Cardiometabolic predictors of quantitative high-risk plaque features in a diverse patient population

Background/Introduction

Little is known about the prevalence of high-risk plaque features or cardiometabolic predictors in diverse patient populations with underrepresented minorities, in the setting of stable chest pain.

Purpose

The goals of our study are to 1) describe plaque characteristics in a diverse patient population with underrepresented minorities and 2) characterize cardiometabolic risk factors associated with high prevalence of high-risk quantitative low attenuation noncalcified plaque (LDNCP) burden.

Methods

Our study included patients with chest pain undergoing CCTA between June 2016 and October 2021 for stable chest pain, who had a complete cardiometabolic panel including lipoprotein(a) and lipid panel, and at least one blood pressure recording before CCTA. Patients with prior PCI or CABG where excluded. CACS was performed before CCTA as per Agatston method and quantified in Agatston Units (AU). Stenosis was graded as per SCCT guidelines by cardiologists and radiologists with level 3 cardiac CT expertise. Plaque measurements were performed using previously validated semiautomated software (AutoPlaque version 2.5) in all patients with CAD-RADS >0 by expert readers blinded from patients' characteristics. Coronary atherosclerotic plaque volumes were measured. Independent predictors for plaque on CCTA among patients were examined using Wilcox multivariate logistic regression.

Results

A total of 227 consecutive patients were included in our study (see table; age 55.00 [47.50–62.00] years, 63% female, 16% diabetes, 44% hypertension, 40% hyperlipidemia and 32% with current or previous smoking history). Majority of patients were Hispanic (64%) and the rest were Black (27%), White (6%) and Asian (3%).

Patients with LDNCP burden >4% were older (60.00 [52.00–66.50] vs 53.00 [43.75–61.00]; p<0.001), more likely to be diabetic (27.7 vs 11.5%; p=0.005), hypertensive (67.7 vs 33.8%; p<0.001), hyperlipidemic (64.6 vs 29.9%; p<0.001) and present smokers (31.3 vs 13.9%; p=0.003). Almost all patients (63/67) with LDNCP burden >4% had non-obstructive disease (CAD-RADS<4).

Patient with LDNCP burden >4% were more likely to be on statin therapy (46.0 vs 30.4%; p=0.041). There was no differences in ethnicity, hemoglobin A1C, TC, LDL-C, HLD-C, TGs, lipoprotein(a), SBP or DBP.

By logistic regression analysis, age (OR [CI]: 1.06 [1.01–1.08]), hypertension (2.20, [1.06–4.63]) and hyperlipidemia (2.73 [1.37–5.47]) increased the likelihood of LDNCP burden >4%, but not Lipoprotein (a)>175 nmol/L (OR [CI]: 1.07 [0.48–2.31].

Conclusions

In our cohort of patients with high number of unrepresented minorities presenting with stable chest pain, almost all patients (94%) with LDNCP burden >4% had non-obstructive CAD (CAD-RADS<4). There were no differences in prevalence of LDNCP or CAD-RADS among different ethnic groups. Age, hypertension and hyperlipidemia, were the cardiometabolic factors related to LDNCP burden >4%.

Funding Acknowledgement

Type of funding sources: None.

Amyloidosis-related echo features and mortality in patients with multiple myeloma

Background/Introduction

Patients with multiple myeloma (MM) are at increased risk of developing AL amyloidosis. It was determined by screening fat pad and bone marrow biopsy that 38% MM patients had amyloidosis at time of diagnosis and the majority were asymptomatic (1). However, whether amyloidosis-related echo features in MM affect survival remains unknown (1, 2).

Purpose

The goals of our study are to: 1) characterize prevalence of amyloidosis-related echo features in patients with multiple myeloma, 2) investigate whether decrease in longitudinal strain affect survival outcomes.

Methods

Patients diagnosed with MM between Jan 1, 2000 and Dec 31, 2017 at our institution were identified through Clinical Looking Glass. Those with echo within 1 year after myeloma diagnosis and left ventricular ejection fraction (LVEF) greater than 40% were included. Global longitudinal strain (GLS) and LVEF measurements were done using EchoGo (Ultromics, Oxford, UK). The average of GLS obtained from apical 4-chamber and apical 2-chamber views was used for analysis, with decreased GLS defined as absolute value less than 18%. Statistical analysis was conducted with STATA13, using Chi square test and Kruskal-Wallis for univariable analysis and Cox regression model for survival analysis.

Results

From a total cohort of 909 patients, 252 met inclusion criteria, of which 59 (23.4%) patients had decreased average GLS (see Table 1). Patients' mean age was 63±11 years, 44.8% were male and most were Black (42.7%) and the rest Hispanic (33.3%) and White (7.9%). Median follow up time was 4.25 years. The group with decreased GLS had lower percentage of females (22% vs 51.8%, p<0.01), higher percentage of previous MI (11.9% vs 1.6%, p<0.01) and more prior diagnosis of heart failure (20.3% vs 1.6%, p<0.01).

Among patients with decreased GLS, five-year mortality rate was 63.3% compared to 46.0% in those with preserved GLS (p<0.036). Median survival time was 3.9 years among those with reduced GLS and 4.3 years in those without (see Figure 1; p<0.01). Reduced GLS correlated with decreased survival (HR 1.6, p=0.03) even after adjusting for demographic variables (age, gender, race), history of MI, history of CHF, Charlson comorbidity index, myeloma RISS stage, and LVEF (≥50% vs 40–50%).

Forty-seven (18.6%) patients had end diastolic inter-ventricular septum (IVSd) thickness ≥1.2cm. Median GLS in patients with increased IVSd thickness was 19% compared to 21% in those without (p=0.01). Nine patients had the apical sparing strain pattern for amyloidosis.

Total of 158 patients had bone marrow specimen stained with Congo-red with 7 (4.4%) testing positive. Median GLS was 19% in the group staining positive for Congo-red compared 21% in the group with negative stain (p=0.03).

Conclusions

Decrease in GLS on baseline echo correlates with increased mortality in patients with MM and may be due to subclinical cardiac amyloidosis.

Funding Acknowledgement

Type of funding sources: None.

Real-world use of mycophenolate mofetil in inflammatory bowel disease: Results from the ENEIDA registry

BACKGROUND

Studies to evaluate the use of mycophenolate mofetil (MMF) in inflammatory bowel disease (IBD) are limited after the appearance of biological treatments.

AIMS

Our primary objective was to evaluate the effectiveness and safety of MMF in IBD.

METHODS

IBD patients who had received MMF were retrieved from the ENEIDA registry. Clinical activity as per the Harvey-Bradshaw Index (HBI), partial Mayo score (pMS), physician global assessment (PGA) and C-reactive protein (CRP) were reviewed at baseline, at 3 and 6 months, and at final follow-up. Adverse events and causes of treatment discontinuation were documented.

RESULTS

A total of 83 patients were included (66 Crohn's disease, 17 ulcerative colitis), 90% of whom had previously received other immunosuppressants. In 61% of patients systemic steroids were used at initiation of MMF, and in 27.3% biological agents were co-administered with MMF. Overall clinical effectiveness was observed in 64.7% of the population. At the end of treatment, 45.6% and 19.1% of subjects showed remission and clinical response, respectively. MMF treatment was maintained for a median of 28.9 months (IQR: 20.4-37.5).

CONCLUSION

Our study suggests, in the largest cohort to date, that MMF may be an effective alternative to thiopurines and methotrexate in IBD.

Evaluation of the detection of Mycobacterium tuberculosis with metabolic activity in culture-negative human clinical samples

Mycobacterium tuberculosis is assumed to remain in a quiescent state during latent infection, being unable to grow in culture. The aim of this study was to evaluate the detection of viable but non-cultivable bacilli with metabolic activity in human clinical samples using a procedure that is independent of the immunological status of the patient. The study was performed on 66 human clinical samples, from patients subjected to routine diagnosis to rule out a mycobacterial infection. Specimens from pulmonary and extra-pulmonary origins were verified to contain human DNA before testing for M. tuberculosis DNA, rRNA and transient RNA by real-time quantitative PCR. Clinical records of 55 patients were also reviewed. We were able to detect viable but non-cultivable bacilli with a metabolic activity in both pulmonary and extra-pulmonary samples. Mycobacterium tuberculosis RNA was detected in the majority of culture-positive samples whereas it was detected in one-third of culture-negative samples, 20% of them showed metabolic activity. Amplifications of the ftsZ gene and particularly of the main promoter of the ribosomal operon rrnA, namely PCL1, seem to be good targets to detect active bacilli putatively involved in latent infection. Moreover, this last target would provide information on the basal metabolic activity of the bacilli detected.

Alignment of multiple complete genomes suggests that gene rearrangements may contribute towards the speciation of Mycobacteria

To more accurately define the taxonomic relationships among species belonging to the genus Mycobacterium we have applied and compared three complete genome sequence comparison procedures to existing systems. These included a nucleotide sequence comparison including both coding and no-coding regions of the genome and two genomic-order comparisons using MAUVE and M-GCAT software to provide comparative gene synteny. These methods clearly differentiated a panel of genomes from reference mycobacterial species. Overall, the speciation of bacteria through determination of gene rearrangements were consistent with the gold standard method for species definition in bacteria, DNA-DNA hybridization however within the context of this system, individual components of the Mycobacterium tuberculosis complex (MTBC) did not show sufficient diversity to classify them as a separate species. The high number of gene rearrangements observed between the species tested suggests that gene reorganization of the genome represents an important contributor to speciation within the genus Mycobacterium and other related genera. The absence of rearrangements amongst MTBC supports their consideration as a single genospecies. Some gene rearrangements provided clear internal synteny between genomes of mycobacterial strains belonging to a same species and we suggest these could be used to classify subspecies.

Gene expression profiling integrated into network modelling reveals heterogeneity in the mechanisms of BRCA1 tumorigenesis

BACKGROUND

Gene expression profiling has distinguished sporadic breast tumour classes with genetic and clinical differences. Less is known about the molecular classification of familial breast tumours, which are generally considered to be less heterogeneous. Here, we describe molecular signatures that define BRCA1 subclasses depending on the expression of the gene encoding for oestrogen receptor, ESR1.

METHODS

For this purpose, we have used the Oncochip v2, a cancer-related cDNA microarray to analyze 14 BRCA1-associated breast tumours.

RESULTS

Signatures were found to be molecularly associated with different biological processes and transcriptional regulatory programs. The signature of ESR1-positive tumours was mainly linked to cell proliferation and regulated by ER, whereas the signature of ESR1-negative tumours was mainly linked to the immune response and possibly regulated by transcription factors of the REL/NFkappaB family. These signatures were then verified in an independent series of familial and sporadic breast tumours, which revealed a possible prognostic value for each subclass. Over-expression of immune response genes seems to be a common feature of ER-negative sporadic and familial breast cancer and may be associated with good prognosis. Interestingly, the ESR1-negative tumours were substratified into two groups presenting slight differences in the magnitude of the expression of immune response transcripts and REL/NFkappaB transcription factors, which could be dependent on the type of BRCA1 germline mutation.

CONCLUSION

This study reveals the molecular complexity of BRCA1 breast tumours, which are found to display similarities to sporadic tumours, and suggests possible prognostic implications.

Cardiac CT for CAD. Do we still need angiography?

Recent technological advances have led to a substantial increase in image quality in multi-detector computed tomography (MDCT). Over the last few years, there has been significant interest and controversy about the clinical application of CT angiography for the evaluation of the coronary anatomy in patients with suspected coronary artery disease (CAD). Unlike invasive coronary angiography, CT coronary angiography provides both visualization of the lumen and the coronary vessel wall. Calcified plaques can be detected without contrast administration and easily quantified. MDCT has largely replaced electron beam computerized tomography for calcium scoring. Growing evidence suggests that measurement of coronary calcium may be particularly valuable in therapy decisions for asymptomatic patients with an intermediate risk of coronary events. Recent studies have also shown an association between non-calcified coronary plaques and acute coronary syndromes in patients with stable angina. Contrast-enhanced CT coronary angiography provides a non-invasive alternative to intravascular ultrasound to evaluate coronary plaque morphology and severity. Contrast-enhanced CT has been extensively validated for the detection of coronary artery stenosis in symptomatic patients with known or suspected CAD. The number of non-evaluable cases has been reduced below 10% with the newest generation scanners. Although there is considerable enthusiasm, many doubts remain about the appropriate clinical indications of CT coronary angiography, even though most experts believe that the high negative predictive value of CT coronary angiography makes this test ideal for establishing or excluding coronary artery disease in patients with low-intermediate probability.

Tularaemia outbreak in Castilla y León, Spain, 2007: an update

Binary file ES_Abstracts_Final_ECDC.txt matches

Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

BACKGROUND

Abnormal papillary muscles (PM) are often found in hypertrophic cardiomyopathy (HCM).

OBJECTIVE

To assess the relationship between morphological alterations of PM in patients with HCM and left ventricular outflow tract (LVOT) obstruction, using magnetic resonance imaging (MRI) and echocardiography.

METHODS

Fifty-six patients with HCM (mean age 42 years (interquartile range 27, 51), 70% male) and 30 controls (mean age (42 (30, 53) years, 80% male) underwent MRI on a 1.5 T scanner (Siemens, Erlangen, Germany). Standard cine images were obtained in short-axis (base to apex), along with two-, three- and four-chamber views. The presence of bifid PM (none, one or both) and anteroapical displacement of anterolateral PM was recorded by MRI and correlated with resting LVOT gradients obtained by echocardiography.

RESULTS

Double bifid PM (70% vs 17%) and anteroapical displacement of anterolateral PM (77% vs 17%) were more prevalent in patients with HCM than in controls (p<0.001). Subjects with anteroapically displaced PM and double bifid PM had higher resting LVOT gradients than controls (45 (6, 81) vs 12 (0, 12) mm Hg (p<0.01) and 42 (6, 64) vs 11 (0, 17) mm Hg (p = 0.02), respectively. In patients with HCM, the odds ratio of having significant (>or=30 mm Hg) peak resting gradient was 7.1 (95% CI 1.4 to 36.7) for anteroapically displaced anterolateral PM and 10.4 (95% CI 1.2 to 91.2) for double bifid PM (both p = 0.005), independent of septal thickness, use of beta-blockers and/or calcium blockers and resting heart rate.

CONCLUSIONS

Patients with HCM with abnormal PM have a higher degree of resting LVOT gradient, which is independent of septal thickness.

Monte Carlo calculations and validation of a gold foil-based Bonner sphere system

The Grup de Física de les Radiacions (GFR) of the Universitat Autònoma de Barcelona (UAB), in collaboration with the Institute for Radiological Protection and Nuclear Safety (IRSN), has developed a passive Bonner sphere system (UAB-BSS), with gold foils as thermal neutron detectors, for application in pulsed neutron fields or in mixed neutron-photon fields with high photon intensities. In such fields, active devices suffer from saturation and dead-time effects. The MCNPX Monte-Carlo code has been used to determine the response to neutrons of different energies of each polyethylene sphere belonging to the BSS. The passive UAB-BSS system was characterised with the ISO (252)Cf reference source at the IRSN facilities. The energy distribution of the reference source neutron fluence was folded with the response functions for comparison with the experimental data. A good agreement between the experimental and calculated count rates was found.

Performance of the UAB and the INFN-LNF Bonner sphere spectrometers in quasi monoenergetic neutron fields

In the framework of collaboration between the Universidad Autónoma de Barcelona and the INFN Frascati National Laboratories, an experimental Bonner Sphere neutron spectrometry exercise has been performed in the 2.5 MeV and 14.2 MeV quasi monoenergetic neutron beams of the ENEA Fast Neutron Generator. The neutron spectra at given distances from the accelerator target have been determined, taking advantage of the new unfolding FRUIT code, recently developed by the LNF group. The results show a good coherence between the two spectrometers, and between the measured and simulated data.

Neutron measurements in a Varian 2,100C LINAC facility using a Bonner sphere system based on passive gold activation detectors

The use of high-energy linear electron accelerators (LINACs) for medical cancer treatments is widespread on an international scale. The associated bremsstrahlung X rays may produce neutrons as a result of subsequent photonuclear reactions with the different materials constituting the accelerator head. The generated neutron field is highly variable and depends strongly on the beam energy, on the accelerator shielding, on the flattering filter as well as on the movable collimators (jaws) design and on the irradiation field geometry. An estimate of this photoneutron component is, thus, of practical interest to quantify the radiological risk for the working staff and patients. Due to high frequency electromagnetic fields, and also to the presence of abundant leaked and scattered photons in these installations, measurements of the corresponding neutron fields by active dosemeters are extremely difficult. A modified version of the Bonner sphere system, based on passive gold activation detectors, has been used to perform neutron measurements at two points in a Varian 2,100C LINAC facility. A home-made unfolding procedure (CDM) has been utilised to determine the neutron spectra present at the measurement points. Results indicate that the giant dipole resonance process is the most adequate model to explain neutron production in the LINAC and that a thermal component is present at the measurement points.

Ultrasonic characterisation of flour-water systems: a new approach to investigate dough properties

The viscoelastic properties of dough are of great interest in the baking industry as they affect the quality of the final product. In this work, the viscoelastic properties of dough were investigated using ultrasonic techniques and then compared with traditional methods. It has been shown that ultrasonics provides a non-destructive, rapid and low cost technique for the measurement of physical food characteristics. A common protocol for dough preparation was used for each type of measurement. Experimental results on more than 30 different flour quality and dough processing were presented. The measurements were correlated and compared with traditional dough quality tests. In addition, the capability of ultrasound measurements for discriminating flours for different purposes was also studied, showing the potential of ultrasound as an alternative measurement method to discriminate types of flours for different purposes.

Using array-comparative genomic hybridization to define molecular portraits of primary breast cancers

We analysed 148 primary breast cancers using BAC-arrays containing 287 clones representing cancer-related gene/loci to obtain genomic molecular portraits. Gains were detected in 136 tumors (91.9%) and losses in 123 tumors (83.1%). Eight tumors (5.4%) did not have any genomic aberrations in the 281 clones analysed. Common (more than 15% of the samples) gains were observed at 8q11-qtel, 1q21-qtel, 17q11-q12 and 11q13, whereas common losses were observed at 16q12-qtel, 11ptel-p15.5, 1p36-ptel, 17p11.2-p12 and 8ptel-p22. Patients with tumors registering either less than 5% (median value) or less than 11% (third quartile) total copy number changes had a better overall survival (log-rank test: P=0.0417 and P=0.0375, respectively). Unsupervised hierarchical clustering based on copy number changes identified four clusters. Women with tumors from the cluster with amplification of three regions containing known breast oncogenes (11q13, 17q12 and 20q13) had a worse prognosis. The good prognosis group (Nottingham Prognostic Index (NPI) <or=3.4) tumors had frequent loss of 16q24-qtel. Genes significantly associated with estrogen receptor (ER), Grade and NPI were used to build k-nearest neighbor (KNN) classifiers that predicted ER, Grade and NPI status in the test set with an average misclassification rate of 24.7, 25.7 and 35.7%, respectively. These data raise the prospect of generating a molecular taxonomy of breast cancer based on copy number profiling using tumor DNA, which may be more generally applicable than expression microarray analysis.

High-resolution analysis of chromosome rearrangements on 8p in breast, colon and pancreatic cancer reveals a complex pattern of loss, gain and translocation

The short arm of chromosome 8, 8p, is often rearranged in carcinomas, typically showing distal loss by unbalanced translocation. We analysed 8p rearrangements in 48 breast, pancreatic and colon cancer cell lines by fluorescence in situ hybridization (FISH) and array comparative genomic hybridization, with a tiling path of 0.2 Mb resolution over 8p12 and 1 Mb resolution over chromosome 8. Selected breast lines (MDA-MB-134, MDA-MB-175, MDA-MB-361, T-47D and ZR-75-1) were analysed further. Most cell lines showed loss of 8p distal to a break that was between 31 Mb (5' to NRG1) and the centromere, but the translocations were accompanied by variable amplifications, deletions and inversions proximal to this break. The 8p12 translocation in T-47D was flanked by an inversion of 4 Mb, with a 100 kb deletion at the proximal end. The dicentric t(8;11) in ZR-75-1 carries multiple rearrangements including interstitial deletions, a triplicated translocation junction between NRG1 and a fragment of 11q (unconnected to CCND1), and two separate amplifications, of FGFR1 and CCND1 . We conclude that if there is a tumour suppressor gene on 8p it may be near 31 Mb, for example WRN; but the complexity of 8p rearrangements suggests that they target various genes proximal to 31 Mb including NRG1 and the amplicon centred around ZNF703/FLJ14299.

Hygrothermal degradation of (3-glycidoxypropyl)trimethoxysilane films studied by neutron and X-ray reflectivity and attenuated total reflection infrared spectroscopy

Thin films of organosilanes have great technological importance in the areas of adhesion promotion, durability, and corrosion resistance. However, it is well-known that water can degrade organosilane films, particularly at elevated temperatures. In this work, X-ray and neutron reflectivity (XR and NR) were combined with attenuated total reflection infrared (ATR-IR) spectroscopy to study the chemical and structural changes within thin films of (3-glycidoxypropyl)trimethoxysilane (GPS) after exposure for various periods of time to air saturated with either D2O or H2O at 80 degrees C. For NR and XR, ultrathin (approximately 100 A) films were prepared by spin-coating. Both D2O and H2O provide neutron scattering contrast with GPS. Variations in the neutron scattering length density (SLD) profiles (a function of mass density and atomic composition) with conditioning time were measured after drying the samples out and also swelled with H2O or D2O vapor at room temperature. For samples that were dried out prior to measurement, little or no change was observed for H2O conditioning up to 3.5 days, but large changes were observed after 30 days of conditioning. The range of conditioning time for this structural change was narrowed to between 4 and 10 days with XR. The SLD profiles indicated that the top portion of the GPS film was transformed into a thick low-density layer after conditioning, but the bottom portion showed little structural change. A previous NR study of as-prepared GPS films involving swelling with deuterated nitrobenzene showed that the central portion of the film has much lower cross-link density than the region nearest the substrate. The present data show that the central portion also swells to a much greater extent with water and hydrolyzes more rapidly. The chemical degradation mechanism was identified by IR as hydrolysis of siloxane bonds. For ATR-IR, GPS films were prepared by dip-coating, which resulted in a greater and more variable thickness than for the spin-coated samples. The IR spectra revealed an increase in vicinal silanol generation over the first 3 days of conditioning followed by geminal silanol generation. Thus, the structural change detected by NR and XR roughly coincided with the onset of geminal silanol generation. Finally, little change in the reflectivity data was observed for films conditioned with D2O at 80 degrees C for 1 month. This indicates that hydrolysis of Si-O-Si is much slower with D2O than with H2O.

Effect of premixed nph and regular insulin on glucose control and health-related quality of life in patients with type 2 diabetes mellitus

OBJECTIVE

To compare the effect of the addition of regular insulin as a premixed 70/30 insulin to the treatment regimen of patients with type 2 diabetes who had used NPH insulin alone relative to overall glycemic control (postprandial blood glucose), patient satisfaction, and health-related quality of life.

METHODS

We studied 90 patients with type 2 diabetes in a 10-week, randomized, double-blind, crossover trial involving 9 clinical investigators. Patients previously treated with NPH insulin alone were transferred to 30% regular insulin added to 70% NPH as a premixed insulin (70/30) administered twice daily. Patients in one sequence group received NPH insulin twice daily for 4 weeks followed by 70/30 insulin for 4 weeks; in the second sequence group, the order was reversed.

RESULTS

The magnitude of the 1.5- and 2-hour postprandial glucose excursion was reduced with 70/30 insulin in comparison with NPH insulin, and patients treated with 70/30 insulin experienced fewer hypoglycemic events than with NPH insulin. With regard to health-related quality of life, patients treated with 70/30 insulin rated their physical functioning as better; rated their ability to be spontaneous, follow the meal plan, and interact socially to be less difficult; and had less fear of hypoglycemia and perceived their diabetes to be better controlled than when treated with NPH insulin alone.

CONCLUSION

In patients with type 2 diabetes mellitus, premixed 70/30 insulin improved postprandial glycemic control and health-related quality of life without increasing the frequency of hypoglycemic events and without any additional cost.

A dynamic approach to identifying desired physiological phases for cardiac imaging using multislice spiral CT

In this investigation, we describe a quantitative technique to measure coronary motion, which can be correlated with cardiac image quality using multislice computed tomography (MSCT) scanners. MSCT scanners, with subsecond scanning, thin-slice imaging (sub-millimeter) and volume scanning capabilities have paved the way for new clinical applications like noninvasive cardiac imaging. ECG-gated spiral CT using MSCT scanners has made it possible to scan the entire heart in a single breath-hold. The continuous data acquisition makes it possible for multiple phases to be reconstructed from a cardiac cycle. We measure the position and three-dimensional velocities of well-known landmarks along the proximal, mid, and distal regions of the major coronary arteries [left main (LM), left anterior descending (LAD), right coronary artery (RCA), and left circumflex (LCX)] during the cardiac cycle. A dynamic model (called the "delay algorithm") is described which enables us to capture the same physiological phase or "state" of the anatomy during the cardiac cycle as the instantaneous heart rate varies during the spiral scan. The coronary arteries are reconstructed from data obtained during different physiological cardiac phases and we correlate image quality of different parts of the coronary anatomy with phases at which minimum velocities occur. The motion characteristics varied depending on the artery, with the highest motion being observed for RCA. The phases with the lowest mean velocities provided the best visualization. Though more than one phase of relative minimum velocity was observed for each artery, the most consistent image quality was observed during mid-diastole ("diastasis") of the cardiac cycle and was judged to be superior to other reconstructed phases in 92% of the cases. In the process, we also investigated correlation between cardiac arterial states and other measures of motion, such as the left ventricular volume during a cardiac cycle, which earlier has been demonstrated as an example of how anatomic-specific information can be used in a knowledge-based cardiac CT algorithm. Using these estimates in characterizing cardiac motion also provides realistic simulation models for higher heart rates and also in optimizing volume reconstructions for individual segments of the cardiac anatomy.

Semi-automated analysis of color M-mode echocardiographic images for determining transmitral pressure gradients using a simplified Euler equation

We hypothesize that a simplified version of the Euler equation (SEE) utilizing differences in velocity over a distance and time as obtained by Color Doppler M-mode (CMM) echocardiography can approximate actual peak transmitral pressure gradients deltaP(TM).

METHODS

In 14 patients undergoing open-heart surgery, deltaP(TM) was measured under various hemodynamic conditions using 2 high fidelity transducers, 5 cm apart. Transesophageal CMM images were simultaneously acquired and a customized image analysis application was used to abstract spatiotemporal velocity characteristics. Using both the SEE and a simplified Bernoulli equations, deltaP(TM) were determined and compared to the actual deltaP(TM).

RESULTS

While the simplified Bernoulli equation resulted in a poor estimate (y=0.075x+0.71, r=0.45), the deltaP(TM) obtained using the SEE correlated strongly (y=0.79x+0.48, r=0.91) with the actual measurements.

CONCLUSIONS

Semi-automated analysis of CMM images using a SEE can accurately estimate actual deltaP(TM).

Characterization of an rRNA operon (rrnB) of Mycobacterium fortuitum and other mycobacterial species: implications for the classification of mycobacteria

Mycobacteria are thought to have either one or two rRNA operons per genome. All mycobacteria investigated to date have an operon, designated rrnA, located downstream from the murA gene. We report that Mycobacteriun fortuitum has a second rrn operon, designated rrnB, which is located downstream from the tyrS gene; tyrS is very close to the 3' end of a gene (3-mag) coding for 3-methylpurine-DNA-glycosylase. The second rrn operon of Mycobacterium smegmatis was shown to have a similar organization, namely, 5' 3-mag-tyrS-rrnB 3'. The rrnB operon of M. fortuitum was found to have a single dedicated promoter. During exponential growth in a rich medium, the rrnB and rrnA operons were the major and minor contributors, respectively, to pre-rRNA synthesis. Genomic DNA was isolated from eight other fast-growing mycobacterial species. Samples were investigated by Southern blot analysis using probes for murA, tyrS, and 16S rRNA sequences. The results revealed that both rrnA and rrnB operons were present in each species. The results form the basis for a proposed new scheme for the classification of mycobacteria. The approach, which is phylogenetic in concept, is based on particular properties of the rrn operons of a cell, namely, the number per genome and a feature of 16S rRNA gene sequences.

Different estimates of cardiac power: relationship to altered loading conditions

Peak instantaneous power is a prognostic index of LV function but is difficult to measure. It is relatively load independent when corrected by preload (EDV2). Easier to acquire power estimates have been proposed--including mean and simplified power. These require only echo Doppler flow and cuff pressures, but their relationship to invasively derived results has not been studied. Using a well-validated numerical model of the cardiovascular system, different estimates of power were compared for varying preload, afterload, and contractility. All power results were divided by EDV2. Estimates of power correlate with peak power over a wide range of physiology. Corrected power estimates were independent of preload and afterload, but predictably increased with contractility. Different estimates of preload corrected power can be derived from non-invasively obtained variables and correlate with corrected peak instantaneous power.

Characterization of a Mycobacterium intracellulare variant strain by molecular techniques

This paper describes a Mycobacterium intracellulare variant strain causing an unusual infection. Several isolates obtained from an immunocompromised patient were identified as members of the Mycobacterium avium complex (MAC) by the commercial AccuProbe system and biochemical standard identification. Further molecular approaches were undertaken for a more accurate characterization of the bacteria. Up to seven different genomic sequences were analyzed, ranging from conserved mycobacterial genes such as 16S ribosomal DNA to MAC-specific genes such as mig (macrophage-induced gene). The results obtained identify the isolates as a variant of M. intracellulare, an example of the internal variability described for members of the MAC, particularly within that species. The application of other molecular approaches is recommended for more accurate identification of bacteria described as MAC members.

Respiratory variation of mitral and pulmonary venous Doppler flow velocities in constrictive pericarditis before and after pericardiectomy

The objective of this study was to determine whether Doppler echocardiography is useful in assessing the effects of pericardiectomy in patients with constrictive pericarditis by studying the postoperative change in the respiratory variation of mitral inflow and pulmonary venous Doppler flows. The study population consisted of 35 cases with surgically proven constrictive pericarditis. Thirty-five patients had preoperative Doppler echocardiography, whereas 4 patients died of non-cardiac causes and 1 patient had a heart transplant before follow-up. Postoperative studies were performed at a mean of 1081 +/- 84 days (range 120-2700 days) after pericardiectomy. The mean (+/- SD) respiratory variation changed after surgery from a baseline value of 17% +/- 14% to 8% +/- 8% for peak mitral E velocity (P <.01); from 25% +/- 18% to 7% +/- 13% (P <.001) for pulmonary venous (PV) peak diastolic flow velocity, and from 21% +/- 13% to 11% +/- 13% (P =.009) for PV peak systolic flow velocity. The 23 patients who became asymptomatic after surgery had a significantly lower mean mitral and PV respiratory variation than the 7 patients who were NYHA class II (4% +/- 4% and 6% +/- 4% vs 21% +/- 6% and 19% +/- 10%, respectively, P <.0001 for both). Pulsed Doppler echocardiographic assessment of respiratory variation is useful for evaluating the outcome of pericardiectomy.

Occurrence of polycyclic aromatic hydrocarbons in sewage sludge and their contribution to its toxicity in the toxalert 100 bioassay

The contribution of polycyclic aromatic hydrocarbons (PAH) present in sewage sludge samples to toxicity was investigated. Chemical analysis using gas chromatography mass spectrometry (GC-MS) and the ToxAlert 100 bioassay, based on the inhibition to Vibrio fischeri, were applied to sludge extracts after purification by column chromatography. The levels of the 16 US EPA PAH analyzed in the sewage sludge samples varied from 17 to 2,030 microg kg(-1). In all samples examined phenanthrene was the most prominent compound. The toxicity data obtained by ToxAlert 100 can be explained by the levels and composition of the different PAH in sewage sludge samples. The present approach can contribute to evaluate the toxicity of sewage sludge.

Interaliasing distance of the flow convergence surface for determining mitral regurgitant volume: a validation study in a chronic animal model

OBJECTIVES

We aimed to validate a new flow convergence (FC) method that eliminated the need to locate the regurgitant orifice and that could be performed semiautomatedly.

BACKGROUND

Complex and time-consuming features of previously validated color Doppler methods for determining mitral regurgitant volume (MRV) have prevented their widespread clinical use.

METHODS

Thirty-nine different hemodynamic conditions in 12 sheep with surgically created flail leaflets inducing chronic mitral regurgitation were studied with two-dimensional (2D) echocardiography. Color Doppler M-mode images along the centerline of the accelerating flow towards the mitral regurgitation orifice were obtained. The distance between the two first aliasing boundaries (interaliasing distance [IAD]) was measured and the FC radius was mathematically derived according to the continuity equation (R(calc) = IAD/(1 - radicalv(1)/v(2)), v(1) and v(2) being the aliasing velocities). The conventional 2D FC radius was also measured (R(meas)). Mitral regurgitant volume was then calculated according to the FC method using both R(calc) and R(meas). Aortic and mitral electromagnetic (EM) flow probes and meters were balanced against each other to determine the reference standard MRV.

RESULTS

Mitral regurgitant volume calculated from R(calc) and R(meas) correlated well with EM-MRV (y = 0.83x + 5.17, r = 0.90 and y = 1.04x + 0.91, r = 0.91, respectively, p < 0.001 for both). However, both methods resulted in slight overestimation of EM-MRV (Delta was 3.3 +/- 2.1 ml for R(calc) and 1.3 +/- 2.3 ml for R(meas)).

CONCLUSIONS

Good correlation was observed between MRV derived from R(calc) (IAD method) and EM-MRV, similar to that observed with R(meas) (conventional FC method) and EM-MRV. The R(calc) using the IAD method has an advantage over conventional R(meas) in that it does not require spatial localization of the regurgitant orifice and can be performed semiautomatedly.

Bisoprolol and nifedipine SR in the treatment of hypertension in the elderly

Forty outpatients (11 men and 29 women) aged between 65 and 85 years (mean age of 68 years) with mild to moderate hypertension [mean systolic/diastolic blood pressure (SBP/DBP) after 2 weeks on placebo of 175/102 mm Hg] were included in a randomized, double-blind, parallel-group study to compare the efficacy and tolerance of 10 mg of bisoprolol once daily (o.d., n = 20) and 20 mg of nifedipine sustained release (SR) b.i.d. (n = 20) during 4 weeks of treatment. SBP and DBP were significantly reduced compared to baseline with both treatments. There was no significant difference in efficacy between the two treatments after 2 and 4 weeks. After 2 weeks, the number of patients with normalized DBP (< or =90 mm Hg) was higher with bisoprolol than with nifedipine, this difference no longer being present after 4 weeks. Resting heart rate was significantly reduced with bisoprolol from 78+/-8 to 68+/-9 beats/min after 4 weeks, but there was no change in heart rate with nifedipine. Adverse events were reported by 6 patients on bisoprolol (20 events) and 12 patients on nifedipine (51 events) and the overall tolerance of bisoprolol was considered to be significantly better than that of nifedipine. Because bisoprolol is equally effective when administered once daily in comparison with nifedipine SR, which has to be given twice daily, and since bisoprolol exhibits a better tolerance, this beta-blocker appears to be a useful drug of first choice for the treatment of elderly hypertensive patients.

Relationship between early diastolic intraventricular pressure gradients, an index of elastic recoil, and improvements in systolic and diastolic function

BACKGROUND

Early diastolic intraventricular pressure gradients (IVPGs) have been proposed to relate to left ventricular (LV) elastic recoil and early ventricular "suction." Animal studies have demonstrated relationships between IVPGs and systolic and diastolic indices during acute ischemia. However, data on the effects of improvements in LV function in humans and the relationship to IVPGs are lacking.

METHODS AND RESULTS

Eight patients undergoing CABG and/or infarct exclusion surgery had a triple-sensor high-fidelity catheter placed across the mitral valve intraoperatively for simultaneous recording of left atrial (LA), basal LV, and apical LV pressures. Hemodynamic data obtained before bypass were compared with those with similar LA pressures and heart rates obtained after bypass. From each LV waveform, the time constant of LV relaxation (tau), +dP/dt(max), and -dP/dt(max) were determined. Transesophageal echocardiography was used to determined end-diastolic (EDV) and end-systolic (ESV) volumes and ejection fractions (EF). At similar LA pressures and heart rates, IVPG increased after bypass (before bypass 1.64+/-0.79 mm Hg; after bypass 2.67+/-1.25 mm Hg; P<0.01). Significant improvements were observed in ESV, as well as in apical and basal +dP/dt(max), -dP/dt(max), and tau (each P<0.05). Overall, IVPGs correlated inversely with both ESV (IVPG=-0.027[ESV]+3.46, r=-0.64) and EDV (IVPG=-0.027[EDV]+4.30, r=-0.70). Improvements in IVPGs correlated with improvements in apical tau (Deltatau =5.93[DeltaIVPG]+4.76, r=0.91) and basal tau (Deltatau =2.41[DeltaIVPG]+5.13, r=-0.67). Relative changes in IVPGs correlated with changes in ESV (DeltaESV=-0.97[%DeltaIVPG]+23.34, r=-0.79), EDV (DeltaEDV=-1.16[%DeltaIVPG]+34.92, r=-0.84), and EF (DeltaEF=0.38[%DeltaIVPG]-8.39, r=0.85).

CONCLUSIONS

Improvements in LV function also increase IVPGs. These changes in IVPGs, suggestive of increases in LV suction and elastic recoil, correlate directly with improvements in LV relaxation and ESV.

Mycobacterium immunogenum sp. nov., a novel species related to Mycobacterium abscessus and associated with clinical disease, pseudo-outbreaks and contaminated metalworking fluids: an international cooperative study on mycobacterial taxonomy

PCR-restriction enzyme pattern analysis of a 439 bp hsp65 gene segment identified 113 unique isolates among non-pigmented rapidly growing mycobacteria (RGM) from clinical and environmental sources that failed to match currently recognized species patterns. This group represented 40% of isolates recovered from bronchoscope contamination pseudo-outbreaks, 0% of disease-associated nosocomial outbreaks and 4% of routine clinical isolates of the Mycobacterium abscessus/Mycobacterium chelonae group submitted to the Mycobacteria/Nocardia laboratory for identification. It is grouped within the Mycobacterium fortuitum complex, with growth in less than 7 d, absence of pigmentation, positive 3-d arylsulfatase reaction and growth on MacConkey agar without crystal violet. It exhibited overlapping biochemical, antimicrobial susceptibility and HPLC characteristics of M. abscessus and M. chelonae. By 16S rRNA gene sequencing, these isolates comprised a homogeneous group with a unique hypervariable region A sequence and differed by 8 and 10 bp, respectively, from M. abscessus and M. chelonae. Surprisingly, this taxon contained two copies of the ribosomal operon, compared with single copies in the two related species. By DNA-DNA hybridization, this new group exhibited <30% homology with recognized RGM species. The name Mycobacterium immunogenum sp. nov. is proposed for this new taxon.

Estimation of diastolic intraventricular pressure gradients by Doppler M-mode echocardiography

Previous studies have shown that small intraventricular pressure gradients (IVPG) are important for efficient filling of the left ventricle (LV) and as a sensitive marker for ischemia. Unfortunately, there has previously been no way of measuring these noninvasively, severely limiting their research and clinical utility. Color Doppler M-mode (CMM) echocardiography provides a spatiotemporal velocity distribution along the inflow tract throughout diastole, which we hypothesized would allow direct estimation of IVPG by using the Euler equation. Digital CMM images, obtained simultaneously with intracardiac pressure waveforms in six dogs, were processed by numerical differentiation for the Euler equation, then integrated to estimate IVPG and the total (left atrial to left ventricular apex) pressure drop. CMM-derived estimates agreed well with invasive measurements (IVPG: y = 0.87 x + 0.22, r = 0.96, P < 0.001, standard error of the estimate = 0.35 mmHg). Quantitative processing of CMM data allows accurate estimation of IVPG and tracking of changes induced by β-adrenergic stimulation. This novel approach provides unique information on LV filling dynamics in an entirely noninvasive way that has previously not been available for assessment of diastolic filling and function.

Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration

OBJECTIVES

We sought to develop and validate a model that estimates the risk of obstructive coronary artery disease in patients undergoing operations for mitral valve degeneration and to demonstrate its potential clinical utility.

METHODS

A total of 722 patients (67% men; age, 61 +/- 12 years) without a history of myocardial infarction, ischemic electrocardiographic changes, or angina who underwent routine coronary angiography before mitral valve prolapse operations between 1989 and 1996 were analyzed. A bootstrap-validated logistic regression model on the basis of clinical risk factors was developed to identify low-risk (< or =5%) patients. Obstructive coronary atherosclerosis was defined as 50% or more luminal narrowing in one or more major epicardial vessels, as determined by means of coronary angiography.

RESULTS

One hundred thirty-nine (19%) patients had obstructive coronary atherosclerosis. Independent predictors of coronary artery disease include age, male sex, hypertension, diabetes mellitus,and hyperlipidemia. Two hundred twenty patients were designated as low risk according to the logistic model. Of these patients, only 3 (1.3%) had single-vessel disease, and none had multivessel disease. The model showed good discrimination, with an area under the receiver-operating characteristic curve of 0.84. Cost analysis indicated that application of this model could safely eliminate 30% of coronary angiograms, corresponding to cost savings of $430,000 per 1000 patients without missing any case of high-risk coronary artery disease.

CONCLUSION

A model with standard clinical predictors can reliably estimate the prevalence of obstructive coronary atherosclerosis in patients undergoing mitral valve prolapse operations. This model can identify low-risk patients in whom routine preoperative angiography may be safely avoided.

Comparison of MPEG-1 digital videotape with digitized sVHS videotape for quantitative echocardiographic measurements

Digital format is rapidly emerging as a preferred method for displaying and retrieving echocardiographic studies. The qualitative diagnostic accuracy of Moving Pictures Experts Group (MPEG-1) compressed digital echocardiographic studies has been previously reported. The goals of the present study were to compare quantitative measurements derived from MPEG-1 recordings with the super-VHS (sVHS) videotape clinical standard. Six reviewers performed blinded measurements from still-frame images selected from 20 echocardiographic studies that were simultaneously acquired in sVHS and MPEG-1 formats. Measurements were obtainable in 1401 (95%) of 1486 MPEG-1 variables compared with 1356 (91%) of 1486 sVHS variables (P <.001). Excellent agreement existed between MPEG-1 and sVHS 2-dimensional linear measurements (r = 0.97; MPEG-1 = 0.95[sVHS] + 1.1 mm; P <.001; Delta = 9% +/- 10%), 2-dimensional area measurements (r = 0.89), color jet areas (r = 0.87, p <.001), and Doppler velocities (r = 0.92, p <.001). Interobserver variability was similar for both sVHS and MPEG-1 readings. Our results indicate that quantitative off-line measurements from MPEG-1 digitized echocardiographic studies are feasible and comparable to those obtained from sVHS.

Estimation of left ventricular operating stiffness from Doppler early filling deceleration time in humans

Shortened early transmitral deceleration times (E(DT)) have been qualitatively associated with increased filling pressure and reduced survival in patients with cardiac disease and increased left ventricular operating stiffness (K(LV)). An equation relating K(LV) quantitatively to E(DT) has previously been described in a canine model but not in humans. During several varying hemodynamic conditions, we studied 18 patients undergoing open-heart surgery. Transesophageal echocardiographic two-dimensional volumes and Doppler flows were combined with high-fidelity left atrial (LA) and left ventricular (LV) pressures to determine K(LV). From digitized Doppler recordings, E(DT) was measured and compared against changes in LV and LA diastolic volumes and pressures. E(DT) (180 +/- 39 ms) was inversely associated with LV end-diastolic pressures (r = -0.56, P = 0.004) and net atrioventricular stiffness (r = -0.55, P = 0.006) but had its strongest association with K(LV) (r = -0.81, P < 0.001). K(LV) was predicted assuming a nonrestrictive orifice (K(nonrest)) from E(DT) as K(nonrest) = (0.07/E(DT))(2) with K(LV) = 1.01 K(nonrest) - 0.02; r = 0.86, P < 0.001, DeltaK (K(nonrest) - K(LV)) = 0.02 +/- 0.06 mm Hg/ml. In adults with cardiac disease, E(DT) provides an accurate estimate of LV operating stiffness and supports its application as a practical noninvasive index in the evaluation of diastolic function.

Right atrial spontaneous echo contrast and thrombi in atrial fibrillation: a transesophageal echocardiography study

BACKGROUND

Previous studies have reported the clinical and echocardiographic findings of patients with left atrial spontaneous echo contrast (SEC) and thrombi. We sought to study these characteristics in patients with right atrial SEC and thrombi.

METHODS

We reviewed 580 consecutive patients from the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Registry and found 79 patients (14%, aged 67 +/-13 years, 67 male) with transesophageal echocardiography (TEE) findings of right atrial SEC or thrombi (group 1). This group was compared with a control group of 75 consecutive patients (group 2) (aged 68 +/- 13 years, P = not significant; 49 male, P <.005) from the registry with no TEE findings of SEC or thrombi in the left or right atrium.

RESULTS

Atrial fibrillation was present in 60 of 79 group 1 patients (76%). Five right atrial (6%) and 11 left atrial (14%) thrombi were identified. Both left ventricular ejection fraction (39% +/- 16% versus 47% +/- 14%; P =.0005) and presence of right ventricular dysfunction (n = 44 versus 18; P =.0001) differed significantly between groups 1 and 2, respectively. Right atrial area (24 +/- 6 cm(2) versus 22 +/- 6 cm(2); P = .02) was larger in patients in group 1. Left atrial SEC was present in 68 of 79 group 1 patients (86%). Patients with right atrial thrombi and right atrial SEC had a longer duration of arrhythmia (524 +/-812 days versus 147 +/-368 days, P <.05) than patients with right atrial SEC only.

CONCLUSIONS

Right atrial SEC has a prevalence of 14% in patients with atrial arrhythmia who undergo TEE-guided cardioversion. Right atrial thrombi are a rare finding and were seen in fewer than 1% (5/580) of patients with atrial arrhythmia. Right atrial thrombi among patients on anticoagulation therapy were not associated with clinically significant pulmonary embolism.

Automated assessment of noninvasive filling pressure using color Doppler M-mode echocardiography

Assessment of left ventricular filling pressure usually requires invasive hemodynamic monitoring to follow the progression of disease or the response to therapy. Previous investigations have shown accurate estimation of wedge pressure using noninvasive Doppler information obtained from the ratio of the wave propagation slope from color M-mode (CMM) images and the peak early diastolic filling velocity from transmitral Doppler images. This study reports an automated algorithm that derives an estimate of wedge pressure based on the spatiotemporal velocity distribution available from digital CMM Doppler images of LV filling.

Automated quantification of mitral valve regurgitation based on normalized centerline velocity distribution

Previous echocardiographic techniques for quantifying valvular regurgitation are limited by factors including uncertainties for orifice location and a hemispheric convergence assumption that often results in over- and underestimation of flow rate and regurgitant orifice area. Using computational fluid dynamics simulations, these factors were eliminated, allowing a more accurate assessment of regurgitation. A model was developed to allow automated quantification of regurgitant orifice diameter based on the centerline velocity data available from color M-mode echocardiography. The model, validated using in vitro unsteady flow data, demonstrated improved accuracy for orifice diameter (y=0.95x + 0.38, r=0.96) and volume (y=1.18x - 4.72, r=0.93).

Relationship between systolic and diastolic function with improvements in forward stroke volume following reduction in mitral regurgitation

Efforts to improve mitral regurgitation (MR) are often performed in conjunction with coronary revascularization. However, the independent effects of a reduced MR area (MRa) are difficult to quantify. Using a previously developed cardiovascular model, ventricular contractility (elastance 1-8 mmHg/ml) and relaxation (tau: 40-150 msec) were independently adjusted for four grades of MR orifice areas (0.0 to 0.8 cm2). Improvements in forward stroke volume (fSV) were determined for the permutations of reduced MRa. For all conditions, LV end-diastolic pressure and volumes ranged from 7.3-24.2 mmHg and 64.8-174.3 ml, respectively. Overall, fSV ranged from 36.0-89.4 (mean: 64.2 +/- 12.8) ml, improved between 6.4 and 35.3% (mean: 15.6 +/- 8.1%), and was best predicted by (r=0.97, p<0.01) %delta(fSV)[correction of fVS]=34[MRa initial] - 46[MRa final] -0.5[elastance]. Reduced MRa, independent of relaxation and minimally influence by contractility, yield improved fSVs.

Effect of cardiac output on mitral valve area in patients with mitral stenosis: validation and pitfalls of the pressure half-time method

BACKGROUND AND AIM OF THE STUDY

The non-invasive evaluation of mitral valve area is often used in the assessment of patients with mitral stenosis. The pressure half-time method is commonly used to calculate valve area, but is inaccurate in many clinical scenarios. We sought to quantify the effects of changing cardiac output on the accuracy of mitral valve area determination.

METHODS

Thirteen patients with mitral stenosis underwent routine stress echocardiography with resting and peak exercise results compared. A previously described and clinically validated mathematical model of the cardiovascular system was used to validate the clinical results. Seven different loading conditions for each of four different stenotic valve areas were modeled.

RESULTS

In patients, with increasing cardiac output, pressure half-time decreased (-30.6+/-35.3 ms/l/min) and calculated valve area increased by 0.25+/-0.30 cm2/l/min. By continuity, it appeared that approximately half of this increase was due to actual valve orifice stretching, the remainder reflecting fundamental changes in the relationship between half-time and valve area. Mathematical modeling resulted in similar changes in pressure half-time and calculated valve area (0.06 to 0.12 cm2/l/min, p = 0.20 versus clinical results).

CONCLUSION

Changes in cardiac output result in predictable changes in pressure half-time, and should be considered when performing serial examinations in patients with mitral stenosis.

Noninvasive assessment of mitral inertness [correction of inertance]: clinical results with numerical model validation

Inertial forces (Mdv/dt) are a significant component of transmitral flow, but cannot be measured with Doppler echo. We validated a method of estimating Mdv/dt. Ten patients had a dual sensor transmitral (TM) catheter placed during cardiac surgery. Doppler and 2D echo was performed while acquiring LA and LV pressures. Mdv/dt was determined from the Bernoulli equation using Doppler velocities and TM gradients. Results were compared with numerical modeling. TM gradients (range: 1.04-14.24 mmHg) consisted of 74.0 +/- 11.0% inertial forcers (range: 0.6-12.9 mmHg). Multivariate analysis predicted Mdv/dt = -4.171(S/D (RATIO)) + 0.063(LAvolume-max) + 5. Using this equation, a strong relationship was obtained for the clinical dataset (y=0.98x - 0.045, r=0.90) and the results of numerical modeling (y=0.96x - 0.16, r=0.84). TM gradients are mainly inertial and, as validated by modeling, can be estimated with echocardiography.

Determinants of diastolic myocardial tissue Doppler velocities: influences of relaxation and preload

Myocardial tissue Doppler echocardiography (TDE) has been proposed as a tool for the assessment of diastolic function. Controversy exists regarding whether TDE measurements are influenced by preload. In this study, left ventricular volume and high-fidelity pressures were obtained in eight closed-chest dogs during intermittent caval occlusion. The time constant of isovolumic ventricular relaxation (tau) was altered with varying doses of dobutamine and esmolol. Peak early diastolic myocardial (E(m)) and transmitral (E) velocities were measured before and after preload reduction. The relative effects of changes in preload and relaxation were determined for E(m) and compared with their effects on E. The following results were observed: caval occlusion significantly decreased E (DeltaE = 16.4 +/- 3.3 cm/s, 36.6 +/- 13.7%, P < 0.01) and E(m) (DeltaE(m) = 1. 3 +/- 0.4 cm/s, 32.5 +/- 26.1%, P < 0.01) under baseline conditions. However, preload reduction was similar for E under all lusitropic conditions (P = not significant), but these effects on E(m) decreased with worsening relaxation. At tau < 50 ms, changes in E(m) with preload reduction were significantly greater (DeltaE(m) = 2.8 +/- 0.6 cm/s) than at tau = 50-65 ms (DeltaE(m) = 1.2 +/- 0.2 cm/s) and at tau >65 ms (DeltaE(m) = 0.5 +/- 0.1 cm/s, P < 0.05). We concluded that TDE E(m) is preload dependent. However, this effect decreases with worsening relaxation.

Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy

This study assesses how the newer modalities of tissue Doppler echocardiography and color M-mode flow propagation compare with respiratory variation of Doppler flow in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. We studied 30 patients referred for further evaluation of diastolic function who had a diagnosis of constrictive pericarditis or restrictive cardiomyopathy established by diagnostic tests, including clinical assessment, magnetic resonance imaging, cardiac catheterization, endomyocardial biopsy, and surgical findings. Nineteen patients had constrictive pericarditis and 11 had restrictive cardiomyopathy. We performed 2-dimensional transesophageal echocardiography combined with pulsed-wave Doppler of the pulmonary veins and mitral inflow with respiratory monitoring, tissue Doppler echocardiography of the lateral mitral annulus, and color M-mode flow propagation of left ventricular filling. Respiratory variation of the mitral inflow peak early (peak E) velocity of > or =10% predicted constrictive pericarditis with 84% sensitivity and 91% specificity and variation in the pulmonary venous peak diastolic (peak D) flow velocity of > or =18% distinguished constriction with 79% sensitivity and 91% specificity. Using tissue Doppler echocardiography, a peak early velocity of longitudinal expansion (peak Ea) of > or =8.0 cm/s differentiated patients with constriction from restriction with 89% sensitivity and 100% specificity. A slope of > or =100 cm/s for the first aliasing contour in color M-mode flow propagation predicted patients with constriction with 74% sensitivity and 91% specificity. Thus, the newer methods of tissue Doppler echocardiography and color M-mode flow propagation are equivalent and complimentary with Doppler respiratory variation in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. The additive role of the new methods needs to be established in difficult cases of constrictive pericarditis where respiratory variation may be absent or decreased.

Echocardiographic assessment of the mechanisms of correction of bileaflet prolapse causing mitral regurgitation with only posterior leaflet repair surgery

Recent data suggest that posterior leaflet repair alone corrects mitral regurgitation in patients with bileaflet prolapse and normal anterior chordae. The purpose of this study was to use echocardiography to define the anatomic differences between posterior and bileaflet prolapse and to determine if posterior leaflet repair alone leads to correction of bileaflet prolapse. We studied patients who underwent quadrangular resection of the posterior mitral valve leaflet to treat bileaflet prolapse (group I, n = 20) or isolated posterior leaflet prolapse (group II, n = 20). Echocardiographic characteristics were compared before and after the procedure. There were no differences in the left ventricular end-diastolic or end-systolic dimensions or function between the 2 groups. However, anterior leaflet length was greater in patients with bileaflet prolapse (3.3 +/- 0.6 cm vs 2.6 +/- 0.4 cm, p = 0.003). In group I, posterior leaflet repair changed anterior leaflet displacement from -0.8 +/- 0.2 to 0.5 +/- 0.4 cm (p <0.001) and posterior leaflet displacement from -0.8 +/- 0.3 cm below to 0.5 +/- 0.4 cm (p <0.001) in front of the mitral annular plane. In group II, anterior leaflet displacement was unchanged from 0.2 +/- 0.1 to 0.3 +/- 0.2 cm (p = 0.22), whereas posterior leaflet displacement changed from -0.7 +/- 0.2 to 0.4 +/- 0.2 cm (p <0.001). Thus, patients with bileaflet prolapse and no ruptured chords have excessive anterior leaflet length. In such patients, posterior leaflet repair alone corrects anterior and posterior leaflet prolapse.

Noninvasive estimation of transmitral pressure drop across the normal mitral valve in humans: importance of convective and inertial forces during left ventricular filling

OBJECTIVES

We hypothesized that color M-mode (CMM) images could be used to solve the Euler equation, yielding regional pressure gradients along the scanline, which could then be integrated to yield the unsteady Bernoulli equation and estimate noninvasively both the convective and inertial components of the transmitral pressure difference.

BACKGROUND

Pulsed and continuous wave Doppler velocity measurements are routinely used clinically to assess severity of stenotic and regurgitant valves. However, only the convective component of the pressure gradient is measured, thereby neglecting the contribution of inertial forces, which may be significant, particularly for nonstenotic valves. Color M-mode provides a spatiotemporal representation of flow across the mitral valve.

METHODS

In eight patients undergoing coronary artery bypass grafting, high-fidelity left atrial and ventricular pressure measurements were obtained synchronously with transmitral CMM digital recordings. The instantaneous diastolic transmitral pressure difference was computed from the M-mode spatiotemporal velocity distribution using the unsteady flow form of the Bernoulli equation and was compared to the catheter measurements.

RESULTS

From 56 beats in 16 hemodynamic stages, inclusion of the inertial term ([deltapI]max = 1.78+/-1.30 mm Hg) in the noninvasive pressure difference calculation significantly increased the temporal correlation with catheter-based measurement (r = 0.35+/-0.24 vs. 0.81+/-0.15, p< 0.0001). It also allowed an accurate approximation of the peak pressure difference ([deltapc+I]max = 0.95 [delta(p)cathh]max + 0.24, r = 0.96, p<0.001, error = 0.08+/-0.54 mm Hg).

CONCLUSIONS

Inertial forces are significant components of the maximal pressure drop across the normal mitral valve. These can be accurately estimated noninvasively using CMM recordings of transmitral flow, which should improve the understanding of diastolic filling and function of the heart.

Qualitative and quantitative effects of harmonic echocardiographic imaging on endocardial edge definition and side-lobe artifacts

Harmonic imaging is a new ultrasonographic technique that is designed to improve image quality by exploiting the spontaneous generation of higher frequencies as ultrasound propagates through tissue. We studied 51 difficult-to-image patients with blinded side-by-side cineloop evaluation of endocardial border definition by harmonic versus fundamental imaging. In addition, quantitative intensities from cavity versus wall were compared for harmonic versus fundamental imaging. Harmonic imaging improved left ventricular endocardial border delineation over fundamental imaging (superior: harmonic = 71.1%, fundamental = 18.7%; similar: 10.2%; P <.001). Quantitative analysis of 100 wall/cavity combinations demonstrated brighter wall segments and more strikingly darker cavities during harmonic imaging (cavity intensity on a 0 to 255 scale: fundamental = 15.6 +/- 8.6; harmonic = 6.0 +/- 5.3; P <.0001), which led to enhanced contrast between the wall and cavity (1.89 versus 1.19, P <.0001). Harmonic imaging reduces side-lobe artifacts, resulting in a darker cavity and brighter walls, thereby improving image contrast and endocardial delineation.