 60 grams for 49 and 60 months; 36 and 98 grams for 61 and 72 months. The 5th and 95th percentile values of V were: 4 and 20 ml for infants aged 0 to 6 months; 12 and 36 ml for 7 to 24 months; 16 and 43 ml for 25 to 36 months; 20 to 55 ml for 37 to 48 months; 27 to 64 ml for 49 to 60 months; 39 to 74 ml for 61 to 72 months. The 5th and 95th percentile values of M/V ranged between 1 and 2.3 for infants aged 0 to 6 months, and 0.7-1.2 for those aged 61 to 72 months. LVM, V and LVM/V were significantly (p < 0.0001) related to age, height, weight and body surface area, but were unrelated to gender.

Intravenous amiodarone in acute anterior myocardial infarction: a controlled study

A randomized, single-blind controlled study intended to assess the potential benefits of intravenous amiodarone in anterior myocardial infarction is presented. Three hundred nineteen patients entered the study, 159 received amiodarone infusion, and 160 received glucose-insulin-potassium (GIK) infusion. Basal characteristics were similar in the two experimental groups, who were randomized on a consecutive basis. Exclusion criteria were shock or pulmonary edema, hypotension, inferoposterior infarction, bradycardia, antrioventricular block, severe diabetes, and other major diseases. Patients aged 27 to 70 years, with a Q-wave anterior infarction, initiated 12-40 hours earlier at the time of admission, entered the trial. Other entry criteria were heart rate higher than 80 beats/min and systolic blood pressure higher than 100 mmHg. Amiodarone was administered in saline infusion 10-20 mg/kg, within 4 to 10 hours, through a central vein. GIK infusion consisted of 150-300 g of glucose, 25-50 IU of insulin, and 80-120 mEq of KCl in 1000 cc of water at a rate of 1.5-2.0 ml/g/hour. Both groups received digitalis, nitrates, sedatives, and diuretics as needed. Although individually the major endpoints of death, reinfarction, and sustained supraventricular and ventricular arrhythmias did not differ significantly, each was less in the amiodarone group than in the control, and the sum of all adverse events was significantly lower for the amiodarone patients (p less than 001). Heart failure and conduction disturbances were not different in the two groups. This study shows that amiodarone, with its vasodilating and antiarrhythmic properties, may be beneficial in acute anterior infarction, but further studies on larger populations will be necessary in order to show a reduction of mortality rate.

[2-dimensional echocardiography in infarct of the right ventricle: correlation with clinical, hemodynamic and scintigraphic findings]

Right ventricular wall motion was studied in 18 patients hospitalized for acute myocardial infarction by means of cross-sectional echocardiography. Diagnosis of right ventricle myocardial infarction was made on the basis of clinical, electrocardiographic, hemodynamic criteria, respectively present in 66%, 80% and 66% of our patients. Echocardiographic criteria of right ventricle infarction were: 1) right ventricle dilatation; 2) segmental or global right ventricle wall motion abnormalities; 3) paradoxical motion of interventricular septum; 4) tricuspid insufficiency; 5) inferior cava vein dilatation with paradoxical respiratory pattern. Seven patients were studied by means of radionuclide techniques, that confirmed right ventricle infarction in 6 patients. We conclude that: 1) the most accurate echocardiographic views for right ventricle wall motion study are subcostal views and, in particular, the subcostal short-axis (OAS 60 degrees); 2) those patients (12/18) with a specific echocardiographic pattern for right ventricle infarction presented a specific clinical and hemodynamic picture; 3) those patients (6/18) with only segmental right ventricular wall motion abnormalities presented an aspecific clinical and hemodynamic picture. Moreover we showed that an improvement of right ventricular wall motion was observed in some cases within a few days of the infarction. Further observations are needed to assess the frequency and late prognosis of acute right ventricle infarction.

Prevention of platelet hyperaggregation during coronary angiography

The authors previously reported an increase in platelet aggregration in the days after coronary angiography, accompanied at times by worrying cardiovascular disorders (ventricular fibrillation in one case, death in two others). In the present study, ten patients received a platelet antiaggregating drug (ticlopidin) 5 days before their coronary angiography. No significant changes were detected in the test for circulating platelet aggregates (CPA test) in these patients.

[Basal left anterior oblique projection in 2-dimensional echocardiography: its usefulness in defects of the atrioventricular septum]

The defects of the A-V septum have been recently classified into classes with separate orifices and classes with common orifice on the basis of the presence or not of a tissue tongue which joins the two bridging anterior and posterior leaflets as single differential feature. The diagnostic usefulness of the subxiphoid projection by conventionally called left oblique anterior basal has been evaluated. It indicates in a single plan-section the two bridging leaflets together with the connecting tongue. In 18 cases of defect of A-V septum echo-angiographic correlation was made. The 2D-echo diagnosed in 10 cases a defect of A-V septum with common orifice and in 8 cases a defect of A-V septum with separate orifices. On the contrary the angiocardiography pointed out in 9 cases a defect of A-V septum with separate orifices. Ten of the eighteen patients examined underwent an operation, which has always confirmed the echocardiographical diagnosis; even in the unique case of echo-angio disagreement the diagnosis of 2D-echo was confirmed. Therefore we propose the above-mentioned projection in order to obtain a more accurate non invasive definition in the defects of A-V septum.

10-year follow-up of patients with intraventricular conduction defects associated with myocardial infarction: the meaning of QRS duration

The 10-year survival rate of 66 patients discharged after an acute myocardial infarction associated with intraventricular conduction delay is reported. The whole population under study consisted of 321 patients followed for 10 years or until death. In 46 patients (69.7%) the conduction delay was a definite complication of infarction, in 15 (22.7%) it preceded the acute event and in 5 (7.5%) the time of onset was undetermined. Mortality in the presence of a conduction delay was 74.2% in 10 years vs 39.2% in its absence (p less than .001). Death was sudden in 41.6% of fatalities when a conduction defect was present and 28% in its absence (p less than .01). The 10-year survival was 55% in patients with conduction defects and QRS less than .12 sec duration, 23.8% if QRS was between .12 and .14 sec, and 4% when QRS duration was greater than .14 sec. 72% of patients of this latter group was in NYHA class 3 or 4, whereas 70% of patients with QRS less than .12 sec and 47% of patients with QRS .12 to .14 sec were in class 1 or 2. These data show that long-term prognosis of conduction delay associated to myocardial infarction is poor and stratification of risk of death is possible among these patients on the basis of QRS duration.

Exercise-induced arrhythmias: angiographic correlation and follow-up

The meaning of exercise-induced arrhythmias was studied in 409 patients who underwent a maximal treadmill test, coronary and ventricular angiography and were followed for 31 +/- 10.6 months. The original population consisted of 1720 patients, of whom 520 were assigned to a group of known or strongly suspected coronary artery disease (Group I) and 1200 were assigned to a group with low likelihood of coronary artery disease (Group II). This division was based on age, history and symptoms. Two hundred and forty-seven (47.5%) patients of group I and 218 (18%) of group II developed ventricular premature beats during the exercise test or the recovery period. The test was positive in 378 (72.6%) patients of group I and in 190 (15.8%) of group II. A complete invasive angiographic study was performed in 233 (44%) patients of group I and 176 (14.6%) of group 2. Exercise-induced ventricular premature beats (VPBs) predicted neither coronary anatomy nor subsequent coronary or surgical events, but a weak relationship was observed with a lower ejection fraction among group I patients. On the other hand, a positive test was predictive of coronary anatomy in both groups and of coronary events in group I. We conclude that, despite a higher prevalence of exercise-induced ventricular premature beats among patients with definite coronary artery disease, an exercise test presenting ventricular premature beats as the only abnormality should not be classified as positive. Patients with such results require further investigation.

[Balloon occlusion aortography in the angiographic study of pulmonary atresia with interventricular defect]

Balloon aortography is a new technique for the angiographic study of pulmonary atresia with ventricular septal defect. A Swan-Ganz angiographic catheter is employed, whose balloon is inflated to stop blood flow in the descending aorta, thus ensuring the opacification of the pulmonary circulation. By this method we have studied 18 patients. Anatomic details of the pulmonary arterial circulation were obtained in all. No complications occurred. Balloon aortography is a simple and safe technique for the routine study of patients with pulmonary atresia and ventricular septal defect, whereas selective injection in collateral arteries or pulmonary veins, which carries more risk and is more complex, should be adopted only in selected cases.