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The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

We report the case of a patient who underwent Cabrol composite graft procedure for ascending aorta aneurysm and aortic regurgitation. Sixteen years later he developed progressive dyspnea and a left-to-right shunt caused by distal detachment of the valve conduit with persistence of the perigraft space-right atrial fistula visualized with echocardiography. Our case shows that late manifestations of surgical complications of the Cabrol procedure may occur and transesophageal echocardiography may allow a comprehensive assessment in these patients. However, because surgical management of ascending aorta aneurysms has changed in the last decades a detailed knowledge of the surgical technique used is mandatory for adequate interpretation of transesophageal echocardiographic results.

Heart failure is the leading cause of hospitalization among the elderly. This study compares clinical characteristics, management, and prognosis of octogenarians (OLD) with younger (YOUNG) patients in the Italian Survey on Acute Heart Failure (AHF).A nationwide, prospective, observational study on AHF was done. Two hundred six Italian departments with intensive cardiac care units enrolled 2,807 patients in 3 months.Octogenarians (mean age 84 +/- 4 years) represented 28% of enrollees. Females were 50% in the OLD group versus 36% in the YOUNG group (P.0001). Risk factors such as obesity, diabetes, and smoking were more frequent in the YOUNG group. Comorbidities such as anemia and renal dysfunction were more common in the OLD group (64% vs 53%, P.0001, and 56% vs 43%, P.0001). More octogenarians were admitted with cardiogenic shock and pulmonary edema, whereas younger patients presented more frequently in New York Heart Association class III to IV (P = .002). Left ventricular ejection fraction was measured in 90% of octogenarians versus 93% of the younger ones and was preserved in 41% of the OLD group versus 31% of the YOUNG group (P.0001). Coronary angiography was performed in 20% of the YOUNG group and 10% of the OLD group. In-hospital mortality was twice as high in the OLD group (11.8% vs 5.6%, P.001). In multivariable analysis, the strongest predictors of this event were use of inotropic agents, advanced age (or =80 years), and elevated troponin at admission.Octogenarians represent more than one fourth of the admissions for AHF and have a more severe clinical presentation. Their management is less aggressive, and treatments recommended by guidelines are underused. In-hospital mortality is high in the OLD group independently of left ventricular ejection fraction.

Aims The aim of this study was to assess the cost-effectiveness of using certified sonographers and miniaturized echocardiography systems to perform echocardiograms at bedside in comparison to moving inpatients from the admission department to the echocardiography laboratory (echo-lab). Methods and results From 26 September 2005 to 27 October 2005, 112 patients admitted in six hospital wards connected through a 100 Mbit LAN to the echo-lab were scanned within the admission ward by sonographers using a miniaturized echo system. Logistical data were collected and results were compared with those obtained from 194 consecutive patients coming from the same wards and studied in the echo-lab with high-end machines between 8 March 2005 and 15 April 2005. Performing echocardiograms in the admission department avoided long waiting time of the inpatients in the echo-lab before and after the study, increased the percentage of patients studied within 3 and 5 days from request (88 vs. 77% and 100 vs. 95%, respectively; P = 0.03), increased both sonographer (by 33.9%; P < 0.001) and echo-lab productivity (by 41%; P < 0.001), and reduced costs of echocardiograms by 29%. Conclusion Implementation of digital echocardiography, certified sonographers, and a miniaturized echo system allowed improvement of the cost-effectiveness of the service provided by the echo-lab for inpatients, and avoided patients' discomfort derived from prolonged waiting time before and after the exam.

Aims: To assess accuracy and reproducibility of real time simultaneous triplane echocardiography (RT3PE) for the assessment of left ventricular (LV) volumes and ejection fraction (EF) using cardiac magnetic resonance (CMR) as a reference method. Methods and Results: A total of 24 patients with various degrees of LV dysfunction (EF from 36 to 57%) in sinus rhythm with good image quality were enrolled in the study. Digital loops of apical views were recorded with standard two-dimensional imaging and with RT3PE. Echocardiography and CMR were performed within 1 hour. RT3PE measurements of LV end-diastolic volume, end-systolic volume, and EF resulted closely correlated to CMR (r = 0.95, 0.97, and 0.95, respectively) with small biases (− 4m l,−6 ml, and 1%, respectively) and narrow limits of agreement (SD = 15 ml, 12 ml, and 6%, respectively). Two-dimensional echocardiography (2DE) showed a weaker correlation with CMR (r = 0.85, 0.91, and 0.83, respectively; P < 0.06) with similar biases (− 4m l,−10 ml, 5%, respectively), but wider limits of agreement (SD = 28 ml, 21 ml, 10%, respectively, P < 0.007). RT3PE showed lower interobserver variability for the assessment of EF (SD = 2% vs. 5%, P = 0.03) and lower measurement time of LV EF (175 ± 54 sec vs. 241 ± 49 sec, respectively; P < 0.0001), as compared to 2DE. Conclusion: RT3PE allows simple and fast image acquisition and volume calculation. In addition, it allows more accurate and reproducible EF measurements than conventional 2DE. (ECHOCARDIOGRAPHY, Volume 26, January 2009) three-dimensional echocardiography, two-dimensional echocardiography, cardiac magnetic resonance, left ventricular function

Aims Several studies have demonstrated the life-saving role of implantable cardioverter-defibrillator (ICD) therapy. In order to evaluate the effects of major trials in clinical practice, we report the clinical data of patients enrolled in the Italian ICD Registry for the years 2005-07. Methods and results The Registry collects prospectively national ICD implantation activity on the basis of EURID Card. The number of ICDs per million of inhabitants was 180.6 in the year 2005, 192.5 in the year 2006, and 220.6 in the year 2007 (P = 0.02). The median age was 69 years for all 3 years considered. Implantable cardioverter-defibrillator implantation for primary prevention concerned 4692 patients in 2005 (44.2%), 5938 patients in 2006 (52.2%), 7324 patients in 2007 (55.7%) and for secondary prevention 5921 patients in 2005 (55.8%), 5447 patients in 2006 (47.8%), and 5828 patients in 2007 (44.3%). Single-chamber ICDs were implanted in 30.9, 31.0, and 28.5% of patients, dual chamber ICDs in 31.9, 31.5, and 31.7%, and biventricular ICDs in 37.2, 37.5, and 39.8%, respectively. Conclusion The ICD implantation rate in Italy increased significantly in the period 2005-07. The registry showed a significant increase in prophylactic and biventricular ICD use, reflecting a favourable adherence to trials and guidelines in the clinical practice.

Background Transient left ventricular apical ballooning syndrome, primarily described in Japanese patients, has been recently recognized outside Japan also. Aim of this study is to elucidate incidence and clinical features of left ventricular apical ballooning syndrome in a tertiary-care hospital in northeastern Italy. Methods and results From January 2002 to August 2006, 29 patients admitted for suspected acute coronary syndrome (25 women, mean age 64 ± 12 years) fulfilled the Mayo Clinic Criteria of left ventricular apical ballooning syndrome. Twenty patients (69%) had an episode of emotional or physiologic stress preceding left ventricular apical ballooning syndrome. Fourteen patients (48%) had at least one risk factor for coronary artery disease. Chest pain was present at admission in 24 patients (83%). Twenty-five patients (86%) had ST–T segment abnormalities at ECG on admission. Four patients were treated with fibrinolytic therapy and one with glycoprotein IIb/IIIa inhibitors. At coronary angiography, 23 patients (79%) had no coronary lesions, 2 (7%) had small vessel occlusion and 4 (14%) had nonsignificant coronary stenosis. ECG changes and echocardiographic wall motion abnormalities completely regressed in all patients within 10 weeks. Neither death nor major complications occurred during in-hospital stay and after discharge. Two patients (7%) experienced a recurrence during follow-up. Conclusion Left ventricular apical ballooning syndrome is a novel syndrome with a nonnegligible incidence, a clinical presentation mimicking acute myocardial infarction and a favorable outcome. The present data confirm a higher prevalence in women and the frequent association with emotional stress. The differential diagnosis with acute myocardial infarction at presentation is still puzzling, and only ECG findings in conjunction with echocardiography and coronary angiography are so far diagnostics.

Left atrial size has shown prognostic importance in a variety of cardiac conditions. Diameters, area, and volume derived from M-mode and two-dimensional (2D) echocardiography are commonly used to estimate left atrial size. However, M-mode and 2D measures of left atrial size rely on various geometrical assumptions and their accuracy remains to be determined. To address this issue, we compared M-mode and 2D parameters routinely used to estimate left atrial size with three-dimensional (3D) echo measured left atrial volume (LAV) as a reference standard.We studied 104 patients (55% males, 62 +/- 15 years, range 10-87 years), presenting for a routine echocardiographic evaluation.The mean 3D LAV for the study population was 90 +/- 68 ml (range 24-458 ml). We found highly significant (P0.0001) correlations between 3D LAV and left atrial anterior-posterior (r = 0.78, 95% CI = 0.69-0.85), superior-inferior (r = 0.74, 95% CI = 0.63-0.81) and medial-lateral (r = 0.91, 95% CI = 0.86-0.93) diameters. A highly significant correlation was also found between 3D LAV and left atrial area (r = 0.94, 95% CI = 0.91-0.96). However, using M-mode anterior-posterior diameter or left atrial area would have misclassified 57% and 70% of our study patients, respectively, regarding the degree of left atrial dilatation. Closer correlations and narrower confidence intervals were found between 3D LAV and single-plane (r = 0.98; 95% CI = 0.94-0.97) and biplane (r = 0.97; 95% CI = 0.96-0.98) 2D LAVs.Left atrial diameters and area measurements were poor predictors of 3D LAV, especially in the enlarged left atria. Therefore, these parameters can be misleading in assessing the severity of left atrial dilatation. Two-dimensional LAVs are accurate in estimating 3D LAV. The small additional accuracy obtained by using the biplane instead of the single-plane area-length method, and the fact that the biplane method is more technically demanding and time consuming, may allow the use of the area-length for routine clinical use.

Infective endocarditis (IE) in chronic haemodialysis (HD) is significantly more common and causes greater morbidity and mortality than in the general population, being second only to cardiovascular disease as the leading cause of death in this group of patients. Because of the peculiarity of this group of patients, it has been recently proposed to add a fifth category (health-care associated and HD-associated IE) in the actually four categories classification of IE (namely, native valve IE, prosthetic valve IE, IE in e.v. drug users, and nosocomial IE). Given that rates of acceptance into HD are increasing (including a higher proportion of older patients in whom valvular calcification is virtually ubiquitous), and along with improved survival in HD patients, the incidence of IE in this subset of patients will probably increase with significant diagnostic and therapeutic implications. In particular cardiac, diagnostic, echocardiographic, and surgical expertises are required to correctly identify patients at higher risk and who may benefit from surgical treatment. The aim of this review is to clarify the peculiar features of chronic HD patients with regard to pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE.

The complex anatomy of cardiac structures requires three-dimensional spatial orientation of images for a better understanding of structure and function, thereby improving image interpretation. Real-time three-dimensional echocardiography is a recently developed technique based on the design of an ultrasound transducer with a matrix array that rapidly acquires image data in a pyramidal volume. The simultaneous display of multiple tomographic images allows three-dimensional perspective and the anatomically correct examination of any structure within the volumetric image. As a consequence, it is less operator-dependent and hence more reproducible. Dedicated software systems and technologies are based on high-performance computers designed for graphic handling of three-dimensional images by providing possibilities beyond those obtainable with echocardiography. This methodology allows simultaneous display of multiple superimposed planes in an interactive manner as well as a quantitative assessment of cardiac volumes and ventricular mass in a three-dimensional format without a pre-established assumption of cardiac chamber geometry. In addition, myocardial contraction and/or perfusion abnormalities are clearly identified. Finally, real-time three-dimensional colour Doppler flow mapping enables complete visualisation of the regurgitant jet and new ways of assessing regurgitant lesion severity. Thus, this technique expands the abilities of non-invasive cardiology and may open new doors for the evaluation of cardiac diseases. In this article, current and future clinical applications of real-time three-dimensional echocardiography are reviewed.

Right after the first signs and symptoms of acute myocardial infarctions the prognosis is determined by the interventions which are carried out at that time. Preservation of as much myocardial tissue is the key element. Early deobstruction and reperfusion of the myocardium at jeopardy can lead to limitation of the ultimate infarct size, improved ventricular function and a halving of the 1-year mortality. Early supportive therapy with beta-blockade and calcium antagonists may enhance this effect. Data in 533 patients randomized to either a reperfusion strategy or to conventional therapy, combined with those from the recent literature on thrombolysis and early beta-blockade, provide the basis for this point of view. Once infarction is unavoidable and in the process of completion, probably 3-4 h after onset of symptoms, only supportive therapy is recommended, which will hardly change the outcome except for interventions during clinical care such as defibrillation. In 351 other survivors of myocardial infarction the value of clinical variables, a symptom-limited bicycle stress test at discharge, radionuclide ventriculography and 24-hour ambulatory electrocardiogram was compared in predicting 1-year survival. A history of previous myocardial infarction and heart failure during the current episode proved to be the strongest clinical predictors of death. Similarly, a low ejection fraction (less than 40%) and an insufficient blood pressure rise during stress testing (less than 30 mm Hg) identified a high risk group. Stress-test-induced angina and ST depression as well as ventricular arrhythmias from 24-hour electrocardiography were less good as predictors. In these patients treatment should be individualized and may require arteriography. Patients eligible for and completing a normal bicycle stress test after myocardial infarction proved to be a low risk group, which may constitute 65% of the total, seen in tertiary referral centers and even more in community hospitals. They neither require therapy nor further investigation. A subgroup with an intermediate risk can be identified when clinical variables, stress testing and/or resting radionuclide ventriculography are abnormal. This group requires 'tailored' therapy. Therefore, after infarction recovery, we recommend a pre-discharge stress test routinely to complement the clinical evaluation, since it also provides information on physical capacity, the indication of arrhythmias and the presence of myocardial ischemia. Thus, optimal management of acute myocardial infarction requires a stratified approach, which does not require expensive testing procedures.

Transesophageal echocardiography (TEE) is the most common imaging modality for the detection of acute aortic syndromes. However anomalous anatomic structures may be occasionally misunderstood as pathologic due of lack of familiarity with anatomical variations; false-positive diagnosis can result, potentially leading to unnecessary surgical intervention. It is crucial for echocardiographers to be aware of possible pitfalls which may create false positive findings, since the complementary use of other imaging modalities, such as multislice spiral computed tomography (MSCT), could improve the diagnostic accuracy of TEE. We report a case in which an image resembling an acute aortic dissection (AAD) on transthoracic (TTE) and transesophageal echocardiography was found in a patient with acute chest pain; MSCT detected an anomalous origin of the right coronary artery as cause of false aortic dissection image at echocardiography.

OBJECTIVE: Heart failure (HF) is a major health problem resulting in a high financial burden for the healthcare system. Many previous HF management programmes reduced adverse clinical outcomes and costs, but they usually involved several professional figures as well as huge investments, requiring resources and budgets not often available in our healthcare system. We evaluated the effects of our HF management programme, which included patient education and regular outpatient contact with the HF team, on re-hospitalisation and death, optimising the few resources already available at our hospital. METHODS: Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were randomised to the intervention group (nurse-led education programme, facilitated telephone communication and follow-up visits with an internist at 15 days, 1 and 6 months) or to the usual care group (follow-up by their primary care physician). The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period. RESULTS: There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group (P = NS). Fourteen patients (14%) in the intervention group and eight patients (8%) in the control group died during the study period (P = NS). Unplanned outpatient visits were less frequent in the intervention group than in the control group (39 [28%] versus 99 [72%], P < 0.001). CONCLUSIONS: The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status. More intense follow-up monitoring and more resources are needed to achieve better results.

The use of stented bioprostheses in elderly patients with degenerative aortic stenosis, despite being desirable, raises concerns about the harmful effects of residual obstruction to left ventricular outflow. To overcome this limitation new stented and stentless bioprostheses have been designed for supra-annular implant. However, the actual hemodynamic advantage of supra-annular implant over the intra-annular one remains incompletely understood. This review focuses on the geometry of biological valve prostheses designed for supra-annular implant and its implications for the echocardiographic assessment of valve hemodynamics. Available data about the hemodynamic performance of these valves implanted in the supra-annular position in comparison with the usual intra-annular implant are also reviewed. Other issues related to biological heart valve performance, such as biomaterials, tissue mechanics, durability, and clinical outcome are not addressed in this review.

Objective: To compare in a prospective, randomised, multicentre trial the relative merits of pre-discharge exercise ECG and early pharmacological stress echocardiography concerning risk stratification and costs of treating patients with uncomplicated acute myocardial infarction. Design: 262 patients from six participating centres with a recent uncomplicated myocardial infarction were randomly assigned to early (day 3–5) pharmacological stress echocardiography (n = 132) or conventional pre-discharge (day 7–9) maximum symptom limited exercise ECG (n = 130). Results: No complication occurred during either stress echocardiography or exercise ECG. At one year follow up there were 26 events (1 death, 5 non-fatal reinfarctions, 20 patients with unstable angina requiring hospitalisation) in patients randomly assigned to early stress echocardiography and 18 events (2 reinfarctions, 16 unstable angina requiring hospitalisation) in the group randomly assigned to exercise ECG (not significant). The negative predictive value was 92% for stress echocardiography and 88% for exercise ECG (not significant). Total costs of the two strategies were similar (not significant). Conclusion: Early pharmacological stress echocardiography and conventional pre-discharge symptom limited exercise ECG have similar clinical outcome and costs after uncomplicated infarction. Early pharmacological stress echocardiography should be considered a valid alternative even for patients with interpretable baseline ECG who can exercise.

BACKGROUND Patients with acute coronary syndromes (ACS) complicated by heart failure (HF) are at increased risk of death. Treatment with angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, and early invasive risk stratification are recommended for these patients. AIM The purpose of the current study was to assess adherence to treatment guidelines of patients with ACS complicated by HF in Europe and the Mediterranean region. METHODS AND RESULTS Of the 10,484 patients who participated in Euro-Heart ACS survey, 9587 had known HF status and were without cardiogenic shock; 7058 (74%) did not have symptomatic HF and 2529 (26%) presented with or developed symptomatic HF during hospitalization. HF patients were older and had more cardiovascular risk factors. ACEI were more commonly used in HF patients (75% vs 56%, P < .01), whereas beta-blockers were less frequently used (75% vs 82%, P < .01). Coronary angiography and in hospital revascularization rates were lower among HF patients (42% vs 57% for coronary angiography, P < .01, and 32% vs 42% for revascularization, P < .01). Similar trends were noticed among patients with left ventricular dysfunction (symptomatic and asymptomatic).Adjusted in-hospital mortality risk was higher among patients with ACS complicated by symptomatic HF regardless of electrocardiographic type of ACS: (ST-elevation ACS, OR 2.5, 95% CI 1.6-3.9; non-ST-elevation ACS, OR 8.9,95% CI 4.5-17.7; undetermined-ECG ACS, OR 9.3, 95% CI 2.5-34). CONCLUSIONS Patients with ACS complicated by HF were at increased risk of dying. A relatively high percentage of HF patients were treated with ACEI and beta-blockers in accordance with current recommendations. Rates of coronary angiography and revascularization were significantly lower in ACS patients with HF versus those without HF, which potentially contributed to their worse mortality [corrected]

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

Item does not contain fulltext OBJECTIVES: The aim of this study was to evaluate percutaneous coronary intervention (PCI) in the Assessment of the Safety and Efficacy of New Thrombolytic Regimens (ASSENT-3) trial. BACKGROUND: In the ASSENT-3 trial, co-therapy with abciximab (ABC) or enoxaparin (ENOX) reduced ischemic complications after ST-elevation acute myocardial infarction treated with tenecteplase when compared with unfractionated heparin (UFH). The effect of these new co-therapies on the results of PCI is unknown. METHODS: Clinical outcomes in patients who received co-therapy with ABC, ENOX, or UFH and subsequently underwent an elective (n = 1,064) or urgent (n = 716) PCI in the ASSENT-3 trial were compared. RESULTS: No significant differences in clinical end points were observed in patients who underwent an elective PCI. A non-significant trend toward fewer in-hospital myocardial re-infarctions was seen with ABC and ENOX when compared with UFH (0.5% vs. 0.6% vs. 1.5%, respectively). The incidence of bleeding complications was similar in the three treatment arms. Significantly fewer ABC- and ENOX-treated patients needed urgent PCI compared with UFH (9.1% vs. 11.9% vs. 14.3%; p < 0.0001), but outcomes in these patients were in general less favorable (30-day mortality: 8.2% vs. 5.4% vs. 4.5%; 1-year mortality: 11.0% vs. 8.5% vs. 5.6%; in-hospital re-infarction: 3.9% vs. 2.5% vs. 2.7%; major bleeding complications: 8.8% vs. 7.0% vs. 3.4%). In pairwise comparisons with UFH, the higher one-year mortality and major bleeding rates after ABC were statistically significant (p = 0.045 and p = 0.012, respectively). CONCLUSIONS: Clinical outcomes after elective PCI were similar with the three antithrombotic co-therapies studied in ASSENT-3. Although fewer patients needed urgent PCI with ABC and ENOX, clinical outcomes were less favorable in this selected population, especially with ABC.

Temporal changes in myocardial perfusion after recanalization and their relation with functional recovery in patients with acute myocardial infarction (AMI) using intravenous myocardial contrast echocardiography (MCE) have not yet been clarified. To address this issue, 19 patients with first, uncomplicated anterior wall AMI were studied using intravenous MCE within 24 hours of recanalization and before discharge. MCE was performed using harmonic power Doppler. Each asynergic left ventricular (LV) myocardial segment was scored for myocardial perfusion (1 = complete, 0.7 = patchy but50%, 0.3 = patchy50%, and 0 = absent) and a regional perfusion index was calculated within the dysfunctioning myocardium. During the day-1 study (11 +/- 2 hours from recanalization), the regional perfusion index was 0.4 +/- 0.3 and the LV wall motion score index was 1.9 +/- 0.2. During the study before discharge (7 +/- 4 days from admission), all but 2 patients showed an improvement of either perfusion index (0.6 +/- 0.3, p0.0001) or wall motion score index (1.7 +/- 0.4, p0.0001). Changes in perfusion score from 24-hours to before discharge showed a significant correlation with LV segment contractile recovery at 2-month of follow-up (R(2) = 0.42, 95% confidence interval 0.33 to 0.50, p0.0001). Thus, our data show that after recanalized AMI, there is a significant amount of microvascular obstruction that recovers in the days after, and the extent of this perfusion improvement appears to be related with early myocardial contractile recovery. Our data provide clinical evidence for a transient microvascular dysfunction after successfully recanalized AMI.

Background: The aim of this study was to assess the utility of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing aortic valve replacement with the CryoLife-O'Brien® (CLOB) Stentless Porcine Aortic Bioprosthesis. Methods: Between May 1994 and March 1995, 26 patients (15 men, mean age 68.4±10.78 years) had a CLOB valve in the aortic position. Transprosthetic gradients and valve regurgitation were detected by intraoperative TEE. Prosthetic regurgitation and transvalvular gradients were evaluated at six-month intervals using transthoracic echo-Doppler (TTE). Results: The majority of implants resulted in low gradients (83.7%), with only four patients exhibiting a moderate gradient (15.3%). Color flow Doppler imaging showed central aortic regurgitation in only four of 25 patients (trivial, n = 4; mild, n = 1). There was one paravalvular leak (trivial. n= 1). At follow-up examination (mean 37±12 months), 24 of 25 patients exhibited low mean gradients (7.25±2.81 mmHg). At follow-up one patient who had low velocities in the LVOT at perioperative evaluation exibited a moderate gradient (45 mmHg) with an effective orifice area of 0.8–0.9 cm2. Conclusions: Intraoperative TEE was effective in assessing prosthetic stentless valve function.

Patient-centered treatment outcomes such as health-related quality of life are recommended in clinical care and research studies. Health-related quality of life questionnaires need to be validated in the language of the target population. The reliability and validity of the Italian version of the MacNew Questionnaire was determined in patients with angina, myocardial infarction, or ischemic heart failure. Sociodemographic and clinical data were collected on 298 patients [angina, n = 88; MI, n = 106; heart failure, n = 104; mean age, 64.8 (±10.6) years] at three centers in Italy. MacNew mean scores were higher (p

In patients with limited exercise capacity and (relative) contraindications to direct vasodilators such as dipyridamole or adenosine, dobutamine stress nuclear myocardial perfusion imaging (DSMPI) represents an alternative, exercise-independent stress modality for the detection of coronary artery disease (CAD). Nondiagnostic test results (absence of reversible perfusion defects with submaximal stress) do occur in approximately 10% of patients. Serious side effects during DSMPI are rare, with no death, myocardial infarction or ventricular fibrillation reported in three DSMPI safety reports for a total of 2,574 patients. On the basis of a total number of 1,014 patients reported in 20 studies, the sensitivity, specificity and accuracy of the test for the detection of CAD were 88%, 74% and 84%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 84%, 95% and 100%, respectively. The sensitivity for detection of left circumflex CAD (50%) was lower, compared with that for left anterior descending CAD (68%) and right CAD (88%). The sensitivity of predicting multivessel disease by multiregion perfusion abnormalities varied widely, from 44% to 89%, although specificity was excellent in all studies (89% to 94%). In direct diagnostic comparisons, DSMPI was more sensitive, but less specific, than dobutamine stress echocardiography and comparable with direct vasodilator myocardial perfusion imaging. In the largest prognostic study, patients with a normal DSMPI study had an annual hard event rate less than 1%. An ischemic scan pattern provided independent prognostic value, with a direct relationship between the extent and severity of the perfusion defects and prognosis. In conclusion, DSMPI seems a safe and useful nonexercise-dependent stress modality to detect CAD and assess prognosis.

Background Patients with left bundle branch block exhibit abnormal septal motion which may limit the interpretation of stress echocardiograms. This study sought to assess the diagnostic value of dobutamine–atropine stress echocardiography in left bundle branch block patients. Methods and Results Sixty-four left bundle branch block patients (mean age 59 years, 24 men) with suspected coronary artery disease underwent dobutamine–atropine stress echocardiography and coronary arteriography. Myocardial ischaemia was defined as new or worsening wall thickening abnormalities. Coronary artery disease was quantitatively defined as a diameter stenosis 50% in a major epicardial artery. Rest septal motion was normal (apart from the early systolic septal notch) in 34 patients (53%) and abnormal in 30 patients (47%). Rest septal thickening was normal in 32 patients (50%) and abnormal in 32 patients (50%). All seven patients with a QRS duration 160 ms and an abnormal QRS axis had abnormal rest septal motion and thickening. Inter-observer agreement for ischaemia was 88%. In all but one patient disagreement was in the septum. For the anterior and posterior circulation, respectively, sensitivity was 60% (9/ 15) and 67% (8/12), specificity was 94% (46/49) and 98% (51/52), and accuracy was 86% (55/64) and 92% (59/64). Sensitivity for the anterior circulation tended to be better in patients with normal rest septal thickening (83% vs 44%). Conclusions Dobutamine–atropine stress echocardiography has excellent diagnostic specificity in left bundle branch block patients with suspected coronary artery disease. In patients with abnormal rest septal thickening, however, dobutamine–atropine stress echocardiography may lack good sensitivity for detection of coronary artery disease in the anterior circulation. Left bundle branch block patients who potentially most benefit from dobutamine–atropine stress echocardiography may initially be selected by their resting electrocardiogram.

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.

RF current delivery may cause acute and chronic dysfunction of previously implanted pacemakers. The aim of this study was to assess prospectively the effects of RF energy on Thera I and Kappa pacemakers in 70 consecutive patients (mean age 70 +/- 11 years, mean left ventricular ejection fraction 48 +/- 15%) who underwent RF ablation of the AV junction for antiarrhythmic drug refractory atrial fibrillation (permanent in 42 patients, paroxysmal in 28). These pacing systems incorporate protection elements to avoid electromagnetic interference. The pacemakers (Thera DR 7960 I in 20 patients, Thera SR 8960 I in 30, Kappa DR 600-601 in 8, Kappa SR 700-701 in 12) were implanted prior to RF ablation in a single session procedure and were transiently programmed to VVI mode at a rate of 30 beats/min. Capsure SP and Z unibipolar leads were used. During RF application there was continuous monitoring of three ECG leads, endocavitary electrograms, and event markers. Complete AV block was achieved in all cases after 3.6 +/- 2.9 RF pulses and 100 +/- 75 seconds of RF energy delivery. The mean time of pacemaker implantation and RF ablation was 60 +/- 20 minutes. Transient or permanent pacemaker dysfunction including under/oversensing, reversion to a "noise-mode" pacing, pacing inhibition, reprogramming, or recycling were not observed. Leads impedance, sensing, and pacing thresholds remained in the normal range in the acute and long-term phase (average follow-up 18 +/- 12 months). In conclusion, Thera I and Kappa pacemakers exhibit excellent protection against interference produced by RF current. The functional integrity of the pacemakers and Capsure leads was observed in the acute and chronic phases. Thus, the implantation of these pacing systems prior to RF ablation of the AV junction can be recommended.

Aims To risk stratify and shorten hospital stay in patients with spontaneous (resting) chest pain and a non-diagnostic electrocardiogram (ECG). Methods and Results The study comprised 102 patients (mean age 58±12 years, 67 men) with spontaneous chest pain and a non-diagnostic ECG. Forty-three patients had suspected coronary artery disease and 59 had known (but of unknown actual significance) coronary artery disease. All patients underwent serial creatine kinase enzyme measurements, continuous ECG monitoring for at least 12h and early dobutamine–atropine stress echocardiography in patients with negative creatine kinase enzymes and normal findings at ECG monitoring. Dobutamine–atropine stress echocardiography was considered positive in patients with new or worsening wall thickening abnormalities. Patients with negative dobutamine–atropine stress echocardiography were discharged after the test. In-hospital and 6 month follow-up events noted were cardiac death, non-fatal myocardial infarction, unstable angina, and coronary artery bypass surgery or angioplasty. Thirteen patients had evidence of evolving myocardial infarction by elevated creatine kinase enzymes, or unstable angina by ECG monitoring. In the remaining 89 patients, dobutamine–atropine stress echocardiography was performed after a median observation period of 31h (range 12–68h). During dobutamine–atropine stress echocardiography no serious complications (death, non-fatal myocardial infarction, sustained ventricular tachycardia or ventricular fibrillation) occurred. Dobutamine–atropine stress echocardiography results were of poor quality in three, non-diagnostic in six, negative in 44 and positive in 36 patients. In the 80 patients with diagnostic dobutamine–atropine stress echocardiography, variables associated with in-hospital events (n=7) were history of exertional angina ( P

Background: Cardiac complications are a major cause for perioperative mortality and morbidity Also, the presence and severity of underlying coronary artery disease (CAD) determine long-ten prognosis after successful surgery. Aim: This overview evaluates the additional value ofdobutamir, stress echocardiography (DSE) to common clinical cardiac risk factors and other noninvasii cardiac imaging modalities for perioperative and late cardiac prognosis. Results: DSE provides tl attending physician with preoperative prognostic information for perioperative and long-ten prognosis for cardiac events. It also enables the selection of high risk patients for evaluation i cardiac risk reduction therapies. Conclusions: DSE is a useful tool for preoperative cardiac ris evaluation in addition to common clinical cardiac risk factors. (ECHOCARDIOGRAPHY, Vo ume 17, January 2000)

Objectives: Evaluation of the long-term functional outcome assessed by exercise myocardial perfusion imaging following excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length. Background: Previous randomized studies evaluating the effect of coronary interventions mainly focused on the long-term clinical and angiographic outcome. The functional outcome, assessed by myocardial perfusion scintigraphy, has not been evaluated in a randomized setting. Methods: A total of 308 patients with stable angina and a longer coronary lesion (>10 mm) were randomized to excimer laser angioplasty or balloon angioplasty. A 99mTechnetium-2-methoxy isobutyl isonitrile (MIBI) single-photon emission computed tomography (SPECT) study was performed in 139 patients before the initial angioplasty procedure and at 6 months follow-up (73 patients in the laser group versus 66 patients in the balloon group, respectively). Exercise tolerance at follow-up was compared to baseline values by means of exercise duration and double product at peak exercise. Myocardial perfusion of the randomized vascular bed was assessed semi-quantitatively on the MIBI SPECT images. The reversible defects were graded as mild, moderate or severe. Myocardial perfusion at follow-up was expressed as a percentage reduction in incidence and grading of the reversible defects compared to baseline values. Results: Forty-four (61%) patients assigned to laser angioplasty were asymptomatic at 6 months follow-up compared to 34 (52%) patients assigned to balloon angioplasty (p = NS). Improvement in exercise duration and double product were 0.7 ± 2.1 min and 4.3 ± 6.2 min/mmHg/1000, respectively, in the laser group, versus 0.3 ± 2.5 min and 3.1 ± 5.5 min/mmHg/1000, respectively, in the balloon group (both p = NS). The percentage reduction of reversible defects was 23% in patients assigned to laser angioplasty vs. 29% in patients assigned to balloon angioplasty (Relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.40–1.57; p = 0.50). The mild, moderate and severe reversible defects improved in 44.4, 63.6 and 66.6%, respectively, in the laser angioplasty group vs. 66.6, 53.8 and 90%, respectively, in the balloon angioplasty group. None of the comparisons were significantly different. Conclusion: Excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length yields a similar long-term functional outcome assessed by anginal status, exercise tolerance and myocardial perfusion.

We describe a singular case of a 75-year-old woman affected by an anterior acute myocardial infarction in the subset of a very recent orthopaedic surgery. She had had severe mitral regurgitation on coronary angiography. A thorough cardiac echocardiographic examination revealed the particular mechanism of mitral incompetence, consisting of a dynamic anterior mitral leaflet displacement caused by a sustained compensatory left ventricle hypercontractility and favored by postsurgical moderate anemia and mild hypertensive hypertrophy. The use of beta-blockers and the avoidance of pure vasodilators permitted complete reversal of such mechanisms during the clinical course.

OBJECTIVESThis study was designed to address, in patients with severe ischemic left ventricular dysfunction, whether dobutamine stress echocardiography (DSE) can predict improvement of left ventricular ejection fraction (LVEF), functional status and long-term prognosis after revascularization.BACKGROUNDDobutamine stress echocardiography can predict improvement of wall motion after revascularization. The relation between viability, improvement of function, improvement of heart failure symptoms and long-term prognosis has not been studied.METHODSWe studied 68 patients with DSE before revascularization; 62 patients underwent resting echocardiography/radionuclide ventriculography before and three months after revascularization. Long-term follow-up data (New York Heart Association [NYHA] functional class, Canadian Cardiovascular Society [CCS] classification and events) were acquired up to two years.RESULTSPatients with ≥4 viable segments on DSE (group A, n = 22) improved in LVEF at three months (from 27 ± 6% to 33 ± 7%, p < 0.01), in NYHA functional class (from 3.2 ± 0.7 to 1.6 ± 0.5, p < 0.01) and in CCS classification (from 2.9 ± 0.3 to 1.2 ± 0.4, p < 0.01); in patients with

Modulation of atrioventricular (AV) node conduction and radiofrequency ablation of AV junction are alternative approaches to control ventricular rate in drug refractory atrial fibrillation (AF). In 2 centers, 120 patients were treated either with AV junction ablation (center 1, group 1, 60 patients [30 men, aged 64 +/- 11 years], paroxysmal AF in 24 patients) or with modulation (group 2, 60 patients [32 men, aged 58 +/- 12 years], paroxysmal AF in 43 patients). In group 1, complete AV block was achieved in all patients. In group 2, the procedure was performed in sinus rhythm (30 patients), prolonging the Wenckebach cycle length from 328 +/- 85 to 466 +/- 80 ms (p0.01) or during AF (30 patients), decreasing ventricular rate from 178 +/- 35 to 96 +/- 35 beats/min (p0.01), and to100 beats/min in 17 patients (61%). Complete AV block was induced in 9 of 60 patients (15%). In groups 1 and 2, at a follow-up of 27 +/- 7 and 26 +/- 6 months, there were 2 deaths (1 cardiac, 1 sudden death) and 1 death for end-stage heart failure, respectively. Hospital readmissions decreased from 3.2 to 0.2 and from 4.2 to 0.2/year; late AF recurrences at of120 beats/min were documented in 6% and 12%, respectively. Symptom score analysis including effort and rest dyspnea, exercise intolerance, weakness, and palpitation showed a significant improvement in both treatment groups, when acutely effective, in patients with paroxysmal and/or chronic AF. In conclusion, ablation of the AV junction shows a higher acute success rate compared with modulation of the AV node conduction in patients with drug refractory AF. Depending on the acute success, both approaches therefore were similarly effective in achieving long-term ventricular rate control and symptom score improvement.

Background —The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease. Methods and Results —Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with an annual event rate of cardiac death or infarction of 1.3% over a 5-year period. Conclusions —In a large group of patients, DSE has an added value for predicting late cardiac events during long-term follow-up, improving the separation between high- risk and very-low-risk patients.

In patients with chronic coronary artery disease and depressed left ventricular function, assessment of residual viability in akinetic myocardium is important for therapeutic management. Intact perfusion, preserved metabolism, and presence of contractile reserve are different aspects of cellular viability. However, not all viable cells exhibit all characteristics; it is thought that contractile reserve is less often preserved compared with metabolic activity or intact perfusion. In this study we performed a direct comparison between perfusion imaging with thallium-201 single photon emission computed tomography (SPECT), metabolic imaging with F18-fluorodeoxyglucose SPECT, and assessment of contractile reserve with low-dose dobutamine echocardiography in akinetic myocardium.Forty patients with depressed left ventricular function (mean left ventricular ejection fraction 31% +/- 16%) were studied. Resting echocardiography showed akinesis in 165 (32%) segments. Most (n = 154, 93%) of these segments demonstrated resting hypoperfusion. F18-fluorodeoxyglucose imaging revealed a perfusion-metabolism mismatch in 41 segments and a match in 113 segments. Contractile reserve was present in 33 (80%) of the segments with a perfusion-metabolism mismatch and in 7 (6%) segments with a match (P.0005). Of the 11 segments with normal perfusion, only 5 (45%) showed contractile reserve. The agreement between SPECT and dobutamine echocardiography was 87%. Although 94% of the segments that were nonviable on scintigraphy did not show contractile reserve, the disagreement between SPECT and dobutamine echocardiography was caused mainly by the absence of contractile reserve in 27% of the segments that were viable on scintigraphy.This study shows a good agreement between SPECT and dobutamine echocardiography, although a substantial number of segments with preserved viability on SPECT do not exhibit contractile reserve, indicating underestimation of viability by dobutamine echocardiography compared with F18-fluorodeoxyglucose imaging.

Subjective interpretation of dobutamine echocardiograms provides only moderate interinstitutional observer agreement if nonunified data acquisition and assessment criteria are applied. The present study was undertaken to evaluate parameters associated with low interinstitutional observer agreement in the interpretation of dobutamine echocardiograms and to analyze whether standardized interpretation criteria improve interinstitutional observer agreement. One hundred fifty dobutamine echocardiograms (dobutamine up to 40 microg/kg/min body weight and atropine up to 1 mg) were evaluated at 5 centers. Clinical, procedural, and echocardiographic parameters were included in the analysis of variables with significant impact on interinstitutional agreement. Standardized interpretative criteria were established, and 90 dobutamine echocardiograms were reanalyzed by 3 observers using a standardized image display. Multivariate analysis demonstrated low image quality (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08 to 0.45, p=0.0002), low severity of induced wall motion abnormality (OR 0.17, 95% CI 0.07 to 0.40, p

In the present multicentre randomized phase II trial, the activity and toxicity of three platinum-based combination regimens for the treatment of advanced non-small-cell lung cancer (NSCLC) were evaluated. The three regimens were: MVP (mitomycin-C 6 mg m(-2) on day 1, vindesine 3 mg m(-2) on days 1 and 15, and cisplatin 80 mg m(-2) on day 1 every 28 days), PIN (cisplatin 80 mg m(-2) day 1, ifosfamide 3 g m(-2) day 1 and vinorelbine 25 mg m(-2) day 1 and 8 every 21 days) and CaN (carboplatin 350 mg m(-2) day 1 and vinorelbine 25 mg m(-2) days 1 and 8 every 28 days). A total of 140 chemotherapy-naive patients entered the study; 49 patients were treated with MVP, 48 with PIN and 43 with CaN. Sixty-seven per cent of the patients had stage IV disease. Response rates, calculated on an 'intention to treat' basis, were as follows: MVP, 14.3% (95% CI 5.94-27.2%); PIN, 16.7% (95% CI 7.4-30.2%); and CaN, 14% (95% CI 5.3-27.9%). The overall median survivals were 256, 269 and 243 days for patients treated with MVP, PIN and CaN respectively. Myelosuppression was the most frequent toxicity: grade 3-4 leucopenia was observed in 14.3%, 25% and 18.6% of patients treated with MVP, PIN and CaN respectively. This multicentre phase II randomized trial shows that MVP, PIN and CaN can be administered on an outpatient basis with acceptable toxicities. Unfortunately, the three regimens showed an activity significantly lower than that reported in previous single-institution phase II trials.

To assess the prognostic significance of a normal dobutamine-atropine stress echocardiogram in relation to the pretest probability of coronary artery disease (CAD), 200 consecutive patients (86 men and 114 women, mean [SD] age 59 [13] years) with a stable chest pain syndrome and a normal dobutamine-atropine stress echocardiogram were followed-up for 21 +/- 16 months. Outcome events were cardiac death, non-fatal myocardial infarction, and coronary revascularization procedures. Low (10%), intermediate (10% to 80%), and high (80%) pretest probabilities of CAD were present in 27 (14%), 108 (54%), and 65 (33%) patients, respectively. During follow-up, 2 patients (annual event rate 0.6%) had cardiac death, none had nonfatal myocardial infarction, and 4 patients (annual event rate 1.1%) underwent a coronary revascularization procedure. All patients with cardiac events had high pretest probabilities of CAD. Patients with cardiac death (but unproven significant CAD) had maximal tests without angina or ischemic electrocardiographic changes. In contrast, all patients with subsequent coronary revascularization had dobutamine-induced angina or ischemic electrocardiographic changes, and all except one study were submaximal. We conclude that patients with a stable chest pain syndrome and normal findings on dobutamine-atropine stress echocardiograms have an excellent cardiac prognosis. However, patients with typical angina, high pre-test probabilities of CAD, and stress-induced angina or ischemic electrocardiographic changes, and in particular those with submaximal stress, still appear to be at risk for functionally important CAD despite a normal dobutamine-atropine stress echocardiogram.

Closed-loop arbutamine stress echocardiography has been shown to be safe and effective for detecting coronary artery disease (CAD) using a standardized infusion protocol and centralized core laboratory analyses. However, the accuracy of arbutamine stress echocardiography using local test interpretation has not been previously tested in a large population. The present study reports the safety, sensitivity, and specificity of arbutamine stress echocardiography in a multicenter trial allowing user-defined, nonstandardized protocols and local test interpretation. In all, 1,070 patients underwent arbutamine stress testing at 81 sites. Heart rate increased from 73 ± 13 to 124 ± 15 beats/min, systolic blood pressure from 144 ± 24 to 174 ± 25 mm Hg, and pressure rate product × 10 3 from 10.5 ± 2.8 to 19.6 ± 3.9. Among 1,070 patients, there were only 2 (0.2%) significant adverse events related to arbutamine, both of which resolved completely with appropriate therapy. There were no incidents of ventricular fibrillation, sustained ventricular tachycardia, or death related to testing. Among 242 patients who underwent arbutamine stress echocardiography and diagnostic coronary angiography within 12 weeks, sensitivity and specificity for detection of CAD were 71% (95% confidence interval 64% to 77%) and 67% (95% confidence interval 52% to 80%), respectively. Closed-loop arbutamine stress echocardiography is a safe and effective method for evaluating CAD in clinical practice.

This paper investigates the possibility of finishing milling of titanium alloy TiAl6V4 compressor gas turbine blades with polycrystalline cubic diamond PCD cutter that can be used successfully for milling “slim” - low stiffness - blades. The tool life of PCD cutter was very long T=381 minutes while surface roughness of the machined surface was low and the geometrical accuracy was satisfactory. A suitable inclination of the cutter axis to the surface has been determined. A basic consideration of milling titanium based alloy with PCD cutter and an analysis and discussion of the chip formation are presented. Better results are obtained when cooling refrigerant was applied. Finishing milling of titanium alloy TiAI6V4 “slim” blades with PCD cutter is promising.

Objectives. This study sought to evaluate the time course of improvement of left ventricular (LV) dysfunction in stable patients and its implications on the accuracy of dobutamine echocardiography for predicting improvement after surgical revascularization. Background. Little is known about the optimal timing for evaluation of postrevascularization recovery of the contractile function of viable myocardium. Methods. Sixty-one patients with chronic ischemic LV dysfunction scheduled for elective surgical revascularization were prospectively selected. They underwent dobutamine echocardiography (5 to 40 μg/kg body weight per min) and radionuclide ventriculography both preoperatively and at 3-month follow-up. At 14 months, another evaluation of LV function was obtained. To analyze echocardiograms, a 16-segment model and a five-point scoring system were used. Dyssynergic segments were considered likely to recover in the presence of a biphasic contractile response to dobutamine. Improvement of global function was defined as a ≥5% increase in LV ejection fraction (LVEF). Results. Of the 61 patients, LVEF improved in 12 at 3 months and in 19 at late follow-up (from 32 ± 8% to 42 ± 9%, p Conclusions. Serial postoperative follow-up studies demonstrate incomplete recovery of contractile function at 3 months. The diagnostic accuracy of dobutamine echocardiography for predicting recovery is dependent on three factors: the combining of low and high dobutamine dosages, the severity of regional dyssynergy and the timing of evaluation.

Objectives. This study evaluated the relative merits of the most frequently used techniques for predicting improvement in regional contractile function after coronary revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease.Background. Several techniques have been proposed for predicting improvement in regional contractile function after revascularization, including thallium-201 (Tl-201) stress–redistribution–reinjection, Tl-201 rest–redistribution, fluorine-18 fluorodeoxyglucose with positron emission tomography, technetium-99m sestamibi imaging and low dose dobutamine echocardiography (LDDE).Methods. A systematic review of all reports on prediction of functional recovery after revascularization in patients with chronic coronary artery disease (published between 1980 and March 1997) revealed 37 with sufficient details for calculating the sensitivity and specificity of each imaging modality. From the pooled data, 95% and 99% confidence intervals were also calculated.Results. Sensitivity for predicting regional functional recovery after revascularization was high for all techniques. The specificity of both Tl-201 protocols was significantly lower (p < 0.05) and LDDE significantly higher (p < 0.01) than that of the other techniques.Conclusions. Pooled analysis of 37 studies showed that although all techniques accurately identify segments with improved contractile function after revascularization, the Tl-201 protocols may overestimate functional recovery. The evidence available thus far indicates that LDDE appears to have the highest predictive accuracy.

Objectives. We evaluated the use of fluorine-18 fluorodeoxyglucose (FDG) and single-photon emission computed tomography (SPECT) to predict improvement of left ventricular ejection fraction (LVEF) after revascularization. Background. FDG SPECT has recently been proposed for assessment of myocardial viability. However, FDG SPECT still awaits validation in terms of predicting improvement of contractile function after revascularization in patients with poor left ventricular (LV) function. Methods. Fifty-five patients with contractile dysfunction (including 22 with LVEF

Most biplane methods for the echocardiographic calculation of left ventricular volumes assume orthogonality between paired views from the apical window. Our aim was to study the accuracy of biplane left ventricular volume calculations when either the apical two-chamber or long-axis views are combined with the four-chamber view. The left ventricular volumes calculated from three-dimensional echocardiographic data sets were used as a reference. Twenty-seven patients underwent precordial three-dimensional echocardiography using rotational acquisition of planes at 2-degree intervals, with ECG and respiratory gating. End-diastolic and end-systolic left ventricular volumes and ejection fraction on three-dimensional echocardiography were calculated by (1) Simpson's methods (3DS) at 3 mm short-axis slice thickness (reference method) and by (2) biplane ellipse from paired views using either apical four- and two-chamber views (BE-A) or apical four- and long-axis views (BE-B). Observer variabilities were studied by the standard error of the estimate % (SEE) in 19 patients for all methods.The spatial angles (mean +/- SD) between the apical two-chamber, long-axis and four-chamber views were 63.3 degrees +/- 19.7 and 99.1 degrees +/- 25.6, respectively. The mean +/- SD of end-diastolic and end-systolic left ventricular volumes (ml) and ejection fraction (%) by 3DS were 142.2 +/- 60.9, 91.8 +/- 59.6 and 39.6 +/- 17.5, while that by BE-A were 126.7 +/- 60.4, 84.0 +/- 57.9 and 39 +/- 17 and by BE-B were 134.3 +/- 62.4, 88.6 +/- 59.7 and 39.1 +/- 16.7, respectively. BE-B intra-observer (8.4, 6.7 and 3.5) and inter-observer (9.8, 11.5 and 5.4) SEE for end-diastolic and end-systolic left ventricular volumes (ml) and ejection fraction (%), respectively, were smaller than that for BE-A (10.8, 8.8 and 4.1 and 11.4, 14.7 and 6.1, respectively). There was excellent correlation between 3DS and BE-A (r = 0.99, 0.98 and 0.98) and BE-B (0.98, 0.98 and 0.98) for calculating end-diastolic and end-systolic left ventricular volume and ejection fractions, respectively. There were no significant differences between BE-A and BE-B with 3DS for end-diastolic and end-systolic left ventricular volume and ejection fraction calculations (P = 0.2, 0.3 and 0.4 and P = 0.5, 0.5 and 0.4, respectively). There were closer limits of agreement (mean +/- 2 SD) between 3DS and BE-B 7.9 +/- 18.8, 3.2 +/- 14.2 and 0.8 +/- 5.8 than that between 3DS and BE-A 15.5 +/- 19.6, 7.8 +/- 16.2 and 1.1 +/- 7.4 for calculating end-diastolic and end-systolic left ventricular volume and ejection fractions, respectively.Both apical two-chamber and apical long-axis views are not orthogonal to the apical four-chamber view. Observer variabilities of BE-B were smaller than that for BE-A. BE-A and BE-B have excellent correlation and non-significant differences with 3DS for left ventricular volume and ejection fraction calculations. There were closer limits of agreement between BE-B with 3DS for left ventricular volume and ejection fraction calculations than that between BE-A and 3DS. Therefore, we recommend the use of the apical long-axis rather than the two-chamber view in combination with the four-chamber view for accurate biplane left ventricular volume and ejection fraction calculations.

Background Pharmacological stress echocardiography and myocardial perfusion scintigraphy are used frequently for risk stratification in patients with suspected myocardial ischemia. However, their relative prognostic strength has never been explored. Methods and Results Two hundred twenty consecutive patients with chest pain (mean age, 60±12 years; 124 men, 115 with previous myocardial infarction) were studied with dobutamine-atropine stress echocardiography (ECHO) and simultaneous 99m Tc sestamibi single photon emission computed tomography imaging (MIBI). Ischemia was defined as deterioration in left ventricular wall motion and reversible perfusion defects, respectively. ECHO was positive for ischemia in 76 and MIBI in 91 patients (agreement, 77%; κ=.51). During follow-up of 31±15 months, 24 patients had hard cardiac events (nonfatal myocardial infarction or cardiac death). By univariate analysis, age, history of congestive heart failure, and any abnormality or ischemia on ECHO or MIBI were associated with cardiac events. Multivariate analysis revealed that age, abnormal ECHO (odds ratio [OR], 18.9; 95% CI, 2.5 to 146.0) or MIBI (OR, 12.8; 95% CI, 1.7 to 98.3), and ischemia on ECHO (OR, 4.0; 95% CI, 1.6 to 9.9) or MIBI (OR, 3.0; 95% CI, 1.2 to 7.4) had independent predictive values. When ECHO was used as a first option, the addition of MIBI to all nonischemic ECHO studies decreased the OR from 4.0 (95% CI, 1.6 to 9.9) to 3.8 (95% CI, 1.4 to 10.2). Addition of MIBI confined to nonischemic ECHO studies in which target heart rate was not attained (nondiagnostic studies) increased the OR to a maximal 5.7 (95% CI, 2.2 to 15.0). In contrast, the addition of ECHO to nondiagnostic MIBI studies was not useful. Conclusions Dobutamine-atropine ECHO and MIBI provide comparable prognostic information. The addition of MIBI to ECHO may be useful in patients with nondiagnostic ECHO studies.

The use of 18F-fluorodeoxyglucose (FDG) imaging with single photon emission computed tomography (SPECT) has been introduced recently to assess myocardial viability. Several centres have now gained experience with cardiac FDG SPECT imaging, and this report is a summary of the currently available FDG SPECT data. Three studies have compared FDG SPECT with FDG positron emission tomography and demonstrated good agreement between them. Initial results in patients undergoing revascularization suggest that FDG SPECT can predict improvement in contractile function after revascularization. Although the initial results are promising, larger studies are needed to determine the precise role of FDG SPECT in the assessment of myocardial viability.

Abstract Dobutamine stress testing is increasingly used for the diagnosis and functional evaluation of coronary artery disease. The aim of this study was to assess the hemodynamic profile, safety, and feasibility of dobutamine stress testing in hypertensive patients. Dobutamine (up to 40 μg/kg per min-ute)–atropine (up to 1 mg) stress echocardiography was performed for the detection of myocardial ischemia in 1164 patients with limited exercise capacity (age, 60±12 years; 761 men); 446 patients were known to have hypertension. The test was considered feasible when 85% of the maximal heart rate and/or an ischemic end point (new or worsened wall motion abnormalities, ST segment depression, or angina) was achieved. No myocardial infarction or death occurred during the test. Dobutamine induced a significant increase of heart rate in patients with and without hypertension (59±25 and 63±23 beats per minute, respectively). Peak rate pressure product was similar in patients with and without hypertension (18 566±4584 and 18 230±4508). Hypotension (systolic pressure drop >40 mm Hg) during the test was more frequent in hypertensive patients (7% versus 4% in normotensive, P

After successful percutaneous transluminal coronary angioplasty (PTCA), restenosis occurs in a relatively high proportion of patients. Exercise thallium scintigraphy is a useful method for the detection of restenosis. In patients unable to exercise, dobutamine perfusion scintigraphy may represent a feasible alternative. However, its diagnostic accuracy in this clinical setting has not been evaluated. We studied 40 patients (29 males, 11 females) aged 57 ± 9 years, at a mean of 185 ± 80 days after successful PTCA with a high-dose dobutamine (up to 40 μg kg -1 min -1 ) stress test, in conjunction with 99 Tc m -methoxyisobutyl isonitrile ( 99 Tc m -MIBI) single photon emission tomography (SPET). Significant restenosis was defined as ≥ 50% luminal diameter stenosis of a coronary segment with previous PTCA and was predicted on the basis of the occurrence of reversible perfusion defects in the corresponding territories. Reversible perfusion defects occurred in 20 of 29 arteries with and in 4 of 17 arteries without restenosis. The sensitivity of dobutamine MIBI for the detection of restenosis in arteries with previous PTCA was 69% (CI = 56-82), the specificity 76% (CI = 64-89), the positive predictive value 83% (CI = 73-94), the negative predictive value 59% (CI = 45-73) and accuracy 72% (CI = 59-85). The overall sensitivity of 99 Tc m -MIBI SPET for the diagnosis of significant coronary stenosis (including arteries without previous PTCA) on a patient basis was 79% (CI = 67-92), the specificity 82% (CI = 70-94) and accuracy 80% (CI = 68-92). The sensitivity of 99 Tc m -MIBI SPET was significantly higher than that of electrocardiography (79 vs 38%, P< 0.005). It is concluded that dobutamine 99 Tc m -MIBI SPET is a useful method for the detection of restenosis after PTCA in patients unable to perform an exercise stress test.