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Abstract: Advances in medical imaging now make it possible to investigate any patient with cardiovascular disease using multiple methods which vary widely in their technical requirements, benefits, limitations, and costs. The appropriate use of alternative tests requires their integration into joint clinical diagnostic services where experts in all methods collaborate. This statement summarises the principles that should guide developments in cardiovascular diagnostic services. [Copyright &y& Elsevier]

Abstract: The current report describes a rare case of a pseudotumor in the left ventricle. Transthoracic and transesophageal echocardiography demonstrated a round, echodense, mobile mass attached to the posterior mitral leaflet and annulus. At surgical exploration caseous annular calcification of the posterior mitral leaflet was diagnosed. After resection of the mass, successful mitral valvular plasty was performed. Review of the literature indicated that mitral annular calcification is associated with an increased risk of stroke. Optimal treatment may be surgery, especially when valve plasty can be performed, although randomized trials are currently lacking. [Copyright &y& Elsevier]

Abstract: The current report describes a case of a primary cardiac lymphoma. For early and appropriate treatment of a cardiac mass it is not only important to determine its localization and extension but also to differentiate between malignant and benign lesions. This report demonstrates that not only transthoracic echocardiography but also the other different forms of echocardiography such as transesophageal echocardiography, as well as contrast and intracardiac echocardiography, are useful tools in the diagnostic workup of cardiac masses. [Copyright &y& Elsevier]

Abstract: This editorial refers to the paper of R. Sharma et al. entitled “Dobutamine stress echocardiography and cardiac troponin T for the detection of significant coronary artery disease and predicting outcome in renal transplant candidates”. The editorial discusses different strategies for cardiac risk assessment in patients with end-stage renal disease undergoing renal transplantation. [Copyright &y& Elsevier]

Abstract: Transesophageal echocardiography (TEE) is a valuable technique to assess mitral valve anatomy and the mechanism of mitral regurgitation (MR). We present the case of a 35-year-old woman with severe MR due to restrictive motion of the posterior mitral leaflet, who was referred for mitral annuloplasty. Under physiologic circumstances, a severe (grade 3+) MR was present, whereas in the operating room during general anesthesia, the MR had disappeared almost completely. The downgrading of MR due to general anesthesia and the associated mechanisms of this phenomenon are discussed in this case. [Copyright &y& Elsevier]

Two-dimensional echocardiography is a valuable tool in visualizing and monitoring aortic valve and root abnormalities. We present a rare case of a patient with massive aortic regurgitation due to cusp aneurysm, which was accurately diagnosed by echocardiography and treated by valve replacement. A complicated course with recurrent aneurysms of the aortic wall after aortic valve replacement was remarkable in this case. Although different possible etiologies could not be determined, endocarditis and/or aortitis may be the most likely explanation of the complicated and finally fatal course of this patient. [ABSTRACT FROM AUTHOR]

Aims: Ventricular tachycardia (VT) frequently has an anatomical substrate. Identification of areas prone to arrhythmogenicity facilitates radiofrequency catheter ablation (RFCA). Furthermore, direct monitoring of complications potentially increases safety of RFCA. The aim of this study was to evaluate the feasibility of guiding RFCA of VT with intracardiac echocardiography (ICE), in order to improve outcome and procedural safety.Methods and Results: Eleven patients (age 59 ± 15) with drug-refractory VT of various etiologies were studied. VT mapping and ablation were performed using standard techniques. ICE was performed with a multifrequency (5–10 MHz) phased-array transducer positioned in the right ventricle. Twenty different VTs were treated (CL 352 ± 120 ms, 2.0±0.9 VT per patient). LV a- or dyskinesia was identified in all post-infarct patients. In patients with arrhythmogenic right ventricular dysplasia, right ventricular aneurysms and dyskinesia could be identified. In all patients catheter position and tip-tissue contact could easily be monitored with ICE. Procedural success (non-inducibility of hemodynamically stable VT) was achieved in all patients. Complications did not occur.Conclusion: ICE is feasible in guiding RFCA of VT of different etiologies. The use of ICE in adjunction with fluoroscopy and mapping procedures will facilitate treatment of VT and may contribute to the safety of the procedure. [ABSTRACT FROM AUTHOR]

Cardiac resynchronisation therapy (CRT) has been shown to improve symptoms, exercise capacity and left ventricular function, as well as a reduction in morbidity/mortality in heart failure patients. Failures following initial success of this treatment are mostly related to lead dislodgement. Another entirely different reason is presented in this case study. [Copyright &y& Elsevier]

Aims: To evaluate whether repetitive assessment of systolic and diastolic cardiac function by dobutamine stress echocardiography (DSE) can predict anthracycline cardiotoxicity.Methods and results: Thirty-one patients (age, 57±13 years, 22 male) were studied before chemotherapy, with follow-ups during, at the end, and 6 months after chemotherapy. Left ventricular (LV) function was assessed by two-dimensional (2D) echocardiographic wall motion score index (WMSI) and by Doppler echocardiography of mitral valve inflow at rest and during DSE. Radionuclide ventriculography was used as an independent reference for ejection fraction (EF). A reduction of EF ≥5% occurred in 17 patients (group A) at the last follow-up. Patients without decreased EF comprised group B. Early/late diastolic velocity of mitral inflow (E/A ratio) at rest was lower in group A (0.91±0.2 vs 1.28±0.3, P<0.001), and it was an independent predictor of cardiotoxicity (adjusted for baseline patient characteristics and parameters of systolic and diastolic function). At follow-up, WMSI at rest paralleled radionuclide EF. Contractile reserve at low-dose DSE was preserved in group A.Conclusions: WMSI measured by 2D echocardiography parallels radionuclide EF at follow-up. Assessment of contractile reserve has no incremental value for the early detection of cardiotoxicity. A baseline abnormal E/A ratio is an independent predictor of anthracycline cardiotoxicity. [ABSTRACT FROM AUTHOR]

Dobutamine stress echocardiography is an established diagnostic method for the detection of myocardial viability in patients with severe left ventricular dysfunction[1]. The presence of viable myocardium identifies patients who will benefit from coronary revascularization, by improving both functional capacity and long-term survival. Occasionally, dobutamine infusion has been combined with other stressors, such as post-extrasystolic potentiation, in order to improve accuracy. The contractile reserve after combined dobutamine infusion and post-extrasystolic potentiation can be quantified by pulsed wave tissue Doppler imaging. We describe a patient with severe left ventricular dysfunction, in which pulsed wave tissue Doppler imaging allowed to demonstrate that post-extrasystolic potentiation superimposed on dobutamine infusion is able to further recruit contractile reserve, as compared to dobutamine infusion alone. A nuclear scan assessing glucose utilization was used as a reference. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM AUTHOR]

The article presents a case study which describes the use of various imaging modalities in atrial fibrillation treatment by radiofrequency catheter ablation in a 30-year-old male who admitted to the hospital because of symptomatic paroxysmal atrial fibrillation. Electrocardiography (ECG) shows sinus rhythm and transthoracic echocardiography was normal except the enlargement of left atrium. It mentions that radiofrequency catheter ablation was used to cure atrial fibrillation.

Objective: To assess the prevalence of myocardial viability by technetium-99m (Tc-99m)-tetrofosmin/ fluorine-18-fluorodeoxyglucose (FDG) single photon emission computed tomography (SPECT) in patients with ischaemic cardiomyopathy. Design: A retrospective observational study. Setting: Thoraxcenter Rotterdam (a tertiary referral centre). Patients: 104 patients with chronic coronary artery disease and severely depressed left ventricular function presenting with heart failure symptoms. Main outcome measures: Prevalence of myocardial viability as evaluated by Tc-99m-tetrofosmin/ FDG SPECT imaging. Two strategies for assessing viability in dysfunctional myocardium were used: perfusion imaging alone, and the combination of perfusion and metabolic imaging. Results: On perfusion imaging alone, 56 patients (54%) had a significant amount of viable myocardium, whereas 48 patients (46%) did not. Among the 48 patients with no significant viability by perfusion imaging alone, seven additional patients (15%) had significantly viable myocardium on combined perfusion and metabolic imaging. Thus with a combination of perfusion and metabolic imaging, 63 patients (61%) had viable myocardium and 41 (39%) did not. Conclusions: On the basis of the presence of viable dysfunctional myocardium, 61% of patients with chronic coronary artery disease and depressed left ventricular ejection fraction presenting with heart failure symptoms may be considered for coronary revascularisation. The combination of perfusion and metabolic imaging identified more patients with significant viability than myocardial perfusion imaging alone. [ABSTRACT FROM AUTHOR]

Aims To test the diagnostic potential of a hand-held ultrasound device for screening for left ventricular hypertrophy in a hypertensive population using a standard echocardiographic system as a reference.Methods One hundred consecutive hypertensive patients were enrolled. An experienced investigator performed measurements of the thickness of the anterior septum and posterior wall using the parasternal 2D-long axis view and the end-diastolic dimension of the left ventricle with both imaging devices. Left ventricular hypertrophy was defined as an increase in left ventricular mass ≥134g.m−2 for men and ≥110g.m−2 for women, when indexed for body surface area and ≥143g.m−1 for men and ≥102g.m−1 for women, when indexed for height.Results Sixty-five men and 35 women were studied (age 60±11 years); mean duration of hypertension: 13±11 years; mean blood pressures: systolic 150±20mmHg and diastolic 89±11mmHg. The anterior septum and posterior wall were visualized in all patients with both imaging devices. The standard echocardiographic system identified left ventricular hypertrophy by body surface area in 18 (18%) patients and by height in 26 (26%) patients. The agreement between the standard echocardiographic system and the hand-held device for the assessment of left ventricular hypertrophy was 93%, kappa: 0·77 (left ventricular mass/body surface area) and 90%, kappa: 0·76 (left ventricular mass/height).Conclusions We conclude that hand-held devices can be effectively applied for screening for left ventricular hypertrophy in hypertensive patients. [ABSTRACT FROM PUBLISHER]

Aims To determine the degree of inter-institutional agreement in the assessment of dobutamine stress echocardiograms using modern stress echocardiographic technology in combination with standardized data acquisition and assessment criteria.Method and Results Among six experienced institutions, 150 dobutamine stress echocardiograms (dobutamine up to 40μg.kg−1 min−1 and atropine up to 1mg) were performed on patients with suspected coronary artery disease using fundamental and harmonic imaging following a consistent digital acquisition protocol. Each dobutamine stress echocardiogram was assessed at every institution regarding endocardial visibility and left ventricular wall motion without knowledge of any other data using standardized reading criteria. No patients were excluded due to poor image quality or inadequate stress level. Coronary angiography was performed within 4 weeks. Coronary angiography demonstrated significant coronary artery disease (≥50% diameter stenosis) in 87 patients. Using harmonic imaging an average of 5·2±0·9 institutions agreed on dobutamine stress echocardiogram results as being normal or abnormal (mean kappa 0·55; 95% CI 0·50–0·60). Agreement was higher in patients with no (equal assessment of dobutamine stress echocardiogram results by 5·5±0·8 institutions) or three-vessel coronary artery disease (5·4± 0·8 institutions) and lower in one- or two- vessel disease (5·0±0·9 and 5·2±1·0 institutions, respectively;P =0·041). Disagreement on test results was greater in only minor wall motion abnormalities. Agreement on dobutamine stress echocardiogram results was lower using fundamental imaging (mean kappa 0·49; 95% CI 0·44–0·54; P<0·01 vs harmonic imaging).Conclusion Modern echocardiographic technology in combination with standardized digital image processing and uniform reading criteria results in a higher inter-institutional agreement in the interpretation of dobutamine stress echocardiogram compared to historic reports. [ABSTRACT FROM PUBLISHER]

The article presents a study which investigates stress echocardiography prognostic value as an accessory to exercise electrocardiography (ECG) in simple acute myocardial infarction patient. The study includes 496 patients who underwent pharmacological stress echocardiography and high level exercise ECG. Results show that stress ECG gave incremental prognostic information after not complicated acute myocardial infarction compared with clinical data.

Aims To assess the accuracy of positron emission tomography to predict recovery of global cardiac function after revascularization in patients with coronary artery disease.Methods and Results One hundred and seventy-eight patients (157 male, 58±10 years) with coronary artery disease and left ventricular dysfunction (mean ejection fraction 39±14%) were enrolled in six European centres. They underwent a common protocol for the assessment of viability using18F-fluoro-2-deoxyglucose (FDG) positron emission tomography during a standardized euglycaemic hyperinsulinaemic glucose clamp before revascularization by either surgery (n=140) or angioplasty (n=38). Seven patients were excluded because of incomplete revascularization of a dysfunctional region. Based on the recovery of global ejection fraction 2–6 months after revascularization, patients were classified into two groups: 82 patients who had a >5% improvement in ejection fraction postoperatively, and 89 patients without postoperative ejection fraction improvement. Optimal cut-off points for postoperative improvement of global cardiac function were computed, using receiver operating curve analysis. The highest sensitivity (79%) and specificity (55%) for predicting postoperative ejection fraction improvement by positron emission tomography was found when three or more dysfunctional segments had a relative FDG uptake >45% of normal remote myocardium (overall accuracy 67%).Conclusions In a large cohort of coronary patients with impaired ejection fraction, FDG positron emission tomography demonstrated high sensitivity and moderate specificity to predict improvement of cardiac function after coronary revascularization. [ABSTRACT FROM PUBLISHER]

Aim To assess the long-term cardioprotective effect of bisoprolol in a randomized high-risk population after successful major vascular surgery. High-risk patients were defined by the presence of one or more cardiac risk factor(s) and a dobutamine echocardiography test positive for ischaemia.Methods 1351 patients were screened prior to surgery, 846 patients had one or more risk factor(s), and 173 of these patients also had ischaemia during dobutamine echocardiography. One hundred and twelve patients could be randomized for additional bisoprolol therapy or standard care. Eleven patients died in the peri-operative period (up to 1 month after surgery). Randomized patients continued bisoprolol or standard care after surgery. During follow-up of 101 survivors (median 22 months, range 11–30) cardiac death or myocardial infarction was noted. No patient was lost during follow-up.Results The incidence of cardiac events during follow-up in the bisoprolol group was 12% vs 32% in the standard care group (P=0·025). Cardiac death occurred in 15 patients, nine patients in the standard care and in six in the bisoprolol group; myocardial infarction occurred in six patients, five in the standard care and one in the bisoprolol group. The odds ratio for cardiac death or myocardial infarction after surgery in high-risk patients with additional bisoprolol therapy was 0·30 (0·11–0·83).Conclusions Bisoprolol significantly reduced long-term cardiac death and myocardial infarction in high-risk patients after successful major cardiac vascular surgery. [ABSTRACT FROM PUBLISHER]

Background Both nuclear imaging with F18-fluorodeoxyglucose and dobutamine stress echocardiography have been used to identify viable myocardium, although dobutamine–stress echocardiography has been demonstrated to be the less sensitive of the two.Aim To compare the accuracy of pulsed-wave Doppler tissue sampling with dobutamine–stress echocardiography for the detection of viable myocardium, using F18-fluorodeoxyglucose imaging as a reference.Methods Forty patients with chronic coronary artery disease and left ventricular dysfunction (mean ejection fraction 33±11%), underwent F18-fluorodeoxyglucose imaging, dobutamine–stress echocardiography and pulsed-wave Doppler tissue sampling. Evaluation was performed using a six-segment model.Results Visual assessment by resting echo was feasible in 230 out of 240 segments (96%); 177 (77%) segments showed severe dyssynergy at rest. F18-fluorodeoxyglucose imaging showed viability in 95 (54%) segments while 82 (46%) were non-viable. Ejection phase velocity at rest was not significantly different; ejection velocities during low-dose and peak-dose dobutamine, however, were significantly higher in viable myocardium (8·6±2·9 vs 6·0±1·8 and 9·3±31 vs 6·2±2·1cm.s−1). Using receiver operating characteristic curves the optimal cut-off value for viability assessment was an increase in the ejection phase velocity low-dose of 1±0·5cm.s−1, while 0±0·5cm.s−1predicted non-viability. The sensitivity and specificity (95%CI) of pulsed-wave Doppler tissue sampling and dobutamine–stress echocardiography for the prediction of viability was respectively 87% (82–92) vs 75% (67–81) (P<0·05) and 52% (44–59) vs 51% (45–59) (P=ns).Conclusions The sensitivity of pulsed-wave Doppler tissue sampling is superior to dobutamine–stress echocardiography for the assessment of myocardial viability. [ABSTRACT FROM PUBLISHER]