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The article presents a case study of a 30-year-old woman who was admitted to the hospital because of general fatigue and difficulties in breathing and was subjected to transoesophageal and transthoracic echocardiography.

Background Quantitative coronary angiography (QCA) has inherent limitations for displaying complex vascular anatomy, yet it remains the gold standard for stenosis quantification. Objective To investigate the accuracy of stenosis assessment by multi-detector computed tomography (MDCT) and QCA compared to known dimensions. Methods Nineteen acrylic coronary vessel phantoms with precisely drilled stenoses of mild (25%), moderate (50%) and severe (75%) grade were studied with 64-slice MDCT and digital flat panel angiography. Fifty-seven stenoses of circular and non-circular shape were imaged with simulated cardiac motion (60 bpm). Image acquisition was optimised for both imaging modalities, and stenoses were quantified by blinded expert readers using electronic callipers (for MDCT) or lumen contour detection software (for QCA). Results Average difference between true and measured per cent diameter stenosis for QCA was similar compared to MDCT: 7 (±6)% vs 7 (±5)% (p=0.78). While QCA performed better than MDCT in stenoses with circular lumen (mean error 4 (±3)% vs 7 (±6)%, p<0.01), MDCT was superior to QCA for evaluating stenoses with non-circular geometry (mean error 10 (±7)% vs 7 (±5)%, p<0.05). In such lesions, QCA underestimated the true diameter stenosis by >20% in 9 of 27 (33%) vs 1 of 29 (3%) in lumen with circular geometry. Conclusions QCA often underestimates diameter stenoses in lumen with non-circular geometry. Compared to QCA, MDCT yields mildly greater measurement errors in perfectly circular lumen but performs better in non-circular lesions. These findings have implications for using QCA as the gold standard for stenosis quantification by MDCT. [ABSTRACT FROM AUTHOR]

In recent decades, the Fontan procedure and its variations have resulted in markedly improved outcomes of patients with single-ventricle physiology. These improvements are expected to increase greatly the number of surviving patients, particularly those surviving long into adulthood. However, there is still a progressive risk of attrition and failure of the Fontan circulation over time, the underlying pathophysiology of which is not fully understood. Current evidence suggests that alterations in the structure and function of the pulmonary vasculature may play a pivotal role. Recent evidence suggests that therapies approved for pulmonary arterial hypertension may provide benefits in this increasingly important patient population. [ABSTRACT FROM AUTHOR]

As a luminogram, coronary angiography provides a good overview of the coronary artery tree. Using quantitative coronary measurements, the degree of coronary obstruction can be determined. The limitation of coronary angiography is that it does not provide information on the arterial wall structure and therefore cannot assess the extent of atherosclerosis. Knowledge about adaptive coronary remodelling processes as compensatory enlargement of the coronary artery has focused diagnostic interest on the non-stenotic lesions of the coronary tree. Intravascular ultrasound (IVUS) can reveal discrepancies between the extent of coronary atherosclerosis and angiography imaging by in vivo plaque imaging. Spectrum analysis of IVUS-derived radiofrequency (RF) data enables a more detailed analysis of plaque composition and morphology. Preliminary in vitro studies correlated four histological plaque components with a specific spectrum analysis of the RF data. The different components (fibrous, fibrofatty, necrotic core and dense calcium) are colour coded. Coronary tissue maps were reconstructed from RF data using IVUS-Virtual Histology (VH IVUS) software (Real-Time VH, Volcano Corporation, Rancho Cordova, California, USA). VH IVUS has the potential to detect high-risk lesions and can provide new insights into the pathophysiology of coronary artery disease. VH IVUS allows the differentiation of different lesion types based on information derived from histopathology. The in vivo specific histological analysis of coronary atherosclerosis may allow better stratification of treatment of patients with coronary artery disease. [ABSTRACT FROM AUTHOR]

Background: Conflicting data have been reported about the correlation between plaque composition assessed by virtual histology (VH) and remodelling index (RI). Aim: To evaluate, in a larger patient population, the relationship between plaque morphology obtained by VH and arterial remodelling. Methods and results: VH intravascular ultrasound was performed on 95 non-bifurcation native significant lesions (>75% stenosis) in 85 patients. Positive remodelling (defined as RI ⩾1.05) was present in 28 lesions, whereas intermediate/negative remodelling (RI <1.05) was present in 67 lesions. Compared with intermediate/negative remodelling, positive remodelling was associated with an increased frequency of patients with acute coronary syndrome (n = 13 (52%) vs n = 15 (25%); p = 0.017), and with a greater plaque burden (mean (SD) 78.3 (6.3)% vs 73.2 (6.8)%, p=0.001). At the minimal lumen site, necrotic core was significantly smaller in lesions with positive remodelling (median (interquartile range) 5.0% (2.2-11 .0%)) than in lesions with intermediate/negative remodelling (median (interquartile range) 9.0% (4.0-16.0%); p=0.048). No differences were observed in the rate of thin-cap fibroatheroma or in the presence of multiple necrotic core layers, and there were no statistical differences for fibrous, fibro fatty and dense calcium percent plaque area at the minimum lumen diameter (MLD), or for the entire lesion length between both groups. Conclusions: In vivo VH analysis shows that lesions with positive remodelling have statistically less necrotic core percent area at the MLD site compared with intermediate/negative remodelling lesions. [ABSTRACT FROM AUTHOR]

Objectives: To test whether an increase in Doppler myocardial performance index (MPI) during dobutamine stress echocardiography, reflecting deterioration of overall left ventricular function, is associated with increased N-terminal pro-brain natriuretic peptide (NT-pro-BNP) concentration and provides prognostic information beyond conventional systolic wall motion analysis after acute myocardial infarction (AMI). Design: Prospective, observational study. Methods: Dobutamine-atropine stress echocardiography (DASE) and NT-pro-BNP were assessed five days after AMI in 109 consecutive patients. MPI was measured at rest and at low-dose (10 µg/kg/min) and peak dobutamine infusion (⩽ 40 µg/kg/min with or without atropine). Main outcome measures: End point was a composite of cardiac death or readmission for heart failure or reinfarction. Results: In 35 patients (32%), MPI increased at low-dose DASE. This was associated with higher NT-pro-BNP concentrations (β = 0.30, p = 0.004). During a mean follow up of 27 (SD 7) months, 8 patients died of cardiac causes and 15 patients were readmitted for heart failure or reinfarction. On Cox regression analysis, an increase in MPI at low-dose DASE (p = 0.02) was an independent predictor of cardiac events. In contrast, traditional wall motion analysis during DASE provided no additional prognostic information. Conclusions: An increase in MPI at low-dose DASE, reflecting early deterioration of overall left ventricular function, is associated with raised NT-pro-BNP concentration and provides prognostic information beyond conventional stress echocardiographic data after AMI. [ABSTRACT FROM AUTHOR]

Objectives: To examine whether the line dividing the septum into two layers is found consistently by conventional echocardiography and to evaluate functional differences in the right and left side of the septum in terms of wall thickening, strain rate, and strain imaging. Design: In a systematic study in 30 normal subjects, M mode and Doppler myocardial imaging data from the interventricular septum (IVS) were recorded. Velocity curves, regional strain rate, and strain profiles were obtained. Systolic deformation (wall thickening, radial and longitudinal strain rate, and strain) of both sides were assessed. Furthermore, three patients with one sided abnormalities were studied. Results: A bright echo consistently segmented the IVS into a left and right part. In this normal population radial deformation was different for the left and right side of the septum (mean (SD) wall thickening on the left, 49 (46)%, and on the right, 17 (38)%; strain rote on the left, 3.8 (0.6) 1/s, and on the right, 2.1 (1.9) 1/s; strain on the left, 41 (17)%, and on the right, 22 (14)%), whereas longitudinal deformation was found to be similar (strain rate on the left, -2.2 (0.7) 1/s, and on the right, -2.0 (0.6) 1/s; strain on the left, -28 (12)%, and on the right, -25 (12)%). The presented clinical examples show that abnormalities can be strictly limited to one layer. Conclusions: Differential radial deformation and knowledge of fibre architecture showing an abrupt change in the middle of the septum, together with the clinical cases, suggest the septum to be a morphologically and functionally bilayered structure potentially supplied by different coronary arteries. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the diagnostic accuracy of 16 slice computed tomography (CT) in determining plaque morphology and composition in an experimental selling. The results were compared with histopathological analysis as the reference standard. Methods: Nine human popliteal arteries derived from amputations because of atherosclerotic disease were investigated with multislice spiral CT (MSCT). Atherosclerotic lesions were morphologically classified (completely or partially occlusive, concentric, eccentric), and tissue densities were determined within these plaques. In addition, vessel dimensions were quantitatively measured. Results: The results were compared with histological analysis. The concordance index K for morphological classification was 0.88. Plaque density (n = 51 lesions) was significantly different (p < 0.0001) between lipid rich, fibrotic, and calcified lesions (Story stage Ill: n = 2, 58 (8) Hounsfield units (HU); Story V: n = 11 ,50 (21)HU;Stary Vl: n = 14, 96(42) HU;Stary VII:n = 6 ,858 (263)HU;Stary VIII:n = 18, 126 (99) HU). The concordance index K for the classification of plaques based on density was 0.51. Vessel dimensions had a good correlation (r = 0.98). Conclusions: 16 slice CT was found to be a reliable non-invasive imaging technique for assessing atherosclerotic plaque morphology and composition. Although calcified lesions can be differentiated from non-calcified lesions, the diagnostic accuracy in further subclassifying non-calcified plaques as lipid rich and fibrotic is low, even under experimental conditions. [ABSTRACT FROM AUTHOR]

Objectives: To clarify the value of cycle dependent variation of myocardial integrated backscatter (CY-IB) analysis, which non-invasively measures acoustic properties of the myocardium, for early detection of cardiac involvement in patients with sarcoidosis. Methods: The study population consisted of 22 consecutive patients with biopsy proven sarcoidosis who did not have any abnormal findings on conventional two dimensional echocardiogram. Cardiac sarcoidosis was diagnosed by radionuclide testing including thallium-201 scintigraphy, gallium-67 scintigraphy, and cardiac fluorine- 18-deoxyglucose positron emission tomography. The magnitude and delay of the CV-IB were analysed in the basal mid septum and the basal mid posterior wall of the left ventricle of all patients. Results: The patients were divided into two groups: 8 patients with cardiac involvement and 14 patients without cardiac involvement. In the basal septum, a major reduction in the magnitude (mean (SD) 1.8(4.4) v 6.6 (l.3),p = 0.012) and an increase in the time delay (1.3 (0.5) v 1.0(0.1), p = 0.038) of CY-IB were observed in patients with cardiac sarcoidosis even in the absence of two dimensional echocardiographic abnormalities. The sensitivity for detecting cardiac involvement was such that the magnitude of CY-IB in the basal septum discriminated 75% of patients with cardiac sarcoidosis from those with non-cardiac sarcoidosis, whereas two dimensional echocardiographic parameters did not discriminate between these two groups. Conclusions: The CY-IB is decreased in the basal septum in patients with cardiac sarcoidosis even in the absence of two dimensional echocardiographic abnormalities. Analysis of CV-IB may be a useful method to detect early myocardial involvement in patients with sarcoidosis. [ABSTRACT FROM AUTHOR]

Objective: To examine the relation between longitudinal left ventricular function assessed by tissue Doppler imaging (TDi) and exercise capacity in heart failure. Subjects: 153 patients with chronic heart failure from left ventricular systolic dysfunction (election fraction < 45%) and 87 age and sex matched controls. Methods: Echocardiography was used to measure conventional indices of left ventricular systolic function. TDi was used to assess left and right ventricular longitudinal function by measuring mitral and lateral tricuspid annular velocities during the cardiac cycle. Velocities measured at each point were the systolic peak (Sm) and the diastolic troughs (Em and Am), corresponding to passive and active (atrial) left ventricular filling. Each patient also underwent treadmill exercise testing with metabolic gas exchange measurements. Results: Left and right ventricular TDi velocities were greater in controls than in patients. Left ventricular ejection fraction (LVEF) correlated with Sm (r = 0.30, p = 0.0005), but not with Em, Am, or the Em/Am ratio. There were no significant differences between New York Heart Association (NYHA) functional class for any of the TDi variables. Right ventricular indices were not related to exercise capacity. Systolic myocardial motion measured by TDi correlated more closely with peak oxygen consumption (p&Vdot;o2) (r = 0.35, p <0.0001) than LVEF (r = 0.21, p <0.02). The Em/Am ratio was not correlated with p&Vdot;o2. In multiple regression, Sm was the only left ventricular TDi variable to predict exercise capacity independently (p < 0.05). Conclusions: Exercise capacity and symptoms are poorly related to conventional measures of cardiac function and more closely correlated with indices of longitudinal left ventricular function as assessed by TDi. [ABSTRACT FROM AUTHOR]

Objective: To make a prospective assessment of the clinical and prognostic correlates of angiographically diffuse non-obstructive coronary lesions.Design: Angiographic vessel and extent scores were calculated in 228 clinically stable patients (mean (SD) age, 60 (11) years; 43 women, 185 men) undergoing prospective follow up for the composite end point of death and myocardial infarction. The effect on outcome of clinical variables (age, sex, previous myocardial infarction, diabetes mellitus, smoking habit, systemic hypertension, hypercholesterolaemia, ejection fraction) and angiographic variables (vessel and extent score) was evaluated by Cox's proportion hazard model.Results: The vessel score was 3 in 34 patients (15%), 2 in 78 (34%), 1 in 87 (38%), and 0 in 29 (13%). Median extent score was 60 (range 6-110; first quartile 40, third quartile 70). Forty one events (nine deaths and 32 myocardial infarcts) occurred over a median follow up period of 30 months. Age and extent score were the only multivariate predictors of outcome, but the latter provided 28% additional prognostic information after adjustment for the most predictive variables (gain in chi2 = 7, p < 0.01). A vessel score of 3 was associated with worse survival, while no significant discrimination was possible among the other groups. However, assignment of patients to two groups according to an ROC curve derived cut off value for the extent score made it possible to obtain significant discrimination of survival even in cases with vessel scores of 0 to 2. Age and diabetes were clinical markers of a higher extent score.Conclusions: The angiographic extent score is a powerful marker of adverse outcome independent of severity and the number of flow limiting coronary lesions, and may reflect the link between clinical risk profile and diffusion of coronary atherosclerosis. Thus it should be of clinical value for targeting aggressive preventive measures. [ABSTRACT FROM AUTHOR]

Background: Intravenous myocardial contrast echocardiography with harmonic power Doppler imaging (HPDI) enables assessment of myocardial perfusion. Its accuracy in comparison with positron emission tomography (PET), which is one of the most reliable clinical gold standards for myocardial perfusion, remains to be determined. Objective: To assess the ability of HPDI to identify myocardial perfusion abnormalities, using PET as a gold standard. Methods: 23 patients with myocardial infarction underwent HPDI. Images were obtained from the apical two and four chamber views at pulsing intervals of one to eight cardiac cycles with continuous infusion of Levovist (Schering, Germany). PET was done within two weeks of HPDI. The left ventricle was divided into 12 segments and myocardial opacification by HPDI and uptake of NH3 by PET in each segment was graded as normal, mildly reduced, or severely reduced. Results: Of the 276 segments examined, adequate image quality was obtained in 226 (82%) by HPDI; 50 segments were excluded because of inadequate image quality. There were more exclusions in the basal segments than in the mid or apical segments (p < 0.0001 ). Of the 226 segments analysed, overall concordance between HPDI and PET was 82% (κ = 0.70). In the apex, more segments were overestimated by HPDI than were underestimated (χ⊃2; = 6.25, p = 0.012). Conclusions: HPDI and PET gave similar results in the assessment of myocardial perfusion abnormalities. However, poor image quality in the basal segments and overestimation of perfusion in the apical segments are current limitations of HPDI. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the relation between coronary flow reserve (CFR), coronary zero flow pressure (Pzf), and residual myocardial viability in patients with acute myocardial infarction.Designs: Prospective study.Setting: Primary care hospital.Patients: 27 consecutive patients with acute anterior myocardial infarction.Main Outcome Measures: F-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in 27 patients who underwent successful intervention within 12 hours of onset of a first acute anterior myocardial infarction. Within three days before discharge they had < 25% stenosis in the culprit lesion as determined by angiography 24 (3) days after acute myocardial infarction. Pzf and the slope index of the flow-pressure relation (SIFP) were calculated from the simultaneously recorded aortic pressure and coronary flow velocity signals at peak hyperaemia.%FDG was quantified by comparing FDG uptake in the infarct myocardium with FDG uptake in the normal myocardium.Results: There was a correlation between %FDG and CFR, where y = -1.477x + 62.517, r = -0.072 (NS). There was also a correlation between %FDG and SIFP, where y = -0.975x + 60.542, r = -0.045 (NS), and a significant correlation between %FDG and Pzf, where y = -0.98x + 85.108, r = -0.696 (p < 0.001).Conclusions: CFR does not correlate with FDG-PET at the time of postreperfusion evaluation of residual myocardial viability. The parameter that correlates best with residual myocardial viability is Pzf and this may be a useful index for predicting patient prognosis. [ABSTRACT FROM AUTHOR]

Objective: To study the possible occurrence of left ventricular (LV) systolic and diastolic asynchrony in patients with systolic heart failure (HF) and narrow QRS complexes.Design: Prospective study.Setting: University teaching hospital.Patients: 200 subjects were studied by echocardiography. 67 patients had HF and narrow QRS complexes (< or = 120 ms), 45 patients had HF and wide QRS complexes (> 120 ms), and 88 served as normal controls.Interventions: Echocardiography with tissue Doppler imaging was performed using a six basal, six mid-segmental model.Main Outcome Measures: Severity and prevalence of systolic and diastolic asynchrony, as assessed by the maximal difference in time to peak myocardial systolic contraction (T(S)) and early diastolic relaxation (T(E)), and the standard deviation of T(S) (T(S)-SD) and of T(E) (T(E)-SD) of the 12 LV segments.Results: The mean (SD) maximal difference in T(S) (controls 53 (23) ms v narrow QRS 107 (54) ms v wide QRS 130 (51) ms, both p < 0.001 v controls) and in T(S)-SD (controls 17.0 (7.8) ms v narrow QRS 33.8 (16.9) ms v wide QRS 42.0 (16.5) ms, both p < 0.001 v controls) was prolonged in the narrow QRS group compared with normal controls. Similarly, the maximal difference in T(E) (controls 59 (19) ms v narrow QRS 104 (71) ms v wide QRS 148 (87) ms, both p < 0.001 v controls) and in T(E)-SD (controls 18.5 (5.8) ms v narrow QRS 33.3 (27.7) ms v wide QRS 48.6 (30.2) ms, both p < 0.001 v controls) was prolonged in the narrow QRS group. The prevalence of systolic and diastolic asynchrony was 51% and 46%, respectively, in the narrow QRS group, and 73% and 69%, respectively, in the wide QRS group. Stepwise multiple regression analysis showed that a low mean myocardial systolic velocity from the six basal LV segments and a large LV end systolic diameter were independent predictors of systolic asynchrony, while a low mean myocardial early diastolic velocity and QRS complex duration were independent predictors of diastolic asynchrony.Conclusions: LV systolic and diastolic mechanical asynchrony is common in patients with HF with narrow QRS complexes. As QRS complex duration is not a determinant of systolic asynchrony, it implies that assessment of intraventricular synchronicity is probably more important than QRS duration in considering cardiac resynchronisation treatment. [ABSTRACT FROM AUTHOR]

Objective: To explore the application of a new 10 French intracardiac echocardiography (ICE) catheter with phased array and Doppler capable transducer for the assessment of epicardial and intramyocardial coronary blood flow.Methods: The coronary arteries were detected by cross sectional imaging in seven closed chest dogs, and coronary blood flow visualised by colour Doppler. Blood flow velocities were recorded by pulsed Doppler at baseline for reproducibility of repeated measurements, and during hyperaemia for coronary flow reserve measurements. Comparisons were made with Doppler guide wire data obtained simultaneously. Intramyocardial coronary artery blood flow was assessed by colour flow mapping, and the blood flow velocities recorded using pulsed Doppler at baseline and during hyperaemia.Results: Seven left main, six left anterior descending, seven left circumflex, and five right coronary arteries were visualised in the seven animals by cross sectional or colour Doppler imaging. Repeated measurements of coronary flow velocity showed a good correlation (mean diastolic velocity, r = 0.93, n = 22, p < 0.0001; peak diastolic velocity, r = 0.96, n = 22, p < 0.0001, respectively). Intraobserver/interobserver variability was satisfactorily low. Coronary flow reserve from ICE correlated highly with the value obtained from the Doppler guide wire (r = 0.90, n = 26, p < 0.0001). Intramyocardial coronary blood flow was identified in all seven dogs, and flow velocities were recorded at baseline and during hyperaemia in four animals.Conclusions: This new ICE catheter provides high quality diagnostic resolution. It is useful for coronary blood flow assessment. [ABSTRACT FROM AUTHOR]

Explores the role of intravascular ultrasound for a contemporary understanding of coronary artery disease. Confirmation of atherosclerotic diseases; Insights into the percutaneous coronary interventions; Assessment of atheroma burden and vulnerability.

Background: Transmitral Doppler Flow indices are used to evaluate diastolic function. Recently, velocities measured by Doppler tissue imaging have been used as an index of left ventricular relaxation. Objective: To determine whether Doppler tissue velocities are influenced by alterations in preload. Methods: Left ventricular preload was altered in 17 patients (all men, mean (SD) age, 49 (8) years) during echocardiographic measurements of left ventricular end diastolic volume, maximum left atrial area, peak early Doppler filling velocity, and left ventricular myocardial velocities during early filling. Preload altering manoeuvres included Trendelenberg (stage 1), reverse Trendelenberg (stage 2), and amyl nitrate (stage 3). Systolic blood pressure was measured at each stage. Results: In comparison with baseline, left ventricular end diastolic volume (p = 0.001), left atrial area (p = 0.003), peak early mitral Doppler filling velocity (p = 0.01), and systolic blood pressures (p = 0.001) were all changed by preload altering manoeuvres. Only left ventricular myocardial velocity during early filling remained unchanged by these manoeuvres. Conclusions: In contrast to standard transmitral Doppler filling indices, Doppler tissue early diastolic velocities are not significantly affected by physiological manoeuvres that alter preload. Thus Doppler tissue velocities during early left ventricular diastole may provide a better index of diastolic function in cardiac patients by providing a preload independent assessment of left ventricular filling. [ABSTRACT FROM AUTHOR]

Background: With faster image acquisition times and thinner slice widths, multislice detector computed tomography (MSCT) allows visualisation of human coronary arteries with diagnostic image quality. In addition to conventional axial slices, virtual coronary angioscopies (VCA) can be reconstructed using MSCT datasets.Objective: To evaluate the feasibility of reconstructing VCA and to determine the clinical value of this new application in detecting atherosclerotic coronary artery lesions.Methods: Datasets obtained by contrast enhanced non-invasive coronary angiography using MSCT (Somatom VZ) were analysed from 14 consecutive patients. VCA were simulated in 14 coronary arteries (left anterior descending, n = 7; right coronary, n = 7). Lesion detection was undertaken on conventional contrast enhanced axial slices, as well as by VCA. Intracoronary ultrasound (ICUS) was used as the gold standard for in vivo plaque detection.Results: 38 lesions were detected both on ICUS and on axial slices: 14 severe target lesions of > 75% area stenosis (11 calcified, three non-calcified), and 24 intermediate lesions of < or = 75% area stenosis (seven calcified, 17 non-calcified). Using VCA, all severe lesions (n = 14) and all calcified intermediate plaques (n = 7) could clearly be identified. However, non-calcified intermediate lesions (n = 17) could not be accurately distinguished from the vessel wall; they were recognised as vessel wall alterations without significant luminal narrowing.Conclusions: Current MSCT technology allows reconstruction of VCA with good image quality. Despite a more anatomical view of heart and coronary vessels on three dimensional reconstruction, conventional axial slices were found to be superior for detecting coronary lesions. Thus further technical innovations are required before VCA can become a useful technique in clinical cardiology. [ABSTRACT FROM AUTHOR]

Objective -- To test the hypothesis that diastolic mitral annular motion velocity, as determined by Doppler tissue imaging and left ventricular diastolic flow propagation velocity, is related to the histological degree of heart transplant rejection according to the International Society of Heart and Lung Transplantation (ISHLT). Methods -- In 41 heart transplant recipients undergoing 151 myocardial biopsies, the following Doppler echocardiographic measurements were performed within one hour of biopsy: transmitral and pulmonary vein flow indices; mitral annular motion velocity indices; left ventricular diastolic flow propagation velocity. Results -- Late diastolic mitral annular motion velocity (ADTI) and mitral annular systolic contraction velocity (SCDTI) were higher in patients with ISHLT < IIIA than in those with ISHLT &ges; IIIA (ADTI, 8.8 cm/s v 7.7 cm/s (p = 0.03); SCDTI, 19.3 cm/s v 9.3 cm/s (p < 0.05)). Sensitivity and specificity of ADTI < 8.7 cm/s (the best cut off value) in predicting significant heart transplant rejection were 82% and 53%, respectively. Early diastolic mitral annular motion velocity (EDTI) and flow propagation velocity were not related to the histological degree of heart transplant rejection. Conclusions -- Doppler tissue imaging of the mitral annulus is useful in diagnosing heart transplant rejection because a high late diastolic mitral annular motion velocity can reliably exclude severe rejection. However, a reduced late diastolic mitral annular motion velocity cannot predict severe rejection reliably because it is not specific enough. [ABSTRACT FROM AUTHOR]

Several photographs of the secundum atrial septal defect (ASD) diagnosis of a 34-year old woman is presented.

The article discusses a study regarding the use of intravascular ultrasound (IVUS) in comparing plaque morphology in acute myocardial infarction and stable angina pectoris. The study used plaque morphology to assess the visual usage of IVUS. Results show that there were no differences in plaque eccentricity or calcification between the two groups of patients, but low echoic thrombus and echolucent areas were more common in the infarction group.

Objective: To examine demographic and clinical characteristics of patients with acute myocardial infarction in order to identify factors affecting the electrocardiographic evolution of injury.Methods: Prospective cohort study of 1399 consecutive patients with a first myocardial infarction. Baseline clinical data associated with ST elevation and Q wave development were identified and 12 month survival was estimated.Results: Smoking had complex effects on the evolution of injury, increasing the odds of ST elevation (odds ratio (OR) 1.61; 95% confidence interval (CI) 1.08 to 2.36), but reducing the odds of Q wave development (OR 0.69, 95% CI 0.49 to 0.96). The effects of previous aspirin treatment were more consistent with reductions in the odds of ST elevation (OR 0.57, 95% CI 0.35 to 0.94) and Q wave development (OR 0.53, 95% CI 0.34 to 0. 84). ST elevation and Q wave development were both associated with an adverse prognosis, with estimated 12 month survival rates of 80. 6% (95% CI 78.2% to 83.1%) and 80.0% (95% CI 77.5% to 82.5%), respectively, compared with 86.5% (95% CI 81.2% to 91.9%) and 89.9% (95% CI 86.2% to 93.7%) for patients without these ECG changes.Conclusions: The thrombogenicity of the blood may be a major determinant of infarct severity. Smoking increases thrombogenicity and the likelihood of ST elevation, but because coronary occlusion is relatively more thrombotic in smokers, responses to both endogenous and exogenous thrombolysis are better, reducing the risk of Q wave development. Previous aspirin treatment reduces thrombogenicity, protecting against ST elevation and Q wave development. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility of anatomical correction based on morphological and echocardiographic findings in patients and preserved hearts with discordant atrioventricular connections.Design: A retrospective study with clinicomorphological correlations to assess potential contraindications for anatomical correction in the setting of discordant atrioventricular connections.Setting: A tertiary referral centre for congenital heart disease.Material: 25 specimens and 53 patients unified by presence of discordant atrioventricular connections.Methods: The potential contraindications for anatomical correction were first evaluated on the basis of morphological findings in all 25 specimens with discordant atrioventricular connections collected in the department museum, including study of the major coronary arterial patterns in 20. These contraindications were then sought in a population of 53 patients examined echocardiographically between January 1992 and October 1997.Results: At least one lesion was discovered that might have contraindicated anatomical correction in 14 of the specimens and in 16 of the patients. The most common lesions that might militate against the anatomical approach were severe Ebstein's malformation or straddling and overriding of the tricuspid valve, each when combined with hypoplasia of the morphologically right ventricle. Other potential contraindications were atrioventricular septal defect with common atrioventricular junction, and obstruction of the left ventricular outlet combined with a restrictive ventricular septal defect, although these may be overcome with increasing experience and expertise.Conclusions: According to the morphological and echocardiographic findings, at least 10 hearts and 37 patients would have produced no anatomical problems for the type of surgical correction in which the morphologically left ventricle is restored its rightful role as the systemic pumping chamber. [ABSTRACT FROM AUTHOR]

Objective: To evaluate changes in coronary artery spasticity in patients with vasospastic angina who had been stable for years under continuous drug treatment.Methods: Follow up coronary angiography was performed under intracoronary ergonovine provocation in 27 well controlled patients with vasospastic angina and no organic stenosis; the tests were done > 24 months after the initial coronary angiography, in which occlusive spasm had been induced by the same regimen of ergonovine provocation.Results: The mean (SD) follow up period was 47.2 (21.6) months. All patients had been free from angina attack for more than 24 months under treatment with antianginal drugs. During this follow up period, organic stenosis developed in only one case. Occlusive spasm was observed during follow up coronary angiography in 23 patients. Spasm with 90% narrowing was observed in three other patients, and diffuse significant narrowing was seen in the final patient. No significant difference was found in spasticity (p = 0.75) between the initial and the follow up tests.Conclusions: Repeated ergonovine provocation during coronary angiography after a controlled period of several years showed that coronary spasm remains inducible in most patients. Discontinuance of drug treatment during the remission from anginal attacks achieved by medication may put the patient at high risk. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To use transthoracic Doppler echocardiography to assess coronary blood flow non-invasively in patients with hypertrophic cardiomyopathy. DESIGN: High frequency transthoracic Doppler echocardiography was used to assess resting phasic coronary velocity patterns in patients with hypertrophic cardiomyopathy and to define the relation between coronary flow patterns and clinical, echocardiographic, and haemodynamic manifestations of this condition. SETTING: A tertiary referral cardiothoracic centre. METHODS: Fifteen patients (10 men and five women, mean (SD) age 49 (10.3) years) with asymmetric hypertrophic cardiomyopathy underwent high frequency (5 MHz) transthoracic Doppler echocardiographic assessment of the left anterior descending coronary artery. In addition, standard two dimensional echocardiography was performed. The results were compared with 16 normal participants (nine men and seven women, mean age 61.2 (10.7) years) who had no evidence of cardiac disease. RESULTS: Biphasic diastolic predominant coronary artery blood velocity profiles were obtained in all patients and controls. Systolic peak blood velocity and velocity time integral were significantly reduced in the hypertrophic cardiomyopathy group compared with controls (11.3 (15.8) cm/s and 1.09 (1.78) cm v 20.5 (13.1) cm/s and 4.23 (2.80) cm, respectively, P < 0.05). A reversed pattern of systolic blood flow velocity was found in three patients with severe anterior wall and septal hypertrophy. During diastole there was prolongation of the diastolic acceleration (203 (53) ms v 110 (60) ms in controls, P < 0.05) and deceleration times (487 (200) ms v 210 (90) ms in controls, P < 0.05). There was no significant difference between those with and without symptoms or a left ventricular outflow tract gradient. CONCLUSIONS: Patients with hypertrophic cardiomyopathy have abnormal systolic and diastolic coronary flow profiles at rest when measured by transthoracic echocardiography. [ABSTRACT FROM PUBLISHER]

BACKGROUND: Left ventricular hypertrophy is associated with an increased risk of cardiovascular morbidity and mortality. Previous studies have shown that patients with left ventricular hypertrophy develop electrocardiographic changes and left ventricular dysfunction during acute hypotension, and suggest that the lower end of autoregulation may be shifted upwards. AIM: To measure coronary blood flow (velocity) and flow reserve during acute hypotension in patients with left ventricular hypertrophy. PATIENTS: Eight patients with atypical chest pain and seven with hypertensive left ventricular hypertrophy; all with angiographically normal epicardial vessels. SETTING: Tertiary referral centre. METHODS: The physiological range of blood pressure was determined by previous ambulatory monitoring. Left ventricular mass was determined by echocardiography. At cardiac catheterisation, left coronary blood flow velocity was measured using a Judkins style Doppler tipped catheter. During acute hypotension with sodium nitroprusside, coronary blood flow velocity was recorded at rest and during maximal hyperaemia induced by intracoronary injection of adenosine. Quantitative coronary angiography was performed manually. RESULTS: For both groups coronary blood flow velocity remained relatively constant over a range of physiological diastolic blood pressures and showed a steep relation with diastolic blood pressure during maximal hyperaemia with intracoronary adenosine. Absolute coronary blood flow (calculated from quantitative angiographic data), standardised for left ventricular mass, showed reduced flow in the hypertensive group at rest and during maximal vasodilatation. CONCLUSION: The results are consistent with an inadequate blood supply to the hypertrophied heart, but no upward shift of the lower end of the autoregulatory range was observed. [ABSTRACT FROM PUBLISHER]

Magnetic resonance coronary angiography, electron beam computed tomography, and multi-slice computed tomography have recently emerged as new noninvasive diagnostic techniques that possess the potential to replace conventional diagnostic angiography. The article also presents a table, which shows diagnostic accuracy to detect a significant coronary stenosis. However, firstly it should be noted that the diagnostic value only concerns the detection of stenoses in the proximal and mid segment of the coronary tree, because the smaller distal segments cannot be adequately visualized. Secondly, only in 70-80 % of these proximal and mid segments is image quality sufficient to allow a semi quantitative assessment.

The non-invasive detection of coronary artery disease is a prime goal for future developments in clinical cardiology. In addition to the documentation of significant tenses, the detection of vulnerable plaques is of major importance for risk stratification and early treatment, in order to prevent plaque ruptures. Recently, a new generation of fast spiral computed tomography scanners has been introduced using a multi-slice technique. The study protocol was approved by the local ethical committee and patients gave informed consent before inclusion in the study.

Objective: To examine the incidence and outcome of cardiac catheter complications related to left main coronary artery disease or damage using the CECCC (Confidential Enquiry into Cardiac Catheter Complications) database.Setting: Coordinating centre for national database.Design: Retrospective analysis of reports to a national multicentre database for cardiac catheter complications. Complications involving the left main coronary artery were flagged at entry. Where necessary additional information was sought from participating centres. 112,921 procedures were registered, 12,849 of which were coronary angioplasties and the remainder diagnostic studies.Results: The total number of cases for which complications were recorded was 993 (0.88%). In 61 (6.14%) of the 993 cases complications were associated with left main coronary disease or damage. In 57 (93%) of these 61 cases complications were major, necessitating resuscitation or immediate coronary bypass grafting. Ten patients (16%) died in the catheter laboratory, a further 9 (15%) within 24 hours, and a total of 23 patients (38%) died within one month of the procedure. Left main stem related complications account for 17% of total mortality in the CECCC database. Urgent coronary bypass grafting was attempted in 42 patients, of whom 31 were alive at one month. In all of the six reported PTCA-related complications the cause was traumatic damage to the left main coronary artery. Operators of all grades of seniority experienced complications in similar proportions.Conclusions: The risk of a complication relating to the left main stem is relatively low, but when such complications occur they tend to be life-threatening and contribute a fifth of total catheter-related mortality. In the absence of a widely available non-invasive investigation with good predictive value for left main stem disease, the best safeguard is careful technique. Patients who do develop complications should have emergency coronary bypass grafting. [ABSTRACT FROM AUTHOR]