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Background: Dobutamine stress echocardiography (DSE) is frequently used in the evaluation of cardiac risk prior to orthotopic liver transplantation (OLT). In the general cardiac population, an inducible left ventricular outflow tract gradient (LVOT Δ) during DSE has variable prognostic importance. The purpose of this study was to determine the prevalence and clinical significance of LVOT Δ in patients undergoing OLT during DSE. Methods: Consecutive medical records of 106 patients who had undergone OLT at our institution from January 1997 until January 2002 were retrospectively analyzed and divided into two groups based on the presence (Group I, LVOT Δ > 36 mmHg) or absence (Group II, LVOT Δ≤ 36 mmHg) of a significant LVOT Δ measured during DSE. We determined any outcome differences between these two groups with regard to intraoperative hypotension, cardiac mortality, length of hospital stay, graft function, and renal function post-OLT. Results: Forty-six patients had an LVOT Δ > 36 mmHg (Group I) and 60 patients had LVOT Δ≤ 36 mmHg (Group II). Baseline demographics were similar in both groups. There was no significant overall difference in cardiac mortality between Group I versus Group II patients (0 versus 1 patient, respectively, P = 0.57). Intraoperative hypotension occurred in 4 patients in Group I versus 0 patient in Group II (P = 0.03). Length of stay, graft function, and postoperative renal function were similar in both groups. Conclusion: A significant LVOT Δ > 36 mmHg is a frequent finding occurring in 46/106 (43%) of patients who have DSE pre-OLT. Intraoperative hypotension is associated with patients having an LVOT Δ. However, post-OLT patients with significant LVOT Δ have a similar in-hospital outcome compared to patients without significant LVOT Δ.

I 1989, a survey of cardiac pacing revealed that 1 million people in the United States had an implanted pacemaker.1 As the general population ages, the number of patients with both an implanted pacemaker and symptoms suggestive of acute ischemia is certain to increase. Unfortunately, the diagnosis of acute ischemia in the presence of a paced rhythm is at best difficult. A discordant ST-segment elevation of 5 mm has previously been considered to be the most specific electrocardiographic criterion for acute myocardial infarction (AMI) in patients with ventricularpaced rhythm (VPR).2 The angiographic significance of such a finding has not been previously evaluated. We analyzed coronary angiograms of patients with VPR who were admitted for evaluation of acute chest pain and had an enzymatically confirmed AMI. This study assesses the angiographic significance of a discordant ST-segment elevation of 5 mm found on the admission electrocardiogram of such patients. • • • The medical records of patients with implanted pacemakers who were admitted to Albert Einstein Medical Center for evaluation of acute chest pain between 1994 and 2002 were reviewed. All patients with enzymatically confirmed AMI were eligible. Inclusion criteria required 100% VPR at the time of admission along with coronary angiography as part of the evaluation of the current clinical event. Exclusion criteria were the use of thrombolytic therapy during the current clinical event and/or delay in the coronary angiography of 1 week after presentation. Patients in whom the pacemaker was placed as a consequence of the current coronary event were also excluded. Electrocardiographic parameters were collected from the admission electrocardiogram. At least 1 standard 12-lead electrocardiogram was required in all patients. The presence or absence of a discordant ST-segment elevation of 5 mm was determined. Two cardiologists performed analysis of the tracings independently. In the event of disagreement, a third independent reading was obtained. A cardiologist who was not aware of the result of the electrocardiographic readings interpreted coronary angiographic findings. To quantify the severity of the underlying coronary artery disease, the Friesinger index (a validated score ranging from 0 to 15 points) was used.3,4 The culprit artery was defined as the coronary vessel believed to be responsible for the acute episode based on its morphologic appearance on angiography. The rate of identification of the culprit artery and the Thrombolysis In Myocardial Infarction (TIMI) flow through it were used as surrogate variables for the severity of the acute ischemic event. They were also scrutinized and recorded in every patient. To perform the statistical analysis, TIMI 0 and 1 flows were considered as occlusive disease, whereas TIMI flow 2 and 3 flows represented patency of the culprit artery. Historical data regarding age, gender, race, risk factors for coronary artery disease, indication for the pacemaker, and type of pacemaker placed were also recorded. We hypothesized that the study outcomes (Friesinger index, rate of identification of the culprit artery, and TIMI flow through it) worsen with the presence of a discordant ST-segment elevation of 5 mm on the admission electrocardiogram. We compared the mean values of the Friesinger index in patients with and without a discordant ST-segment elevation of 5 mm using a 2-sample t test. We computed the difference between the means and the corresponding 95% confidence interval (CI). To assess the differences in both the rate of identification of and TIMI flow through the culprit artery, we used Fisher’s exact test. All p values were 2 sided and a p value 0.05 was considered statistically significant. Statistical analysis was performed using Stata version 6.0 (College Station, Texas). In all, 20 patients with an implanted pacemaker were admitted for evaluation of acute chest pain and had enzymatically confirmed AMI during the study period. Seven patients were excluded because of inhibition of the pacemaker by the patient’s own rhythm (n 3), the administration of thrombolytic therapy (n 1), or the lack of performance of coronary angiography (n 3). The mean SD time from admission to coronary angiography was 35 29 hours. Of the 13 patients meeting the inclusion criteria, 11 were men and 2 were women (mean age SD 75.3 8.45 years [range 54 to 88]) (Table 1). Analysis of the admission electrocardiograms in the 13 patients revealed that only 5 patients (38%) had a discordant ST-segment elevation of 5 mm (Figure 1). This pattern was found predominantly in the anterolateral leads, with only 1 patient exhibiting such From the Department of Medicine, Division of Cardiology, and Office of Research and Technology Development, Albert Einstein Medical Center, Philadelphia, Pennsylvania. Dr. Caldera’s address is: Department of Medicine, Albert Einstein Medical Center, 5401 Old York Road, Philadelphia, Pennsylvania 19141. E-mail: calderaa@ aehn2.einstein.edu. Manuscript received May 6, 2002; revised manuscript received and accepted July 26, 2002.

OBJECTIVE Many prognostic variables have been studied in patients with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome (AIDS). The role of the electrocardiogram in this setting has not been previously evaluated. We analyzed the admission electrocardiogram in patients with Pneumocystis carinii pneumonia and AIDS in an attempt to identify electrocardiogram findings that could be associated with adverse clinical outcomes and worse prognostic variables. DESIGN A retrospective medical chart review. SETTING All confirmed cases of Pneumocystis carinii pneumonia in patients positive for human immunodeficiency virus admitted to Albert Einstein Medical Center from 1994 to 2000. METHODS Patients were assigned increasing severity ranks based on the findings on the admission electrocardiogram (normal sinus rhythm, sinus tachycardia, and right ventricular strain pattern). Data were extracted regarding study outcomes (admission to intensive care unit, mechanical ventilation, and hospital mortality) and prognostic variables. MAIN RESULTS Of the 40 study patients, 14 (35%) had normal sinus rhythm, 15 (37.5%) had sinus tachycardia, and 11 (27.5%) presented with signs of right ventricular strain. The number of admissions to the intensive care unit, use of mechanical ventilation, and hospital mortality rate all increased with the severity of the electrocardiogram findings (p < or =.03). The serum lactate dehydrogenase concentrations and the alveolar-arterial oxygen gradient both increased with the severity of the electrocardiogram findings (p < or =.02). CONCLUSION Electrocardiogram findings of sinus tachycardia and right heart strain are common in Pneumocystis carinii pneumonia. These findings are associated with adverse clinical outcomes as well as worsening of prognostic variables. The electrocardiogram may be useful in predicting outcome in patients with Pneumocystis carinii pneumonia.

Clinical prediction of portopulmonary hypertension(PPHTN) is critical in the preoperative evaluation of candidates for orthotopic liver transplantation (OLT) because of its association with significant morbidity and mortality. To determine the clinical, laboratory, and echocardiographic predictors of PPHTN, we retrospectively evaluated 55 candidates before OLT From those, 8 candidates had pulmonary hypertension ([HTN] group A) and 47 candidates did not (group B). Pulmonary HTN was defined as a mean pulmonary artery pressure (PAP) of 25 mm Hg or greater and either elevated pulmonary vascular resistance or normal pulmonary artery wedge pressure. The significant predictors of PPHTN were (1) systemic arterial HTN (63% in group A v 9% in group B; P < .001), (2) loud pulmonary component of the second heart sound (38% v 2%; P = .001), (3) right ventricular (RV) heave (38% v 4%; P = .002), (4) RV dilatation by echocardiogram (63% v 0%; P < .001), (5) RV hypertrophy by echocardiogram (38% v 0%; P = .001), and (6) echocardiogram-estimated systolic PAP (SPAP) greater than 40 mm Hg (63% v 2%; P < .001). The sensitivity of these variables for the detection of pulmonary HTN ranges from 37% to 63%, and their specificity from 91% to 100%. We conclude that several clinical and echocardiographic features are significantly associated with pulmonary HTN in patients with cirrhosis. In particular, echocardiogram-estimated SPAP greater than 40 mm Hg is strongly associated with pulmonary HTN and is specific. These predictors, however, are not sensitive enough to identify all the patients with PPHTN. Therefore, the evaluation of a combination of these variables may be useful for the preoperative identification of pulmonary HTN in liver transplant candidates.

To compare the predictive validity of several measures of motivation to quit smoking among inpatients enrolled in a smoking cessation program.Data collected during face-to-face counseling sessions included a standard measure of motivation to quit (stage of readiness [Stage]: precontemplation, contemplation, or preparation) and four items with responses grouped in three categories: "How much do you want to quit smoking" (Want), "How likely is it that you will stay off cigarettes after you leave the hospital" (Likely), "Rate your confidence on a scale from 0 to 100 about successfully quitting in the next month" (Confidence), and a counselor assessment in response to the question, "How motivated is this patient to quit?" (Motivation). Patients were classified as nonsmokers if they reported not smoking at both the 6-month and 12-month interviews. All patients lost to follow-up were considered smokers.At 1 year, the smoking cessation rate was 22. 5%. Each measure of motivation to quit was independently associated with cessation ( p.001) when added individually to an adjusted model. Likely was most closely associated with cessation and Stage was least. Likely had a sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of 70.2%, 68.1%, 39.3%, 88.6%, and 2.2, respectively.The motivation of inpatient smokers to quit may be as easily and as accurately predicted with a single question as with the series of questions that are typically used.

This article reviews cardiac and noncardiac complications encountered with various procedures used in cardiology practice. Some of the common complications associated with transesophageal echocardiography are hypoxia, laryngospasm, bronchospasm, and brady- or tachyarrhythmias. Death is a rare complication. The overall prevalence of complications associated with external cardioversion is low. Major complications include death, cardiac arrhythmias, pulmonary edema, systemic embolism, and cerebral embolism. The main indication for endomyocardial biopsy at present is to assess cardiac transplant rejection. Complications occurring most frequently are carotid artery puncture, arrhythmias, and conduction abnormalities. The most commonly occurring complications of electrophysiological studies are pneumothorax, venous thrombosis, and hypotension. Cardiac catheterization is an invaluable procedure in the assessment of patients with ischemic heart disease. Major complications include vascular complications, arrhythmias, complications due to contrast agents, and death. Central venous catheterization is used to deliver medication and parenteral nutrition and also in the hemodynamic monitoring of patients. Local infection, sepsis, noninfectious phlebitis, and catheter dislodgment are some of the more commonly occurring associated complications. Swan-Ganz catheters are indicated for the hemodynamic monitoring of critically ill patients. Major associated complications include pneumothorax, arterial puncture, air embolism, tracheal and esophageal puncture, arrhythmias, valvular damage, infection, thrombosis, and pulmonary infarction. The use of intra-aortic balloon pumps can be complicated by ischemia, bleeding, intraaortic balloon pump rupture, vascular complications (mainly limb ischemia), and death. Some of the common underlying mechanisms responsible for complications during interventional procedures are abrupt closure, noreflow phenomenon, coronary artery spasm, distal embolization, and side branch occlusion. The use of abciximab may be associated with an increased risk of major bleeding. Acute profound thrombocytopenia is another potential complication associated with abciximab use. Heparin usage may be associated with bleeding, thrombocytopenia, skin necrosis, osteoporosis and hypersensitivity reactions. Some of the more common complications of thrombolytic therapy are bleeding, myocardial rupture, hypotension, allergic reactions, anaphylaxis, thromboembolic complications, reperfusion arrhythmias, and splenic rupture.

Left internal mammary arteries (LIMA) are used routinely as grafts to the left anterior descending coronary artery (LAD) in selected patients undergoing coronary artery bypass graft (CABG) surgery because of better long-term patency rates. Pathology other than fibrointimal hyperplasia, accelerated atherosclerosis, or thrombus can sometimes cause obstructive lesions in such grafts. This report illustrates a kink in a LIMA graft to the LAD causing an obstructive lesion shortly after surgery and describes the subsequent management of this lesion with intracoronary stents. Cathet. Cardiovasc. Intervent. 46:223–226, 1999. © 1999 Wiley-Liss, Inc.

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.

The precise diagnosis of the presence of significant left main coronary artery disease has profound prognostic and therapeutic implications. Coronary cineangiography has shown to be imprecise and inaccurate to determine the percent stenosis of the left main coronary artery. We report a case with significant left main coronary artery disease in whom coronary cineangiography was in discordance with the clinical data and intravascular ultrasonography. Based on the intravascular ultrasound findings, the patient underwent coronary artery bypass graft surgery. Therefore, the intravascular ultrasonography may be the procedure of choice for assessing indeterminant left main coronary artery lesions by coronary angiography. intravascular ultrasound, left main coronary artery, coronary cineangiography

Obstructive apneas produce high negative intrathoracic pressure that imposes an afterload burden on the left ventricle. Such episodes might produce structural changes in the left ventricle over time. Doppler echocardiograms were obtained within 2 months of attended polysomnography. Patients were grouped according to apnea-hypopnea index (AHI): mild/no obstructive sleep apnea (OSA; AHI

Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients.To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features.None.This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%).Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

Transthoracic echocardiographic studies have shown that color Doppler mapping of the aortic regurgitation (AR) jet correlated well with the severity of regurgitation as assessed by contrast aortography. The present study was performed to assess whether these parameters could be similarly applied to measurements determined by transesophageal echocardiography (TEE). In order to determine and validate criteria for the assessment of AR severity, 39 clinically stable patients with a TEE color Doppler study and contrast aortography within a 2-week period were identified. The ratio of the jet area (JA) to left ventricular diastolic area (LVDA) had the best correlation to AR severity as determined by contrast aortography (r = 0.89). Jet length, JA, the ratio of jet width to the width of the left ventricular outflow tract and jet width had r values of 0.88, 0.88, 0.83, and 0.84, respectively. The best sensitivity and specificity for the assessment of AR by TEE were obtained as follows: JA/LVDA ratio of 0%-7% predicts 0-1 + AR; 8%-20% 2-3 + AR, and greater than 20% 4 + AR. Of the three patients miscategorized, none was misgraded by more than one angiographic grade of AR. Jets that measure more than 6 cm in length or have an area of greater than 10 cm 2 have a 100% sensitivity and specificity for diagnosing 4 + AR. In the present study the ratio of JA to LVDA area correlates best with AR severity as determined by angiography.

While Doppler echocardiography has become the gold standard for the diagnosis of hypertrophic cardiomyopathy, there are many pitfalls in its use. Some of these pitfalls are technical in nature resulting from inadequate image quality, incorrect transducer angulation, and improper equipment settings. Other pitfalls relate to the diversity and heterogeneity in defining hypertrophic cardiomyopathy and to the host of disorders that may mimic it by echocardiography. The pattern and extent of ventricular hypertrophy, systolic anterior motion of the mitral valve, and Doppler determination of left ventricular outflow tract obstruction, diastolic dysfunction, and mitral regurgitation are discussed, as are wall-motion abnormalities and myocardial echo reflectivity. While these echocardiographic features of hypertrophic cardiomyopathy are nonspecific when seen in isolation, their combined presence in the appropriate clinical setting makes the diagnosis likely.

Marked bulging of the interventricular septum toward the left ventricle has been described as a reliable index of right ventricular systolic hypertension. We report a patient with Eisenmenger syndrome who has systolic aneurysmal protrusion of the interventricular septum into the left ventricular outflow tract. To our knowledge, this is the first report of systolic indentation of the left ventricular outflow tract in a patient with right ventricular pressure/volume overload.

Transesophageal echocardiography (TEE) allows an unobscured view of the left atrium for the assessment of mitral regurgitation (MR). However, criteria for assessing MR by TEE have not been carefully validated. In order to determine and validate criteria for the assessment of MR severity, 65 clinically stable patients with a TEE color Doppler study and contrast ventriculography within a 2-week period were identified. Maximal or peak mitral regurgitation jet area to left atrial area ratio (MR/LA) derived solely from TEE imaging had the best correlation to MR severity by contrast ventriculography (r = 0.89). Utilizing MR jet area without correction for LA size resulted in r = 0.72 to 0.75. Utilizing LA area data from transthoracic echocardiograms in a subset of 29 patients resulted in r = 0.77. Best sensitivity and specificity for the assessment of MR by TEE were obtained using the following criteria: Peak MR/LA of 0%-9% predicts 0 + MR; 10%-28% 1 + MR; 29%-54% 2 + to 3 + MR; and greater than 55% 4 + MR. Best sensitivity and specificity occurs for assessment of 0 + and 4 + MR. Considerable overlap in data occurs in the 1 + and 3 + MR range utilizing the above stated criteria. Peak MR/LA ratio derived from a single TEE view in which the MR jet is maximally imaged is the best determinant of MR severity.

6. Donaldson RM, Raphael MJ. Missing coronary artery: review of technical problems in coronary arteriography resulting from anatomical variants. Br Heart J 1982;47:62-70. Chaitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical, angiographic, and hemodynamic findings in patienti with anomalous origin of the coronary arteries. Circulation 1976; 52122-31. Liberthson RR, Dinsmore RE, Fallon JT. Aberrant coronary artery origin from the aorta: report of 18 patients. Review of literature and delineation of natural history and management. Circulation 1979;59:748-54. Roberta WC, Siegel RJ, Zipes DP. Origin of the right coronary artery from the left sinus of Valsalva and its functional consequences: analysis of 10 necropsy patients. Am J Cardiol 1982;49:863-8. Brandt III B, Martins JB, Marcus ML. Anomalous origin of the right coronary artery from the left sinus of Valsalva. N Engl J Med 1983;309:596-8. King III SB, Douglas Jr JS. Coronary arteriography and angioplasty. New York: McGraw-Hill Book Company, Inc., 198541.

Mitral annular calcification is known to be associated with conduction abnormalities, embolic phenomena, endocarditis, mitral regurgitation, and thromboembolic cerebrovascular events in the younger population. The size of our elderly population is growing dramatically with the fastest growth in those aged greater than 85 years. The incidence of mitral annular calcification increases sharply in these “very elderly group of patients.” To determine if mitral annular calcification in the elderly patients has the same implications as in the younger population, electrocardiographic and echocardiography (M-mode, two-dimensional, Doppler) data from 553 octogenarian patients who were referred for a variety of clinical indications were analyzed. Patients with mitral annular calcification were quantified into mild, moderate, and severe, and the association of each was determined with various cardiac abnormalities. Mitral annular calcification was found in 59% of the octogenarian patients. Out of these, mild mitral annular calcification was present in 38%, moderate in 40%, and severe mitral annular calcification in 22% of the patients. Mild mitral annular calcification was not associated with an increased incidence of any cardiac abnormalities. Moderate mitral annular calcification was also not associated with any increased incidence of significant aortic stenosis, conduction abnormalities, and enlarged left ventricular size. However, severe mitral annular calcification was associated with all these findings. Moderate and severe mitral annular calcification were associated with significant mitral regurgitation and left ventricular hypertrophy. Thus, in the majority of elderly patients with mild and moderate mitral annular calcification (78%), its presence merely represents an aging process and an innocent bystander as compared to elderly patients without mitral annular calcification. However, only severe mitral annular calcification is strongly associated with cardiac abnormalities. Therefore, quantification of mitral annular calcification in the elderly is important before associating it with various cardiac abnormalities. (ECHOCARDIOGRAPHY, Volume 8, May 1991)

Dilated cardiomyopathy is a condition characterized by chamber dilatation and impaired systolic function, resulting in the clinical manifestations of congestive heart failure. Mitral regurgitation occurs with varying frequency in dilated cardiomyopathy, and its detection depends on the diagnostic modality utilized. The presence of mitral regurgitation imposes an additional burden on the failing ventricle, and appears to be an independent prognostic indicator of mortality. The mechanism of mitral regurgitation in dilated cardiomyopathy is complex, controversial, and incompletely understood. The mitral apparatus consists of the left atrial wall, mitral annulus, mitral leaflets, chordae tendineae, papillary muscles, and left ventricular wall, and each of these components and the intimate interrelationship between these structures may contribute to the development of mitral regurgitation. Left atrial enlargement, reduced left atrial contractility, mitral leaflet retraction, abnormal vector of chordal tendineae pull, papillary muscle dysfunction (either asynergic contraction or malalignment), mitral annular dilatation, and changes in the size, shape, and function of the left ventricle have been suggested as possible mechanisms for the development of mitral regurgitation in dilated cardiomyopathy. The primary event in the development of mitral regurgitation appears to be left ventricular dilatation and dysfunction. Controversy persists as to whether the associated mechanism is annular dilatation, papillary muscle or free left ventricular wall dysfunction, or a combination of all, but recent echo-Doppler studies reviewed in this article support the notion that annular dilatation is the predominant mechanism. Improved understanding of the mechanism of mitral regurgitation in dilated cardiomyopathy may lead to a more aggressive approach with regard to pharmacological therapy, thus impacting on survival in this group of patients. (ECHOCARDIOGRAPHY, Volume 8, March 1991)

Exercise testing is commonly performed to assess the functional result of coronary revascularization procedures and is usually not associated with any complications. However, this report documents a rare case of coronary dissection and thrombosis, which resulted in an acute myocardial infarction, in a patient who underwent stress testing 3 months following successful coronary stent implantation.

In 48 patients with dilated cardiomyopathy, pulsed-wave and color Doppler examination were performed. In addition, 14 normal patients served as control subjects. Peak inflow velocity at the level of the mitral valve, middle left ventricle, and apex and outflow velocity at the level of the apex, middle left ventricle, and subaortic area were measured. In normal patients there was brisk propagation of inflow velocity to the apex. Patients with dilated cardiomyopathy demonstrated delayed propagation and prolongation of the duration of inflow compared with control subjects (p less than 0.04). Continuous apical flow was visualized in 25% of dilated cardiomyopathies and in no normal patients. Apical velocities were significantly increased in cardiomyopathies with significant mitral regurgitation. Outflow velocities were decreased in dilated cardiomyopathy. In patients with dilated cardiomyopathy and apical dyskinesis, flow directed toward the base was measured in the middle left ventricle during isovolumic relaxation secondary to dyskinetic rebound. Patterns of abnormal flow in dilated cardiomyopathies are readily apparent by color M-mode and two-dimensional color Doppler.

Left ventricular outflow tract (LVOT) obstruction is a rare complication of mitral valve replacement. In this article, we describe three patients in whom left ventricular outflow tract obstruction occurred following Carpentier-Edwards porcine mitral valve replacement. All three patients presented with symptomatic mitral regurgitation (angiographic grade 3–4) requiring mitral valve replacement. Preoperatively there was no evidence of hypertrophic obstructive cardiomyopathy by physical exam, echocardiography, or by cardiac catheterization. At the time of surgery all three were shown to have severe mitral valve prolapse. The native anterior mitral leaflet was left intact and pledgeted to the mitral annulus. Following surgery a new systolic murmur was appreciated. Echocardiographic exam visualized obstruction of the left ventricular outflow tract by the prosthetic strut in two cases and by a flail anterior leaflet in one case. Continuous-wave Doppler measured a calculated peak gradient of 72 to 81 mmHg across the left ventricular outflow tract. In one case simultaneous Doppler and cardiac catheterization confirmed the diagnosis and severity of left ventricular outflow tract obstruction. Mechanisms of left ventricular outflow tract obstruction following Carpentier-Edwards porcine mitral valve replacement are discussed. These three cases highlight the importance of echo-Doppler techniques in understanding the mechanism of newly detected systolic murmurs following mitral valve replacement.

angioplasty for coarctation of the aorta. Am J Cardiol 1986;57:828-32. 6. Morrow WR, Vick GW, Nihill MR, Rokey R, Johnston DL, Hedrick TD, Mullins CE. Balloon dilation of unoperated coarctation of the aorta: shortand intermediate-term results. J Am Coll Cardiol 1988;11:133-8. 7. Marvin WJ, Mahoney LT, Rose EF. Pathologic sequelae of balloon dilation angioplasty for unoperated coarctation of the aorta [Abstract]. J Am Coil Cardiol 1986;7:117A. 8. Boxer RA, LaCorte MA, Singh S, Cooper R, Fishman MC, Goldman M, Stein HL. Nuclear magnetic resonance imaging in evaluation and follow-up of children treated for coarctation of the aorta. J Am Coll Cardiol 1986;7:1095-8. 9. Finley JP, BeauUeu RG, Nanton MA, Roy DL. Balloon catheter dilatation of coarctation of the aorta in young infants. Br Heart J 1983;50:411-15. 10. Lock JE, Niemi T, Burke BA, Einzig S, Castaneda-Zuniga WK. Transcutaneous angioplasty of experimental aortic coarctation. Circulation 1982;66:1280-6.

To characterize the differences between hypertrophic obstructive cardiomyopathy, left ventricular cavity obliteration and midventricuiar obstruction, a systematic analysis of the flow profiles was performed utilizing pulsed, continuous and color flow Doppler imaging in 31 patients (13 with hypertrophic obstructive cardiomyopathy, 9 with left ventricular cavity obliteration and 9 with midventricuiar obstruction). All three groups showed similar high velocity jets that initially gradually, then rapidly increased in systole (‘ski-slope’ systolic flow profiles). The calculated mean gradient was higher in the hypertrophic obstructive group than in the left ventricular cavity obliteration and midventricuiar obstruction groups. All patients in the midventricuiar obstruction group had increased early diastolic velocity at midventricuiar level (36.4 ± 32.2 cm/s), whereas the normal progressive decrease in velocity through the ventricle was observed in the other groups. A distinct outflow-directed isovolumic signal was observed in 7 of the 9 patients with apical dyskinesia in the midventricuiar obstruction group. In addition, an apically-directed isovolumic signal was present in 10 of 13 patients with hypertrophic obstructive cardiomyopathy in 6 of 9 patients with left ventricular cavity obliteration and in 2 of 9 with midventricuiar obstruction. Thus, two-dimensional echocardiography coupled with Doppler evaluation allows characterization of dynamic intracavitary obstruction syndromes.

The number of patients with end-stage renal disease (ESRD) has risen dramatically over the last decade. There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year. Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient-care months. Few other medical conditions, except for chemotherapy-induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia. IE occurs in approximately 2% to 6% of patients receiving HD. The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD.

A right ventricular thrombus (RVT) is an unusual finding on echocardiography. We describe a healthy young male patient who developed RVT with subsequent pulmonary embolism (PE), the etiology of which remains uncertain.

The influence of age on the clinical and angiographic outcome of directional coronary atherectomy is evaluated. Results demonstrate that DCA can be performed successfully in the vast majority (78.7-90%) of patients in all age groups. However, there is a non-statistical trend toward decreased success rates in the elderly (P > .05). Major ischemic complications and groin complications tend to be more common in the elderly (P > .05). Blood transfusions are required significantly more often in the elderly (P < .05). Directional coronary atherectomy is a useful method of coronary artery revascularization in all age groups, including the elderly.

In summary, in patients with rapid progression of AS, 3 variables-patients on hemodialysis, those taking a calcium supplement, and those with elevated serum creatinine-were predictors of accelerated AS compared with variables in slow progressors.

Penetrating aortic ulceration is a disease of the descending thoracic aorta characterized by ulceration of an atheromatous plaque disrupting the internal elastic lamina. The ulcerated atheroma may extend into the media, resulting in intramural hematoma; it may penetrate the media; resulting in pseudoaneurysm formation; or it may perforate through the adventitia, resulting in transmural aortic rupture.l Penetrating aortic ulceration has similar chnical features to aortic dissection and rapid expansion or contained rupture of a thoracic aortic aneurysm.1-3 However, it represents a unique pathology with distinct radiographic and echocardiographic features. While aortography has been regarded as the gold standard in the diagnosis of penetrating aortic ulcers, computed tomography2 and mag

8. cular hyperplasia: extension of the therapeutic outcome. Results of the University Hospital Zurich Cooperation Study on fibromuscular hyperplasia. Nephron 1986;44(suppl. 1):109-14. James TA, Froggatt P, Marshall TK. Sudden death in young athletes. Ann Intern Med 1967;67:1013-21. dames TA, Marshall TK. De subitaneis mortibus XVII. Multifocal stenoses due to fibromuscular dysplasia of the sinus node artery. Circulation 1976;53:736-42. Rossi L, Thiene G. Recent advances in clinicohistopathologic correlates of sudden cardiac death. AM HEART J 1981;102:47884. Nichols GR II, Davis GJ, Lefkowitz JB. Sudden death due to fibromuscuiar dysplasia of the sinoatrial nodal artery. KMA J 1989;87:504-5. Lie JT, Berg KK. Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction. Hum Path01 1987;18:654-6.

The Doppler-derived mean mitral valve gradient (DeltaP(M)) based on the simplified Bernoulli equation requires computerized integration of the Doppler signal and evaluation by a technician with the use of special equipment. We have noted empirically that the DeltaP(M) can be derived by the equation DeltaP(M) = (P(P) - P(T)) / 3 + P(T). Peak (P(P)) and trough (P(T)) pressures are derived from the simplified Bernoulli equation (P = 4V(2)). This equation can be used by the experienced observer to calculate the mean mitral valve gradient without specialized equipment. The purpose of this study is to validate the above empirically derived equation in patients with mitral stenosis. We retrospectively reviewed 41 consecutive studies done at our institution from October 1, 1997, through September 30, 1998, in which mean mitral valve gradient was assessed. Each study was reviewed and the DeltaP(M), P(P), and P(T) were measured for 3 beats by using the software package on an HP Sonos 2500. DeltaP(M) was also calculated with our formula. A linear regression model was used to compare the results of the measured versus the calculated DeltaP(M). The following sub-categories were also evaluated: transthoracic studies (TTE), transesophageal studies (TEE), native valve gradients (NV), prosthetic valve gradients (PV), sinus rhythm (SR), and atrial fibrillation (AF). The results of the regression analysis of the entire population of mean versus calculated DeltaP(M) are n = 41, r = 0.99, P.001, and standard error of the estimate (SEE) = 0.67. The regression results for the subgroups are as follows: TTE: n = 30, r = 0.99, P.001, SEE = 0.51; TEE: n = 11, r = 0.99, P.001, SEE = 59; NV: n = 26, r = 0.99, P.001, SEE = 0.59; PV: n = 15, r = 0.98, P.001, SEE = 0.84; SR: n = 23, r = 0.99, P.001, SEE = 0.58; and AF: n = 18, r = 0.98, P.001, SEE = 0.82. In conclusion, the simple formula that we have derived is an accurate method for calculation of mean mitral valve gradient, and it is accurate over multiple subgroups. Furthermore, the formula allows visual verification of mean mitral gradient without specialized software.

New indications for permanent cardiac pacing have been developed in recent years, with numerous studies demonstrating improved clinical outcomes in a variety of disorders. Because hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy, heart failure, neurocardiogenic syncope, and atrial fibrillation are common conditions, every clinician should be aware of evolving alternative therapies for them. Observational studies in patients with refractory, symptomatic hypertrophic obstructive cardiomyopathy and significant left ventricular outflow gradient at rest suggest that cardiac pacing may result in symptomatic and hemodynamic improvement. Clinical trials have not shown conclusive evidence regarding the long-term benefit from pacing in these patients, and it is unclear whether pacing will be a preferred treatment option. Preliminary data suggest that pacing is a viable adjunctive therapeutic approach for improving symptoms in patients with dilated cardiomyopathy and heart failure. Mortality benefit has yet to be established, but it is to be hoped that ongoing randomized clinical trials will provide definitive information on that issue. Patients with refractory neurocardiogenic syncope or those who are intolerant of medical treatment may benefit from pacing therapies, especially those that use rate-drop sensor algorithms. Biatrial pacing has emerged as a technique that resynchronizes atrial electrical activity and has been shown to prevent atrial fibrillation. Multisite atrial pacing for the prevention of atrial fibrillation is considered investigational but seems promising. Newer indications for pacing are expected to result in improved clinical outcomes for hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy and heart failure, neurocardiogenic syncope, and the prevention of atrial fibrillation.

Congenital coronary artery fistulas are important coronary artery anomalies. Bilateral coronary artery fistulas are very rare and coronary artery to left ventricular communications are even more infrequent. This report describes a patient with bilateral right and left coronary artery fistulas draining into a common channel and emptying into the left ventricular cavity.

Coronary artery bypass graft (CABG) surgery, performed for the control of angina pectoris, leads to postoperative relief from symptoms in most patients. Amelioration of ischemia and improvement in exercise capacity after CABG are well documented. However, patients currently undergoing CABG are more complex than in the past--they are older and are maintained on medical therapy for longer periods. A large number of these patients have had one or more previous myocardial revascularization procedures. The post-operative period would appear to be a time of vulnerability for coronary events. However, previous investigators have focused on the pre- and intraoperative aspects of peri-CABG ischemia. Outcome data suggest that the postoperative interval is at least equally important as a determinant of short- and long-term morbidity and mortality. We discuss the epidemiology, etiology, pathophysiology, and treatment of ischemic syndromes in the postoperative period after CABG. In addition, we review recent data from a series of 14 patients, observed at our institution, who underwent cardiac catheterization and, in some cases, angioplasty of the culprit vessel in the immediate postoperative period.

Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are frequently utilized in patient's with suspected cerebral vascular ischemia. We describe a patient with suspected cerebral vascular ischemic event whom was found to have a mobile valvular mass by TTE and TEE. The lesion was unusual due to its rapid development over a period 6 months, which was documented on serial echocardiography. The mass was excised surgically and pathology showed a papillary fibroelastoma with extensive thrombus. The differential diagnosis of a cardiac valvular mass and the treatment of cardiac fibroelastomas are reviewed. In this case, both TTE and TEE were valuable in diagnosis and facilitating surgical management of a cardiac fibroelastoma.

The influence of gender on the procedural outcome of directional coronary atherectomy (DCA) is controversial. This study of 373 consecutive patients (418 lesions) undergoing DCA demonstrates that the procedural success rate of DCA is significantly lower in women compared with men (72.7 vs. 82.9%, p = 0.011). Women have significantly smaller coronary arteries than men (2.5 mm vs. 2.7 mm, p = 0.028) and were older than men (66 vs. 61 years, p = 0.0001). Multivariate analysis identifies small coronary vessel size rather than female gender per se as an independent predictor of poor procedural outcome. Procedural success rates in women with coronary vessel sizeor = 2.5 mm is significantly higher (92.2%) than in women with coronary vessel size2.5 mm (73.1%), and parallels that in men with vessel sizeor = 2.5 mm (89.3%). Inability to engage the ostium of the coronary artery adequately with the guiding catheter and to cross the lesion with the atherectomy device is significantly more common in women compared with men. Major ischemic complication rates are similar in women and men (8.5 vs. 8.7%). Groin complications are significantly more common in women compared with men (13.5 vs. 2.9%). We conclude that procedural success rates in women may be improved by careful patient selection, with particular attention to small vessel size. DCA is best performed in vessels2.5 mm in diameter.

Paravalvular regurgitation (PVR) is an uncommon complication of mitral valve replacement (MVR). Although severe PVR is almost always repaired immediately when recognized during surgery, there are little data available on the management of patients with mild and moderate PVR. This study includes eight patients with mild ( n = 6) and moderate ( n = 2) PVR identified by transesophageal echocardiography at the time of MVR who were treated conservatively. Clinical and echocardiographic follow-up was obtained at a mean of 16.3 months. Two of six patients with mild PVR at the time of MVR and two of two patients with moderate PVR at the time of MVR deteriorated clinically and echocardiographically over time. We suggest that moderate PVR should be corrected at the time of valve-replacement surgery, if this can be performed without high operative risk. Mild PVR should probably also be repaired, if this can be performed at low risk, because some will progress. Patients left with mild PVR after surgery, or patients in whom PVR is recognized only after surgery, should be followed up carefully with serial clinical and echocardiographic examinations.

We report the case of a 60-year-old woman with a history of ataxia who sought evaluation after a syncopal episode. A diagnostic workup revealed pulmonary emboli, pernicious anemia (PA), hyperhomocysteinemia, and a G20210A prothrombin gene mutation. She was successfully treated with homocysteine-lowering therapy, including high doses of oral cobalamin. She also received oral anticoagulation for 6 months. At 1 year of follow-up, no further thrombotic episodes had occurred. Our report highlights the thrombotic risk of hyperhomocysteinemia secondary to PA in a patient with the G20210A prothrombin gene mutation.

Tissue plasminogen activator (t-PA) developed from recombinant DNA technology is a highly effective thrombolytic agent. Its main clinical application is in the treatment of acute myocardial infarction (MI), with most beneficial results occurring in patients treated early after the onset of symptoms. When t-PA was compared with other thrombolytic agents, such as streptokinase (SK) and anisolyted plasminogen streptokinase (APSAC), the data obtained from the mega trials (GISSI 2 and ISIS 3) revealed no significant difference in mortality. However, in the recent GUSTO trial involving 41,000 patients, t-PA-treated patients had a significantly lower mortality rate compared to SK-treated patients. Aggressive adjunctive therapy, including intravenous heparin in combination with aspirin, may have accounted for this difference.

Transesophageal echocardiography (TEE) is a useful technique in the diagnosis and intraoperative assessment of discrete subaortic stenosis (DSS). It allows clear visualization of the subaortic membrane, which may be missed by transthoracic echocardiography, differentiates DSS from other causes of left ventricular outflow tract obstruction, and accurately detects the presence of associated aortic regurgitation and bacterial endocarditis. Limitations in its use include inadequate visualization of the left ventricular outflow tract by TEE in the presence of a prosthetic mitral valve or mitral annular calcification, and improper alignment of the Doppler cursor across the outflow tract.

This retrospective study examines whether a relationship exists between the severity of mitral regurgitation (MR) and the presence of left atrial spontaneous echo contrast and/or thrombus (SEC/THR) as assessed by transesophageal echocardiography in 427 consecutive patients. Clinical data were evaluated in 316 of these patients. Nine percent of patients with MRor = 2+ versus1% of those with MRor = 3+ had SEC/THR (p0.03). Atrial fibrillation, left ventricular dysfunction, mitral stenosis, and mitral valve prosthesis were demonstrated to be independent positive predictors of left atrial SEC/THR, whereas MRor = 3+ was an independent negative predictor of SEC/THR. SEC/THR was less common in patients with MRor = 3+ than in patients with MRor = 2+ for any given number of independent positive predictors of SEC/THR. This relationship did not hold true in patients with a mechanical mitral prosthetic valve. Clinical data revealed a trend towards a lower prevalence of stroke or transient ischemic attacks in patients with MRor = 3+. Stroke and transient ischemic attacks were significantly more common in patients with SEC/THR (p0.001). We suggest that significant MR may be protective against the formation of left atrial SEC/THR.

Percutaneous transluminal coronary angioplasty (PTCA) of heavily calcified rigid coronary arteries has decreased success and increased complication rates. Three cases are presented describing a new technique for the dilatation of severely calcified coronary arteries that were not dilatable by conventional angioplasty methods. This technique involves the use of a balloon dilatation catheter system parallel to a guide wire. © 1993 Wiley-Liss, Inc.

Diaphragmatic hernia may mimic a left atrial mass when imaged by transthoracic echocardiography. In this case study we emphasize the value of transesophageal echocardiography in clarifying the cause of this apparent atrial mass.